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 results
Idris Habib
All Responded
2022-0020 24 Jan 2022 Mid Kent and Medway
HMP Swaleside
Concerns summary (AI 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.
Action Taken (AI summary) HMP Swaleside issued a notice in November 2021 reminding staff of cell clearance procedures and reinforced the process during staff briefings. Since the inquest, the prison has introduced a welfare check at approximately 8am requiring staff to gain a verbal response from the occupant, with completion of the check recorded in the wing assurance book, with staff re-issued a notice to remind them to satisfy themselves of the prisoner's wellbeing.
Thomas Moffett
Partially Responded
2022-0018 22 Jan 2022 Lancashire and Blackburn with Darwen
HMP Preston HMPPS
Concerns summary (AI 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.
Action Taken (AI summary) Spectrum CIC has held a meeting between the healthcare team, the Safer Custody Governor, and the Governing Governor at HMP Preston to develop a new system that ensures that healthcare staff are able to communicate efficiently with the prison control room and ambulance control. HMP Preston staff are to receive training in ambulance categorisation and the Governing Governor sent a Governor's Order clarifying the process in line with PSI 03/2013.
Ian Miller
Partially Responded
2022-0001 5 Jan 2022 Gwent
HM Prison Usk Ministry of Justice
Concerns summary (AI 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.
Action Taken (AI summary) The prison updated its prisoner induction process in January 2022 to include information on in-possession medication, the dangers of misusing prescription drugs, and instructions to report concerns. Guidance was issued to staff in January 2022 on identifying risks, amnesty bins have been added to wings, and random medication checks have increased to 10% of the prison population.
Kyle Nel
All Responded
2021-0426 22 Dec 2021 Dorset
HMP Guy’s Marsh and Prisons and Probati…
Concerns summary (AI 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.
Action Taken (AI summary) HMPPS replaced the Custodial Violence Management Model with the Challenge, Support and Intervention Plan (CSIP), a violence reduction case management model, and HMP Guys Marsh has a dedicated drug strategy manager in place since Autumn 2021 as part of the accelerator project.
Saul Thomas
All Responded
2021-0423 21 Dec 2021 Worcestershire
HMP Birmingham
Concerns summary (AI 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.
Action Planned (AI summary) HMP Birmingham plans to train 80% of staff in suicide and self-harm (SASH) over the next six months, prioritizing high-risk areas and ensuring new staff receive SASH training; a new handover process is in place for prisoners transferring with healthcare needs. HMP Hewell delivered training to 205 staff in the latest version of ACCT in December 2021 and is working to train a larger percentage of staff.
Martin Brown
All Responded
2021-0417 15 Dec 2021 Lancashire and Blackburn with Darwen
HMP Lancaster Farms
Concerns summary (AI 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.
Action Taken (AI summary) Spectrum has developed an Emergency Response in Custody (ERIC) presentation and has been delivering training sessions to prison staff since January 2022. They have also implemented a system using a spare radio net for healthcare staff to communicate directly with the prison's communications room during medical emergencies, which went live on January 31st after a successful trial. The prison has distributed ERIC cards to all staff and commenced additional ERIC training delivered by the Head of Healthcare, with new staff receiving this training as part of their induction. A new radio channel process has been implemented for healthcare staff to communicate with the control room and ambulance service during emergencies.
Connor Hoult
All Responded
2021-0405 30 Nov 2021 West Yorkshire (Eastern)
HMP Wakefield and Minister of State for…
Concerns summary (AI 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.
Action Taken (AI summary) HMP Wakefield issued a Governor’s Order in January 2020 regarding verbal responses during roll checks and unlocking procedures. The Governor has now circulated a Notice to Staff reminding them to assure themselves of prisoners' wellbeing during unlock, and the concerns will be discussed with relevant staff.
Robert Ellery
All Responded
2021-0390 19 Nov 2021 South Wales Central
HM Prison Cardiff
Concerns summary (AI 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.
Action Taken (AI summary) HMP Cardiff has devised a Local Operating Protocol and will pilot a mobile phone carried by officers to enable direct communication with the Welsh Ambulance Service.
Christian Hinkley
All Responded
2021-0376 4 Nov 2021 Mid Kent and Medway
Minister of State for Prisons and Proba…
Concerns summary (AI 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.
Action Taken (AI summary) HMPPS is investing £315m to improve fire safety, including in-cell fire detectors, portable fire detection devices, water mist firefighting equipment, and smoke ventilation fans. Cell fire response training was revised in December 2021 to include scenarios for obstructed inundation ports.
Fishmongers’ Hall Inquests
All Responded
2021-0362 3 Nov 2021 London City
College of Policing Department for Education Home Office +7 more
Concerns summary (AI summary) This document is a questionnaire for the jury, intended to determine the means and circumstances by which Jack Merritt and Saskia Jones died, focusing on identifying any errors, omissions, or circumstances that may have caused or contributed to their deaths.
Noted (AI summary) The Learning Together Network CIC states it cannot take steps on the recommendations as it did not employ staff or run partnerships, and will be dissolved in January 2022. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders. The Office for Students will write to all registered higher education providers in England, making them aware of the report and asking them to consider changes to their approach to risk assessment of events, programmes, and information sharing. The College of Policing acknowledges the concerns raised and states its commitment to supporting other bodies in achieving improvements in terrorist offender management. They provide broader offender management training products and guidance and will work with partners to ensure they are updated. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders and now feed this into the MAPPA panel. MoJ accepted recommendations relating to the Fishmongers' Hall attack. A new framework is being designed for Learning Together activity in prisons. Statutory guidance on MAPPA meetings will be strengthened, and the Police, Crime, Sentencing and Courts Bill includes a power for police to search terrorist offenders on licence. The University of Cambridge has created a new policy and guidance for staff and students working with people who have offended, and the Institute of Criminology has developed a Risk Assessment Form for all activities. The University has also stopped delivering the Learning Together programme. The government is legislating a new power of personal search through the Police, Crime, Sentencing and Courts Bill, allowing police to stop and search terrorist offenders on license under certain circumstances. The Secretary of State will engage with the higher education sector to encourage action to implement the recommendations and officials have spoken to the Office for Students to encourage them to take action. Officials have also engaged with HMPPS to design a new framework to define roles and responsibilities of prisons and higher education providers.
Anthony Clacher
All Responded
2021-0356 22 Oct 2021 Dorset
Department of Health and Social Care HM Prison and Probation Service NHS England and NHS Digital
Concerns summary (AI 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.
Noted (AI summary) NHS England highlights that the Digital Person Escort Record (DPER) has been live across the prison estate since November 2020, and all reception healthcare staff should have access to the DPER prior to arrival of persons at the site; further a review and update of the reception and secondary screening templates for healthcare is ongoing. NHS Digital is considering the coroner's concerns about SystmOne in prisons when developing the capabilities for the HJIS re-procurement in 2022/23 and will consider adopting GP IT related products such as GP2GP and the Primary Care Registration Management system in FY22/23. The Department of Health and Social Care acknowledges the concerns raised, highlights the National Partnership Agreement for Prison Healthcare, and notes actions NHS England is taking regarding substance misuse in prisons. HMPPS is considering a national rollout of local initiatives (including those from HMP Guys Marsh) to improve welfare checks on prisoners under the influence of psychoactive substances, and is developing a new version of the ACCT (Assessment, Care in Custody and Teamwork) processes with revised training modules being rolled out nationally for all staff involved in the delivery of ACCT.
Richard Franks
All Responded
2021-0355 21 Oct 2021 West Yorkshire Eastern
David Ake & Co Solicitors
Concerns summary (AI 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.
Action Planned (AI summary) The solicitors will ensure that they remind appropriate organisations each time a threat to self-harm is repeated.
Caden Stewart
All Responded
2021-0328 4 Oct 2021 Mid Kent and Medway
HMYOI Cookham Wood
Concerns summary (AI 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.
Action Taken (AI summary) In September 2021, HMP Cookham Wood issued a Notice to Staff reminding PE staff of PSI 58/2011 requirements and introduced daily roll books to record time spent in activities and healthcare requests. The logs provide for comments to be added and ‘guidance prompts’ are now in place which outline the importance of providing this information so that it is available to all staff.
Stephen Cope
Partially Responded
2021-0332 30 Sep 2021 Inner London South
Department of Health and Social Care HMP Belmarsh Ministry of Justice +1 more
Concerns summary (AI 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.
Action Planned (AI summary) HMPPS implemented a revised version of ACCT in July 2021 that focuses on a person-centred approach, information sharing, improved case reviews and a strengthened post-closure period and shared a learning bulletin about transferring prisoners on an open ACCT which emphasises the importance of good communication and information-sharing. The Department of Health and Social Care is working with partners on the next version of the National Partnership Agreement (NPA) for Prison Healthcare, due in April 2022. NHS England is also reviewing the ACCT process in prisons and healthcare attendance, with findings anticipated in early 2022.
Charlie Todd
All Responded
2021-0318 21 Sep 2021 County Durham and Darlington
HMP Durham
Concerns summary (AI 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.
Action Taken (AI summary) HMP Durham has provided additional officer and administrative resources to the Separation and Care Unit (SACU). A "Know Your Job" sheet will be provided to staff working on the unit, and a SACU pilot will consider operational processes and health support.
Colin Blackburn
Partially Responded
2021-0311 17 Sep 2021 Worcestershire
HMP Hewell Practice Plus Group
Concerns summary (AI 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.
Action Taken (AI summary) Practice Plus Group, in conjunction with MPFT, has taken several actions including ensuring all staff at HMP Hewell are aware of processes to ensure prisoners receive urgent mental health care at weekends, an Out of Office message has been added to the mental health team’s generic email inbox at weekends and an answer phone has been purchased for the mental health team.
Lee Thrumble
Historic (No Identified Response)
2021-0304 10 Sep 2021 Mid Kent and Medway
Department of Health and Social Care
Concerns summary (AI summary) Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.
Carl Walters
All Responded
2021-0256 28 Jul 2021 Exeter and Greater Devon
HMP Exeter
Concerns summary (AI summary) The failure to preserve key evidence hindered the inquest, raising concerns that dangerous conditions could go undiscovered and preventative measures overlooked.
Action Taken (AI summary) HMP Exeter created a local operating policy for deaths in custody, including a list of essential documents to retain (cell bell records, CCTV, body-worn video). A new CCTV system has been installed, and all deaths in custody are subject to a quick-time learning review by the Head of Safety and Regional Groups Safety Lead.
Joanna Daly
All Responded
2021-0245 16 Jul 2021 West Yorkshire (Eastern)
Ministry of Justice
Concerns summary (AI 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.
Action Taken (AI summary) HMP New Hall introduced new processes in July 2021 to improve the quality of welfare checks, including requiring a response from residents in the First Night Centre and clarifying the purpose and requirements of the checks in a notice to staff and local operating instructions.
Khairul Rahman
Partially Responded
2021-0226 2 Jul 2021 Inner London North
Head of Healthcare) and HMP Pentonville
Concerns summary (AI 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.
Action Planned (AI summary) Practice Plus Group has begun a service improvement project to encourage the appropriate use of NEWS2 scoring and embedding this into practice, including a ‘Back to Basics’ workshop on ‘Identifying the Deteriorating Patient’ for the healthcare team at HMP Pentonville by 30th November 2021.
Wayne Boughen
Partially Responded
2021-0217 23 Jun 2021 West Yorkshire Eastern
Government Legal Department HMP Leeds
Concerns summary (AI 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.
Action Taken (AI summary) HMPPS acknowledges the lack of certified safer cells at HMP Leeds but highlights the improvements made to the ACCT (Assessment, Care in Custody and Teamwork) system. All staff at the prison have received awareness training specific to their roles and responsibilities and to highlight the key changes to the procedures.
Serena Nicolle
Historic (No Identified Response)
2021-0212 22 Jun 2021 Surrey
Ministry of Justice
Concerns summary (AI 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.
Geoffrey Hutton
All Responded
2021-0191 4 Jun 2021 Worcestershire
HMP Long Lartin
Concerns summary (AI 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.
Action Taken (AI summary) HMP Long Lartin reviewed its adult safeguarding policy, is working on a memorandum of understanding with Worcestershire County Council, and is developing a directory of interventions for staff. They are implementing a new database for allocating ACCT Case Coordinators and making SASH training mandatory for OSGs.
Mark Culverhouse
All Responded
2021-0189 2 Jun 2021 Milton Keynes
Ministry of Justice
Concerns summary (AI 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.
Disputed (AI summary) HMPPS does not consider it possible to comply with the recommendation to calculate release dates prior to a recall decision due to complexities, staffing constraints and potential risks. They will however issue further communication to staff about using alerts on NOMIS to flag prisoners with unspent remand time.
James Devenny
All Responded
2021-0179 25 May 2021 Mid Kent and Medway
HMP Elmley and Director General – Priso…
Concerns summary (AI 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.
Action Taken (AI summary) HMP Elmley has equipped nearly all cells with in-cell phones and ensures access to Samaritans. ACCT version 6 has been rolled out across the male estate and training modules and awareness materials have been made available to all staff. The prison also operates a Key Worker scheme and uses an updated safety diagnostic tool.