State Custody related deaths

Concerns summary HMP Wealstun lacks night-time healthcare staff, and prison officers are inadequately trained in CPR and defibrillator use for self-harm incidents, compounded by a missing policy directive for immediate resuscitation.

Concerns summary There's a lack of emergency access protocols for consular officers to detained British nationals, especially those in mental health crisis. FCDO travel advice is insufficient regarding the specific consequences of detention in Dubai.

Concerns summary Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable prisoner. A delay in emergency response due to staffing shortages also put his life at risk.

Concerns summary There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.

Concerns summary A patient with chronic suicide risk was observed deteriorating after refusing medication. There is a systemic concern regarding items prisoners can possess in their cells overnight, and a national proposal is underway to remove identified risks.

Concerns summary HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately captured after a death, hindering investigations and preventing lessons from being learned.

Concerns summary Prison healthcare failed to follow up on significant discrepancies between a prisoner's self-reported mental health and his GP records, particularly concerning past suicide attempts, leaving him vulnerable in early custody.

Concerns summary Mental health services at HMP Northumberland failed to ensure inmates received appointment notifications, leading to discharge without assessment. The "Did Not Attend" policy lacked in-person follow-up before discharge, and urgent weekend referrals were not triaged.

Concerns summary The prison repeatedly failed to retain and preserve crucial evidence following deaths in custody, undermining investigations and preventing lessons from being learned, indicating a serious local systemic issue.

Concerns summary A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without plans for remedy.

Concerns summary A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.

Concerns summary Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose significant ongoing safety risks.

Concerns summary Accepting a "grunt" as a verbal response during prison welfare checks is insufficient for assessing a prisoner's true welfare, potentially missing signs of distress or incapacitation.

Concerns summary Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.

Concerns summary Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' actions.

Concerns summary Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across multiple prisons, indicate a potential national systemic problem.

Concerns summary A lack of secure medication management in prison, where prisoners controlled their own drugs, led to widespread trading of prescribed medication, posing a significant risk to prisoner safety.

Concerns summary The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known security flaws with fences enabling drug transfers between units.

Concerns summary A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included in handovers between prisons, posing a risk of future deaths.

Concerns summary Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and ambulance services, and communication between emergency responders and the control room was inadequate.

Concerns summary Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing asleep, risking missed signs of distress or concerns.

Concerns summary The prison control room delayed relaying critical information to the ambulance service, and a lack of direct communication between emergency operators and prison first responders hindered resuscitation efforts.

Concerns summary Prison fire detection systems are inadequate and unable to reliably detect cell fires early enough to save lives. Despite repeated warnings and notices issued since 2015, in-cell automatic fire detectors remain uninstalled.

Concerns summary The provided text outlines jury instructions for determining the means and circumstances of death, rather than detailing specific coroner's concerns regarding systemic failures or safety issues for future prevention.