State Custody related deaths

Concerns summary A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses significant risks of physical and mental health deterioration, including death.

Concerns summary Critical information regarding a prisoner's suicidal intent expressed at court was not communicated to prison staff, leading to inadequate monitoring and a lack of necessary support measures.

Concerns summary Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding a prisoner's unwell status and need for healthcare, leading to missed checks and handovers.

Concerns summary The rapid closure of an ACCT for newly transferred prisoners, often based on minimal review, poses a risk as it fails to allow adequate time for staff to assess and understand the individual's needs.

Concerns summary A lack of supervisory oversight, inadequate staffing, and a manual, untracked system for hourly checks in the SACU led to incomplete observations and a failure to ensure prisoner safety.

Concerns summary Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient observations, exacerbated by high demands and inadequate training, leading to significant risks of suicide/self-harm.

Concerns summary Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.

Concerns summary The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and preventative measures overlooked.

Concerns summary Prison staff conducting welfare checks on vulnerable first-night prisoners lack specific guidance, raising concerns about the quality and effectiveness of these critical observations.

Concerns summary The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.

Concerns summary HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for self-harm in an ordinary cell.

Concerns summary The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading to erroneous assessments and a risk of future deaths.

Concerns summary HMP Long Lartin lacked effective systems for social care referrals and allocating ACCT Case Managers, resulting in insufficient oversight of vulnerable prisoners and inadequate staff training.

Concerns summary A prisoner was unlawfully detained due to a system failure where release dates were calculated after recall decisions, leading to unnecessary imprisonment, particularly over bank holidays.

Concerns summary Prisoners lack direct access to Samaritans, relying on staff, which is especially difficult for those with violence risks. Prison officers are not routinely briefed on prisoners' significant self-harm history.

Concerns summary HMP Dartmoor failed to open a mandatory ACCT for a self-harming prisoner, indicating inadequate training, and an ambulance was dangerously delayed at the prison gate during an emergency.

Concerns summary A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information about the patient's condition to emergency services, highlighting a gap in following emergency protocols.

Concerns summary Poor hygiene in non-clinical prison healthcare areas creates infection risks. A systemic failure allowed a senior house officer to miss a critical post-surgery VTE risk assessment, indicating a broader protocol adherence issue.

Concerns summary Nursing staff misdiagnosed post-mortem conditions due to inadequate training in identification, and resuscitation guidance documents contained confusing definitions, risking proper emergency response.

Concerns summary The prison lacked an efficient, tested system for emergency ambulance exit, leading to delays in transferring a seriously ill prisoner to hospital.

Concerns summary National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.

Concerns summary Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. This creates a potential for prisoners to self-harm.

Concerns summary HMP Belmarsh's immediate needs form inadequately assesses self-harm risk for new prisoners without existing care plans. The nightly roll check system lacks robust auditing, risking missed checks and compromising prisoner safety.

Concerns summary The Laurel Ward's scalable perimeter fence and dense, unsearched shrubbery facilitated repeated absconding and concealment of dangerous items, compounded by a lack of observation and CCTV in the garden.

Concerns summary Redundant television brackets in prison cells, including the deceased's, remain as obvious ligature points, posing a significant ongoing risk.