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).

Responded 263 No Response 11 Historic 80 Pending 2

Action Taken 58%

Action Planned 27%

Noted 14%

Disputed 0%

Based on 401 classified responses

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PFD Reports

161 results

Peter Mackie

2014-0528 5 Dec 2014 Buckinghamshire

Springhill Prison

Concerns summary (AI 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.

Action Planned (AI summary) HMP Grendon and Springhill are working to increase the number of trained first aid staff, a new risk assessment will be completed to ensure appropriate levels of staff are identified to provide 24 hour cover and staff will receive written advice on when to commence CPR by 31 January 2015.

William Davies

2014-0475 5 Nov 2014 London Inner (North)

Care UK Limited

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

Action Taken (AI summary) Care UK has re-briefed control room staff, created a crib sheet for ambulance calls, launched a publicity campaign on emergency response codes, and improved intranet information and signage. The National Medical Director clarified GPs' responsibilities regarding verifying death, and guidance/training is being developed to support decision-making in unexpected collapse or death cases.

Vincent Oliver

2014-0438 9 Oct 2014 Northumberland (North)

HMP Northumberland

Concerns summary (AI 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.

Action Taken (AI summary) HMPS Northumberland has introduced a written system for recording wellbeing checks of prisoners throughout the day, with wing diaries amended to reflect the change.

Satheeskumar Mahatheaven

2014-0412 19 Sep 2014 London Inner (North)

HMP Pentonville

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

Action Taken (AI summary) HMP Pentonville and HMP Thameside have implemented local policies to ensure appropriate information sharing and effective communication between prison staff and healthcare providers. Community GP records are now routinely requested in all cases with health concerns, and all new healthcare staff are shown how to use the SystmOne electronic record system correctly.

Yohannes Kidane

2014-0392 3 Sep 2014 Birmingham & Solihull

Birmingham and Solihull Mental Health T… Birmingham Prison

Concerns summary (AI 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.

Noted (AI summary) NOMS reviewed the night staffing level for HMP Birmingham and found it acceptable, noting G4S's deployment of a Prison Custody Officer. They state that the Night Orderly Officer arranges cover for breaks, and additional staff are provided for prisoners under continuous supervision. The Trust has liaised with Birmingham Community Healthcare Trust and G4S to address staffing concerns and is considering options for staff breaks, including administrative duty sharing. They are engaging the commissioner regarding funding for an extra staff member and have met with G4S to discuss non-clinical duties.

Sean Brock

2014-0381 8 Aug 2014 Milton Keynes

National Offender Management Service

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

Noted (AI summary) HMP Woodhill staffing levels have been benchmarked and agreed upon, with ongoing local and national recruitment efforts to address vacancies. Information sharing between prison staff and contractors is a priority.

Marcin Stoga

2014-0576 21 Jul 2014 Oxfordshire

Concerns summary (AI 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.

Action Planned (AI summary) HM Prison and Probation Service is trialling revised Prisoner Escort Records including a 'Red Flag' page to highlight key risk/vulnerability information. They also highlight existing protocols for screening prisoners returning from court for healthcare or self-harm issues.

Adam Williams

2014-0324 14 Jul 2014 Staffordshire (South)

HMP Featherstone

Concerns summary (AI 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.

Action Taken (AI summary) HMP Featherstone now requires two healthcare staff to attend all health emergencies called over the radio. Duty Managers have received advice and guidance on emergency escorts, and this issue is regularly reviewed by the Senior Management Team.

Lloyd Butler

2014-0281 25 Jun 2014 Birmingham & Solihull

West Midlands Police

Concerns summary (AI 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.

Action Taken (AI summary) West Midlands Police instigated misconduct procedures against officers and staff involved, resulting in disciplinary sanctions. They have provided clear guidance on dealing with individuals arrested for being drunk and incapable, directing that they be treated as a medical emergency and taken directly to hospital.

Kevin Scarlett

2014-0174 15 Apr 2014 Milton Keynes

National Offender Management Service

Concerns summary (AI 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.

Action Taken (AI summary) HMP Woodhill reviewed the local ACCT process in December 2013, revised the case review process, and issued guidance to staff. A governor grade is appointed to manage the case of each prisoner subject to the ACCT process who is assessed as having complex needs.

David Oldfield

2014-0117 14 Mar 2014 West Yorkshire (East)

West Yorkshire Police Force

Concerns summary (AI 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.

Noted (AI summary) West Yorkshire Police acknowledge the concerns raised, particularly regarding officer accounts, and state that the IPCC was informed. They also offer a visit to their training facilities to demonstrate Taser training and usage.