State Custody related deaths

Concerns summary Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.

Concerns summary Prison discipline and healthcare staff exhibited confirmation bias regarding drug use, leading to inadequate investigation, poor record-keeping, insufficient training on new psychoactive substances, and a lack of clear escalation protocols for medical emergencies.

Concerns summary Healthcare staff require improved training on *when* to make referrals. Additionally, concerns about detainees are not simultaneously reported to healthcare managers, hindering joint working and risking critical issues being missed.

Concerns summary Welsh prisons lack an integrated treatment system, failing to automatically offer opiate substitution therapy to new arrivals addicted to opiates, creating an inequality in healthcare provision compared to England.

Concerns summary The prison service demonstrated a reduced capacity for self-harm risk assessment, with failures in re-evaluating risk after significant patient changes, providing adequate pain management, and informing new wings of altered risk profiles.

Concerns summary A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient understanding of autistic prisoners' needs pose significant risks.

Concerns summary Failures in checking medical records upon prison admission led to missed antidepressant medication, exacerbated by staff shortages, heavy workloads, and the absence of a "red flag" warning system for suicide risk.

Concerns summary Critical prisoner information from different systems (NOMIS, medical, security) was not consistently accessible to all prison staff, highlighting a systemic failure in information sharing.

Concerns summary Prison staff lacked accessible, up-to-date training records for critical safety procedures (ACCT & SASH), indicating a national issue with tracking and ensuring current staff competence.

Concerns summary The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, unpopulated summary sections, and a non-functional keyword search.

Concerns summary Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.

Concerns summary There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.

Concerns summary Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT training meant officers lacked understanding of their crucial responsibilities.

Concerns summary Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.

Concerns summary Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of future deaths.

Concerns summary The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care practices, or national guidance documents like ACCT.

Concerns summary ACCT reviews in prison were frequently held without healthcare staff present, and relevant information from prior ACCTs was not consistently used when new ones were opened.

Concerns summary Prison staff lacked training in recognising and responding to opiate overdose, including Naloxone administration. Naloxone was not readily available in all risk areas, and no clear local protocol existed for its use.

Concerns summary A lack of consistent case management for the ACCT process resulted in fragmented oversight, inadequate care planning, and critical information about the deceased's deteriorating mental state and specific concerns not being recorded.

Concerns summary Inadequate resuscitation efforts by prison nurses included failure to continuously check breathing for 11 minutes and insufficient oxygenation, alongside conflicting assessments of the patient's body temperature.

Concerns summary Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal ACCTs.

Concerns summary The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug misuse.

Concerns summary E-cigarettes in prison are being misused as heating devices for drug preparation, highlighting a significant safety risk related to both illicit drug use and potential fires.

Concerns summary Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.