State Custody related deaths

Concerns summary Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent CPR training among prison officers due to resource limitations.

Concerns summary A vulnerable child was sentenced without forensic psychiatric assessment, and mental health support conflicted with disciplinary procedures, failing to adopt a holistic approach or consult outside agencies. A social worker allocation was also significantly delayed.

Concerns summary The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training for night-time assessments and inconsistent recording of critical healthcare information.

Concerns summary There was a clear breakdown in mental health information sharing within ACCT reviews, where mental health input was not sufficiently weighted and members often relied on potentially misleading face-to-face assessments without reviewing documentation.

Concerns summary Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of clear guidance for staff on when and how to commence CPR.

Concerns summary Significant confusion exists among prison staff, including GPs, regarding emergency ambulance procedures and death verification, leading to inappropriate actions and potential fatal delays.

Concerns summary A prison officer's failure to check a prisoner's well-being during unlocking, combined with a lack of recorded compliance with physical response requirements during roll checks, risks missed deaths.

Concerns summary Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.

Concerns summary Insufficient night staffing on prison healthcare wards compromised effective ACCT observations and overall prisoner care. Additionally, staff were not taking breaks, impacting their wellbeing and the quality of care provided.

Concerns summary A significant reduction in prison officer numbers at HMP Woodhill directly compromises prisoner safety and poses a risk to lives.

Concerns summary Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health risks are not routinely or thoroughly assessed upon return from court, leaving significant gaps in their care and safety.

Concerns summary Concerns raised regarding the need for improved emergency communication training for nursing staff and a more robust dynamic assessment process for prisoner restraint, with potential for further CCTV installation.

Concerns summary A pervasive lack of professionalism, leadership, and appropriate training in the custody suite led to an unacceptable culture and inadequate control over staff behavior with vulnerable detainees.

Concerns summary The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.

Concerns summary Concerns were raised about the appropriateness and justification of tasering the deceased, given discrepancies in officer accounts. Unjustified tasering unnecessarily increases the risk of serious injury or death.

Concerns summary GMP policy of not staffing the Prisoner Processing Unit overnight leads to unnecessary and prolonged custody times for individuals awaiting interview.