State Custody related deaths

Concerns summary Delayed prison cell bell responses, lack of a system to track bell activation times, and inadequate post-incident review contributed to a prisoner's death.

Concerns summary HMP Rye Hill's healthcare was inadequately resourced and unprepared for its re-roll to house sex offenders, resulting in substandard patient care. This raises concerns about similar risks in future national prison re-rolls.

Concerns summary Insufficient staffing levels at HMP Wormwood Scrubs prevent the implementation of a nominated Officer scheme, despite prior recommendations, impacting prisoner welfare and safety.

Concerns summary Many prison cell doors lack anti-ligature strips due to an absent retrofit program. Furthermore, the ACCT process lacks a structured national pro forma, leading to inconsistent risk assessments and over-reliance on current prisoner demeanour.

Concerns summary Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.

Concerns summary Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and lapsed prescriptions, and there was no policy for constant medical supervision for high-risk prisoners.

Concerns summary The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in reception and care areas within prisons.

Concerns summary A disabled prisoner's essential daily living needs were unmet as the prison environment lacked adaptations and no care provider took responsibility for vital 'social services' support.

Concerns summary Critical medication doses were missed, VTE risk assessments were incomplete, and an inadequate hospital discharge summary failed to communicate essential treatment plans to prison healthcare, compounded by a risky late Friday discharge.

Concerns summary Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly call emergency services.

Concerns 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.

Concerns 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.

Concerns summary Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.

Concerns 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.

Concerns summary A critical failure to complete a cell sharing risk assessment for an epileptic prisoner, coupled with widespread staff unfamiliarity and unclear communication regarding such assessments, created an unsafe cell allocation system.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.

Concerns summary Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.

Concerns summary Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.

Concerns summary Older prisoners lacked appropriate access to speech and language therapists to assess and manage swallowing difficulties, including recommendations for diet and fluid intake.