State Custody related deaths

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 Systemic failures in medication review led to a patient receiving double the maximum dose for six months. Additionally, inadequate security and search procedures in a mental health hospital allowed illicit drugs to be present.

Concerns summary A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other prisoners, potentially delaying critical medical responses.

Concerns summary Investigations into a death in custody were not effectively disseminated to directly involved staff, hindering learning and preventing recommendations from being fully acted upon.

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 Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages significantly harmed prisoner mental health.

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 officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.

Concerns summary Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising unconsciousness had not been implemented.

Concerns summary A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. The absence of a national directory for prison healthcare facilities exacerbated risks for prisoners with complex needs.

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 Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks to their health and safety.

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 Healthcare Professionals in police custody suites may lack sufficient and adequate training to practice effectively or safely, potentially compromising clinical assessment and treatment for detainees.

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.