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 resultsThomas Huntley
All Responded
2023-0461
14 May 2023
Hampshire, Portsmouth and Southampton
HM Prison and Probation Service
Concerns summary (AI summary)
Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training and audit quality. Inadequate information sharing between healthcare and prison systems also posed significant risks.
Action Taken
(AI summary)
HMP Winchester delivers monthly ACCT v6 and SASH training, reviews staff training needs, reinforces ACCT procedures, facilitates multi-disciplinary discussions, and reviews the use of SIM forms. A review of ligature-resistant cells is also underway nationally.
Jai Singh
All Responded
2023-0094Deceased
15 Mar 2023
Birmingham and Solihull
Birmingham and Solihull Mental Health F…
Concerns summary (AI summary)
Multiple systemic failings, including communication breakdowns, insufficient family engagement, and repeated missed opportunities for inpatient admission, were compounded by the mental health team's lack of a psychiatrist and ongoing risk assessment documentation.
Noted
(AI summary)
NHS England acknowledges the concerns but states that matters relating to interpreters, communication, and family engagement are for local response. Regarding risk assessment documentation, NHS England states that risk assessments are carried out in line with NICE guidance and templates are available within SystmOne. Birmingham and Solihull Mental Health Trust has begun a 3-month pilot to ensure a Consultant Psychiatrist attends MDT meetings at the prison each week. A risk assessment template has been added to the SystemOne software accessible to Trust staff, and is being rolled out with a dissemination plan to ensure completion. TPP acknowledges the coroner's concerns, explains the capabilities of SystmOne, and states that it is working correctly. TPP defers to NHS England and local commissioners regarding specific configurations and usage of the system for mental health assessments in prisons.
Jason Williams
All Responded
2023-0039Deceased
2 Feb 2023
Dorset
HM Prison and Probation Service, NHS En…
Concerns summary (AI summary)
Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor prison staff record-keeping due to insufficient refresher training, compromised care.
Noted
(AI summary)
NHS England developed a training programme for Adult Safeguarding in Secure and Detained Settings in conjunction with HMPPS and HEE. The response also mentions a Ministry of Justice NPS toolkit. HMPPS will review and develop the key work model to improve safety and reduce reoffending, including making it more flexible. HMP Guys Marsh introduced an assurance check for weekly case notes and a weekly multi-disciplinary meeting to discuss and share information regarding drug ingress, issuing Governor's Notices and harm minimisation guidance as needed. The response refers to the Director General's letter which outlines the actions being taken at HMP Guys Marsh, such as introducing a Buddy scheme, writing local guidance, introducing an assurance check, and a weekly multi-disciplinary meeting.
Nathan Forrester
All Responded
2023-0035Deceased
31 Jan 2023
Inner South London
HM Prison and Probation Service, NHS En…
Concerns summary (AI summary)
Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR training and insufficient emergency airway equipment.
Noted
(AI summary)
NHS England commissions healthcare in prisons and ensures equivalence of care. They state that shortcomings in training have been addressed locally and all nurses in Oxleas NHS Trust are trained annually to ILS level. All reports received are discussed by the Regulation 28 Working Group. All new prison officers receive first aid training covering moving individuals for CPR, and manual handling training has been updated to a digital format. eLearning is available to all staff.
Andrew Shirley
All Responded
2023-0063Deceased
27 Jan 2023
Worcestershire
Various
Concerns summary (AI summary)
HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and did not adequately share information with prison staff. The Duty Governor also failed to make sufficient enquiries regarding health screens.
Action Planned
(AI summary)
Following Mr Shirley’s death, a thorough investigation into the care delivered by the Midlands Partnership Foundation Trust was undertaken. The Access Team call handler aide memoire has been updated. Practice Plus Group have healthcare staff being trained to deliver ACCT training. Training compliance at HMP Hewell is currently 88%, and further dates have been arranged to ensure full compliance by 31 March 2023. Training has also been delivered to all healthcare staff regarding the initial segregation health screen. HMP Hewell is delivering training sessions that incorporate both ACCT v6 and SASH training to all staff with the expectation that this will be completed by July 2023. HMP Hewell has developed Duty Governor guidance for managing the risk of segregation and delivered a training session to all Duty Governors in March 2023.
Joseph Price
All Responded
2023-0019Deceased
19 Jan 2023
County Durham and Darlington
NHS England
Concerns summary (AI summary)
Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health screenings, missing opportunities to identify and screen at-risk inmates.
Action Planned
(AI summary)
NHS England acknowledges the concerns and is refreshing the secondary health screening template to include a specific prompt for users to ask relevant questions relating to family history. All reports received are discussed by the Regulation 28 Working Group to ensure that key learnings are shared across the NHS.
John Henderson
All Responded
2023-0025Deceased
17 Jan 2023
Mid Kent and Medway
HM Prison and Probation Service, HMP Ro…
Concerns summary (AI summary)
There was no clear process for sharing critical medical information about prisoners with chronic conditions with frontline staff, leaving officers unaware of potential medical emergencies and appropriate responses.
Action Taken
(AI summary)
Oxleas NHS Foundation Trust has introduced a Personal Management Plan (PMP) in collaboration with HMPPS, which allows healthcare staff to share information with prison officers about prisoners with chronic conditions, including alerts on their NOMIS record and guidance for staff.
Floyd Carruthers
All Responded
2023-0006Deceased
5 Jan 2023
Birmingham and Solihull
Minister of State, HM Prison and Probat…
Concerns summary (AI summary)
Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, creating a gap in addressing non-violent injurious activity.
Action Taken
(AI summary)
HMP Birmingham issued a notice to staff about safeguarding and the need to take action when prisoners neglect their welfare. Safeguarding is now a standing item at weekly briefings, and trainers will emphasize self-neglect; a HMPPS training program on safeguarding will be available from December 2023. A learning bulletin will remind staff to identify and refer prisoners who appear to be self-neglecting.
Alexander Braund
All Responded
2022-0407Deceased
20 Dec 2022
Nottingham City and Nottinghamshire
HMP Nottingham, Forensic Services Notti…
Concerns summary (AI summary)
There are continuous failures in applying the NEWS2 system for acutely unwell patients in a secure setting due to insufficient training, guidance, and robust compliance auditing, risking deaths from unrecognized deterioration.
Noted
(AI summary)
TPP explains how the SystmOne electronic patient record system tracks amendments to consultations, stating that users are informed when an amendment has been made, by whom, and when, and that the audit trail is readily accessible. HMPPS has implemented a training program on medical emergency procedures for staff, including the use of emergency codes and cell entry protocols. A joint training event with healthcare staff was also held to improve care for acutely unwell prisoners, and weekly safety intervention meetings were introduced. The Trust has implemented compliance audit plans for NEWS2, is undertaking joint training with the prison service on several topics, and holds daily handover meetings to discuss prisoner clinical issues.
Lewis Johnson
Partially Responded
2022-0397
12 Dec 2022
West Yorkshire (Eastern)
HM Prison Wealstun
Ministry of Justice
Concerns summary (AI 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.
Action Planned
(AI summary)
HMPPS will update a training video for staff on emergency response, ligature use, and CPR (available Spring 2023). HMP Wealstun will resume FAW and EFAW training from April 2023, prioritizing night staff and custodial managers. HMPPS is reviewing the first aid policy and will update guidance on CPR commencement.
Lee Brown
All Responded
2022-0360
13 Nov 2022
East London
Department for Foreign, Commonwealth an…
Concerns summary (AI 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.
Action Taken
(AI summary)
The FCDO highlights updated training for consular staff, including mental health awareness, and clarifies the protocol for sharing information without consent when an individual's vital interests are at risk. They emphasize that the host state is responsible for the safety and security of individuals.
Michael Smith
Partially Responded
2022-0417Deceased
10 Nov 2022
County Durham and Darlington
Ministry of Justice
HM Prison and Probation Service
Concerns summary (AI 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.
Action Taken
(AI summary)
HMP Durham SACU staffing levels are above national benchmarking, overseen by a dedicated Custodial Manager. A full-time nurse is based within the SACU to provide more flexible healthcare input. HMP Durham will review its contingency plans to incorporate learning from this incident, to allow for appropriate deployment of staff should other incidents occur at the same time.
Liridon Saliuka
All Responded
2022-0355
8 Nov 2022
Inner South London
HMP Belmarsh
Oxleas NHS Trust
Concerns summary (AI 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.
Action Planned
(AI summary)
Oxleas NHS Foundation Trust will now document adjustments required for a patient's disability on the Prison Nomis (P-Nomis) system, accessible by prison staff, healthcare, and social services. A fortnightly meeting involving all providers has now convened allowing discussion of patients presenting with disability that may be of concern, to facilitate improved care planning and communication. HMP Belmarsh will be holding monthly training sessions throughout 2023, alongside Oxleas NHS Trust and RGB, for all operational staff. These sessions will focus on encouraging staff to think differently about disability and to improve how they engage with disabled prisoners.
Bradleigh Barnes
All Responded
2022-0332
24 Oct 2022
Dorset
HMPPS
HMP YOI Portland
NHS England
+1 more
Noted
(AI summary)
A memorandum of understanding has been put in place between healthcare and the prison regarding attendance of healthcare and all planned use of force interventions and healthcare staff are to be trained alongside prison officers. NHS England will request assurance from regional Directors of Commissioning that actions regarding the use of the PSA (proactive systematic assessment) vital signs tool have been implemented and evidenced by April 2023. They will also work with HMPPS on their review of PSO 1600: Use of Force, providing clinical leadership on section 6. HMPPS implemented a memorandum of understanding with the new healthcare provider at HMP Portland regarding the role of healthcare during use of force incidents. Whitewood furniture beds have replaced metal bedframes at HMP Portland. The Governor of HMP Portland confirms their involvement in the HMPPS response to the Regulation 28 report.
Carl Langdell
Partially Responded
2022-0331
21 Oct 2022
West Yorkshire Western
HMP Wakefield
Ministry of Justice
Concerns summary (AI 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.
Action Planned
(AI summary)
HM Prison and Probation Services conducted pilots across the prison estate, testing alternatives to the current wet shave provision, to be evaluated in Spring 2023.
Robert Evans
All Responded
2022-0322
18 Oct 2022
Swansea and Neath Port Talbot
HMP Swansea
Concerns summary (AI 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.
Action Planned
(AI summary)
HM Prison and Probation Services is drafting a new HMPPS Policy Framework, updating the policy for prisons to follow in the event of a death in custody, including guidance to ensure that staff who have relevant information are identified and prompted to make a record of this at an early stage.
Gary McDonald
Partially Responded
2022-0291
20 Sep 2022
Worcestshire
HMP Hewell
Practice Plus Group
Concerns summary (AI summary)
The report identifies that, despite a prisoner's GP records showing a history of depression and overdoses, no appointment was made to follow up or discuss his mental health.
Action Taken
(AI summary)
Practice Plus Group has implemented changes to the Early Days in Custody (EDiC) pathway. This includes ensuring patients are provided with another opportunity to discuss their current position with a member of the healthcare team if there are discrepancies in their records.
Allan Waddup
All Responded
2022-0343
10 Aug 2022
North Northumberland and South Northumberland
Tees, Esk and Wear Valley NHS
Concerns summary (AI 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.
Action Taken
(AI summary)
Appointment letter templates have been reviewed and updated and have now been introduced across all prison establishments, including HMP Northumberland, to notify inmates of planned appointments. Also, the prison service provider at HMP Northumberland has granted the request to remove the ability to refer to mental health services via kiosk and posters have been produced and displayed on the wings providing information about how to refer to the mental health team.
Nigel Saunders
All Responded
2022-0300
3 Aug 2022
Nottinghamshire and Nottingham
HMP Lowdham Grange
Concerns summary (AI 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.
Noted
(AI summary)
HMP Lowdham Grange has updated its DIC checklist to include the Oscar Journal. The use of ACCT tick sheets has been discontinued and all records are contained within the ACCT book. This is a response from a coroner to HMP Lowdham Grange, acknowledging the measures taken and suggesting further alignment with Chief Coroner guidance on disclosure.
Ezra Tamiem
Historic (No Identified Response)
2022-0220
19 Jul 2022
Bedfordshire and Luton
HMP Bedford
HMPPS
Concerns summary (AI 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.
Khalid Abiaz
All Responded
2022-0184
20 Jun 2022
Manchester South
HMP Swansea, Ministry of Justice and Sw…
Concerns summary (AI 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.
Action Planned
(AI summary)
Swansea Bay University Hospital will ringfence two slots per ACCT training session for Health Board staff and will roster health staff to attend ACCT Awareness training as a priority. Health Board bank staff will no longer undertake the reception or screening function unless they are key trained. HM Prison and Probation Service rolled out ACCT version 6 across the prison estate and has produced and delivered training materials to support staff understanding. Fifteen staff members received the new training module, and the Governor has issued guidance on risk identification. The Governor has also requested that bank nurses are not deployed in the reception area of the prison.
Saifur Rahman
All Responded
2022-0155
26 May 2022
Birmingham and Solihull
Birmingham and Solihull Mental Health N…
Ministry of Justice
Concerns summary (AI 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.
Action Taken
(AI summary)
BSMHFT states that it had already updated the sampling of cells under the Ligature Risk Assessment to enable greater coverage of cells from year to year, and to generate an audit trail for those cells which had been viewed in previous years. They have asked for a formal process with the prison to be placed on the agenda for the Local Delivery Board meeting. HMPPS reports that HMP Birmingham has undertaken initiatives to maintain staff awareness of medical emergency procedures, including safety talks and signage. The Governor has reviewed the local medical emergency response code protocol to ensure up to date training for all staff which is currently in progress. A central record of cell fabric history has been implemented and the prison maintenance database has been updated. A formalised process for cell ligature risk assessments is underway with the Health and Safety team, in partnership with the NHS.
Jamie Bennett
Response Pending
2022-0136
South Yorkshire (West)
Practice Plus Group
The Ministry of Justice, Justice and De…
Concerns summary (AI summary)
Lack of clear instructions for welfare checks, unclear task responsibility for agency night staff, and absent audit processes risk inadequate patient supervision and future deaths.
Action Taken
(AI summary)
Practice Plus Group has updated its Naloxone disclaimer form to clarify risks of refusal and revised its information-sharing process for patients discharged from HMP Moorlands, implementing new clinical handover templates and quality assurance for discharge summaries.
Nicholas Rose
All Responded
2022-0106
7 Apr 2022
Dorset
HMP Guys Marsh Prison
Concerns summary (AI 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.
Action Taken
(AI summary)
HMP Guys Marsh has republished notices to staff and prisoners regarding the requirement for verbal responses during welfare checks, with compliance checks by wing Custodial Managers, and has introduced toolbox talks for Prison Officers, including training on welfare checks.
Ketheeswaren Kunarathnam
All Responded
2022-0030
26 Jan 2022
West London
Home Office
Concerns summary (AI 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.
Action Taken
(AI summary)
The Home Office outlines actions taken to address concerns, including mandatory training for officials engaged in detention, focusing on best practice and vulnerability, and Self Harm Awareness Sessions run by HMPPS for front-line immigration officers in prisons. They also highlight improvements to the Adults at Risk in Immigration Detention policy and the introduction of Detention Case Progress Panels.