State Custody related deaths

Concerns summary Mismatched healthcare and Home Office interpretations of Rule 35 led to a failure in reporting suicidal intentions, and an inappropriate "closed" visit denied a detainee physical contact and private conversation with family.

Concerns summary Critical mental health referrals, including urgent self-harm concerns, were not recorded or considered by assessing clinicians. The care coordinator then improperly prioritized Oliver's case, failing to ensure timely support before going on leave.

Concerns summary There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare concerns are unaddressed by consultants.

Concerns summary Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training to perform robust, positive-response checks in cells.

Concerns summary Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.

Concerns summary Prison staff failed to escalate or monitor a prisoner's reported refusal of food and fluids, highlighting a national absence of formal policy for monitoring prisoner meal collection.

Concerns summary Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent information sharing policies between healthcare and prison staff regarding medication and risk.

Concerns summary Prison ACCT observations allowed overly long gaps, and fixed shower rails presented ligature risks. Staff lacked training on personality disorder/learning disability, and vulnerable prisoners were held in unsuitable cells.

Concerns summary Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in non-24-hour healthcare facilities, risking missed opportunities for life-saving resuscitation.

Concerns summary Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.

Concerns summary The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no joint prison/healthcare oversight.

Concerns summary Critical failures included poor communication between healthcare and prison, inadequate discharge planning, lack of staff escort during transfer, and insufficient prison resources or policies for complex patient needs. Staff were also fatigued and felt unable to raise concerns.

Concerns summary Concerns are raised about the welfare of individuals subject to IPP sentences, highlighting anxiety over recall and the belief that seeking mental health support could hinder their discharge process.

Concerns summary Acutely psychotic prisoners requiring transfer for treatment are left untreated and at risk due to a shortage of timely psychiatric hospital bed availability.

Concerns summary Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.

Concerns summary The prison failed to adequately monitor and manage a patient's epilepsy with no seizure care plan or effective communication between healthcare and prison staff, compounded by a lack of staff training.

Concerns summary Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding of emergency transfer protocols, led to significant delays.

Concerns summary The absence of in-cell ligature point risk assessments, ligature point maps, and mandatory "Safer Cells" in prisons creates critical missed opportunities to prevent self-harm by ligation.

Concerns summary Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough record review, and system limitations meant crucial information was frequently overlooked.

Concerns summary The electronic patient system (SystmOne) lacks an automated flag for prisoners who are not medication compliant, leading to delayed identification and referral. The manual workaround is inefficient and poses significant risks.

Concerns summary Inconsistent and inaccurately recorded observations for suicide prevention, coupled with staff misinterpretation of guidelines and excessive working hours, posed significant risks in state custody.

Concerns summary There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance for prisoners on how to respond to a cellmate having a fit.

Concerns summary HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, impacting daily operations, training, incident response, and the management of vulnerable prisoners.

Concerns summary Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.

Concerns summary Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to dangerous delays.