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).
PFD Reports
357 resultsPaul Gobell
All Responded
2025-0047
3 Dec 2024
Nottingham City and Nottinghamshire
HM Inspectorate of Prisons
Ministry of Justice
Concerns summary (AI summary)
There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated to prisoners. Furthermore, probation staff failed to report critical disclosures, resulting in an uninformed suitability assessment.
Noted
(AI summary)
HM Inspectorate of Prisons acknowledges the concerns raised and states that the issues are covered in their inspection criteria. They will keep the findings on file for future inspections of HMP Whatton and HMP Hollesley Bay. HMP Whatton will update their Induction policy to include a "late arrivals form" for prisoners when a normal induction cannot be facilitated, and has amended their local safety strategy to ensure prisoners are informed in writing when their CSRA levels change. HMP Hollesley Bay will seek POM attendance at local stability meetings where OCSAs are being discussed wherever possible.
Jonathon Lawlor
All Responded
2024-0667
25 Nov 2024
Mid Kent and Medway
HM Prison and Probation Service
Concerns summary (AI summary)
Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.
Action Planned
(AI summary)
HMP Elmley has been compiling a Key Work Delivery Strategy to address and improve the issue of key work, with the goal of ensuring that all prisoners are allocated a key worker and that specific cohorts of prisoners at risk of harm or self-harm are identified and supported by trained staff members. For 2025/6 the minimum expectation for key work delivery will rise to two key work sessions every four weeks as a minimum.
Kirsten Hocking
Partially Responded
2024-0617
11 Nov 2024
West Sussex, Brighton & Hove
HMPPS
Probation Service
Steps2Recovery
Concerns summary (AI summary)
There is a critical lack of specialist rehabilitation accommodation for women at high risk of self-harm, leading to ineffective post-release support. Probation officers also lack sufficient understanding of available housing options and appropriate release planning.
Action Planned
(AI summary)
Steps2Recovery has implemented several measures including clarity in communication, improved referrals, reconsideration policies, leadership experience, policy reviews, staff training, and enhancements to its case management system. The Probation Service is promoting community disposals and engaging with regional female leads to promote Approved Premises placements for women with complex needs; Female AP briefings for practitioners will emphasize this point from September.
Wayne Bayley
All Responded
2024-0605
31 Oct 2024
Inner North London
Ministry of Justice
NHS England
Concerns summary (AI summary)
National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across all UK prisons, posing a risk that lessons learned are not widely applied.
Noted
(AI summary)
NHS England is undertaking training and upskilling of healthcare and prison staff in the London region. They are also reviewing service specifications and will use learning from the case to strengthen requirements around assessment and management of long-term conditions. HMPPS acknowledges the concerns and refers to ongoing work led by NHS England to improve awareness of sickle cell disease and other long-term conditions, stating their commitment to working collaboratively with healthcare providers.
Frank Ospina
All Responded
2025-0338
25 Oct 2024
West London
Home Office
Mitie
NHS England
Concerns summary (AI 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.
Action Planned
(AI summary)
NHS England plans to revise Detention Services Order 09/2016, Rule 35 assessments towards a multidisciplinary approach to safeguarding and vulnerability management in Immigration Removal Centres, and will jointly develop a stakeholder engagement session with the Home Office to share the revised requirements with IRC providers and operators. The Home Office is developing an interim update to its Rule 35 guidance, strengthening monitoring in detention, and implementing a 'Prevention of future deaths in immigration detention strategy'. Progress will be reported through the MBDC governance structures. Mitie Care and Custody has implemented a revised Standard Operating Procedure to prevent "closed visits" and has introduced a website translation and accessibility service called 'Recite' across its immigration removal centres.
George Kyriacos Petrou
All Responded
2024-0592
25 Oct 2024
Inner North London
Barnet, Enfield and Haringey Mental Hea…
Concerns summary (AI summary)
Some prison mental health staff improperly prioritized a prisoner's refusal of suicide watch over policy guidance, creating a risk that vulnerable individuals with suicidal intentions may not receive necessary observation.
Action Planned
(AI summary)
The Trust will continue to assure training standards around ACCT are sustained, will continue to participate in ACCT reviews in accordance with its operational policy, and will implement a learning event for the Unscheduled Care Team workers and clinicians. The learning event will focus on the message, ‘if in doubt, implement an ACCT’.
Mark Beresford
All Responded
2024-0577
25 Oct 2024
Nottingham City and Nottinghamshire
HMP Ranby
Concerns summary (AI summary)
Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.
Action Taken
(AI summary)
HMP Ranby provides regular training and guidance to staff on the ACCT process, and guidance has been issued to staff to improve understanding of ACCT. A three-stage quality assurance process is in place to identify areas where individual or wider upskilling is required.
Stephen Sleaford
Partially Responded CC
2024-0550
14 Oct 2024
Leicester City and South Leicestershire
HM Prison and Probation Service
Ministry of Justice
Concerns summary (AI summary)
There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical response gaps. Routinely obscured cell observation panels and unclear guidance on emergency cell entry further compromise prisoner safety.
Action Taken
(AI summary)
HMPPS re-issued the First Aid Policy Framework in August 2023, re-issued a notice to staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels, and issued a new film, ‘Responding to emergency situations’.
Oliver Davies
All Responded
2024-0541
11 Oct 2024
Worcestershire
Midlands Partnership NHS Foundation Tru…
Concerns summary (AI 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.
Action Taken
(AI summary)
The Trust has implemented several changes, including disseminating SIM meeting outcomes to care coordinators, documenting patient concerns on SystmOne, emphasizing risk mitigation in clinical supervision, and embedding a process for continuity of care during staff absences. A standing agenda item was added to daily meetings to address patient care during staff absence, with documented handover of responsibilities.
John Eyre
All Responded
2024-0534
7 Oct 2024
Mid Kent and Medway
Department of Health and Social Care
Concerns summary (AI 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.
Action Taken
(AI summary)
Medway Maritime Hospital is working with system partners to co-create a written document setting out the process for effective and safe discharges of prisoners and has implemented twice-daily board rounds to discuss patient status. NHS England will share learnings with regional leads.
Brandon Johnson
All Responded
2024-0523
1 Oct 2024
Inner West London
HMP Wandsworth
Concerns summary (AI 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.
Action Taken
(AI summary)
HMP Wandsworth issued a notice in March 2021 to remind staff to have clear sight of prisoners and obtain signs of life during roll checks and have published further communications since. In 2024, they introduced a quality assurance process for roll checks and the Standards Coaching Team provided support to staff over the summer.
Ian Deavall
Partially Responded
2024-0485
9 Sep 2024
Greater Manchester West
HM Prison and Probation Service
Ministry of Justice
Concerns summary (AI 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.
Action Taken
(AI summary)
HMP Forest Bank has split the induction across two wings, housing vulnerable prisoners and non-vulnerable prisoners separately, eliminating the risk of cell call bells being cancelled by other prisoners. Plans for future investment with regards to the cell call system will be determined by the competitions process and award of future contracts.
Amanda Richardson
Partially Responded
2024-0484
9 Sep 2024
West Yorkshire (East)
In Mind Healthcare Group Ltd
Waterloo Manor Hospital
Concerns summary (AI 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.
Action Taken
(AI summary)
Inmind Healthcare states that they completed a Serious Incident Report and implemented an action plan of recommendations, with details of steps and actions implemented and embedded by Inmind following this incident detailed at length within a witness statement and in oral evidence at the inquest.
Craig Steadman
Partially Responded
2024-0442
12 Aug 2024
Hampshire, Portsmouth and Southampton
Chief Coroners Office
HMP Winchester
Practice Plus Group
Concerns summary (AI 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.
Action Taken
(AI summary)
HMP Winchester shared and discussed the investigation report with relevant staff, and the Head of Safety will now routinely share reports and learning points. Recommendations are also used to produce national learning bulletins across the prison estate.
Kevin McDonnell
All Responded
2024-0433
7 Aug 2024
Nottingham City and Nottinghamshire
HM Prison and Probation Service
Concerns summary (AI 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.
Action Taken
(AI summary)
HMP Nottingham has increased SASH/ACCT awareness training for staff and introduced a 'trigger' database for sharing pertinent risk information. ACCT books are no longer removed from the wing during quality checks to ensure contemporaneous entries.
Matthew Braben
No Identified Response CC
2024-0423
1 Aug 2024
West London
His Majesty’s Prison and Probation Serv…
Ministry of Justice
Concerns summary (AI 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.
Russell Irvine
All Responded
2024-0393
22 Jul 2024
Durham & Darlington
Concerns summary (AI 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.
Action Planned
(AI summary)
While stating existing policy covers monitoring food refusals, HMPPS will write to all Governors to remind staff of their role in early identification of food and/or fluid refusals, and to satisfy themselves that systems are in place for recording information and sharing it with healthcare providers.
Benjamin Harrison
All Responded
2024-0394
19 Jul 2024
Mid Kent & Medway
HMP Rochester
Oxleas NHS Foundation Trust
Concerns summary (AI 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.
Action Planned
(AI summary)
Oxleas will ensure the healthcare team is aware of relevant policies and that these are shared and discussed, and has updated on-call GP guidance. A review of policies has been completed and shared. HMPPS has issued an order to staff regarding escalating concerns about prisoners under the influence of illicit substances. They are also embedding a process for sharing information about at-risk prisoners with medication in their possession, and are consulting on new guidance around prisoners under the influence.
Yasmin Adams
All Responded
2024-0330
20 Jun 2024
Derby and Derbyshire
Ministry of Justice
Concerns summary (AI 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.
Noted
(AI summary)
HMPPS acknowledges concerns about ACCT observations, shower rails, personality disorder training, and cellular confinement, explaining existing policies and planned improvements without committing to specific new actions.
Yuri Hatton
No Identified Response CC
2024-0608
11 Jun 2024
Inner West London
HMPPS
HMP Wandsworth
Concerns summary (AI 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.
Daniel Beckford
No Identified Response CC
2024-0607
11 Jun 2024
Inner West London
HMPPS
HMP Wandsworth
Concerns summary (AI summary)
Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.
Frazer Williams
Partially Responded
2024-0294
31 May 2024
Dorset
Department of Health and Social Care
HMP Guys Marsh
HM Prisons and Probation Service
+2 more
Concerns summary (AI 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.
Noted
(AI summary)
NHS England is responding to 'The Long Wait' HMIP report, and is working with HMPPS nationally and regionally to support the ACCT process. HMP Guys Marsh issued guidance to healthcare staff and relevant training was provided to induction and reception staff who conduct first night interviews. NHS England South West region supported the development of e-learning training for healthcare staff on safeguarding in secure and detained settings. Unilink will raise the issue of prisoner transfer information with the Ministry of Justice to explore the possibility of sharing relevant information to better manage and redirect communications. The response is a cover letter forwarding the PFD response, but contains no details itself. The Department of Health and Social Care acknowledges concerns about mental health treatment equity in prisons and delays in transferring mentally unwell prisoners. They mention the Mental Health Bill, which will introduce a 28-day statutory time limit for transfers from prison to hospital, and that they expect other recipients of the report to address concerns around national guidance, ACCT processes and engagement with family members.
Paul Day
All Responded
2024-0274
10 May 2024
Derby and Derbyshire
Ministry of Justice
Concerns summary (AI 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.
Action Planned
(AI summary)
HM Prison and Probation Service acknowledges concerns about CPR guidance and will review and revise the guidance regarding rigor mortis as a sign of death, following advice from the Resuscitation Council UK.
Mohammed Azizi
All Responded
2024-0235
1 May 2024
Norfolk
HMP Norwich
Concerns summary (AI summary)
Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.
Action Planned
(AI summary)
The organisation will provide advice and guidance to the staff member involved in the incident, ensure all future support and advice for staff during an inquest will be provided by the SPOC and regional safety specialist, support management grades to identify data losses, and write to all sites in the region to remind them of their responsibilities in supplying documentation without delay.
Marlin Burrows
All Responded
2024-0230
30 Apr 2024
Liverpool and Wirral
HMP Garth
Concerns summary (AI 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.
Action Planned
(AI summary)
Healthcare staff at HMP Garth have been instructed to review and sign the welfare checklist document upon arrival at the wing to inform clinical decision making, with monthly assurance checks to be completed by the Primary Care Manager. A Standard Operating Procedure (SOP) will be co-produced with prison staff following the publication of national guidance from HMPPS. HMPPS is developing national guidance for managing prisoners under the influence of illicit substances, which is currently in the consultation stage. Once agreed, the guidance will be rolled out via regional and local drug strategy leads, who will also develop local guidance and conduct assurance checks.