State Custody related deaths

Concerns summary Prison healthcare suffered from inadequate medical monitoring, substandard care, and a lack of emergency protocols, compounded by fragmented responsibility across multiple agencies with poor communication and separate IT systems.

Concerns summary Fragmented prison healthcare failed to obtain medical history, create care plans, or assign a single clinician, missing opportunities to diagnose cancer and cancelling vital appointments due to resource shortages across multiple agencies with separate databases.

Concerns summary Ambulance crews attending the prison lack access to the main radio system, and the first response to emergencies does not consistently include a fully qualified paramedic, impacting effective communication and care.

Concerns summary A significant gap in mandatory basic life support training for prison officers employed during a specific period leads to delayed CPR, with no retrospective training efforts to rectify this.

Concerns summary HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.

Concerns summary The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk information pose significant safety concerns.

Concerns summary The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid training.

Concerns summary Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration between prison and healthcare services.

Concerns summary Concerns remain that policies for medical emergencies in state custody, outside of Code Red/Blue scenarios, lack input from an emergency medicine expert, potentially missing cases requiring immediate hospital transfer.

Concerns summary There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.

Concerns summary Critical self-harm risk information for incoming prisoners is poorly shared between external agencies, prison, and healthcare. Systemic gaps in IT and manual communication methods mean vital data is not consistently accessible to staff.

Concerns summary Concerns exist regarding the content of police training for restraint and Appropriate Adult responsibilities. Criteria for identifying and transporting individuals to a place of safety under MHA 1983 also require review.

Concerns summary The ACCT process at HMP Hewell suffered from inadequate documentation, poor healthcare input, and inconsistent staff communication, leading to incomplete patient information. These systemic failings are recurring despite previous assurances.

Concerns summary Concerns exist regarding the availability of appropriate equipment, specifically a hooligan bar, for dealing with cell door barricade incidents in prisons, potentially delaying emergency access to inmates.

Concerns summary Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels are resumed.

Concerns summary Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked a formal system to inform the Home Office, impeding Article 2 obligations.

Concerns summary Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed through the plumbing system, and contraband mobile phones exacerbated substance misuse.

Concerns summary Widespread Spice use, an unfit-for-purpose IT system causing incomplete medical records, and a lack of awareness and support for a deaf prisoner all contributed to significant safety concerns within the prison.

Concerns summary Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and airport-style scanners at entry points.

Concerns summary Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for critical processes, inadequate response to previous concerns, and insufficient staff training on withdrawal.

Concerns summary The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.

Concerns summary Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal advice. Mezzanine safety at HMP Altcourse and the Home Office's conduct during proceedings were also concerns.

Concerns summary National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.

Concerns summary Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments to ensure consistent and effective application across all prisons.

Concerns summary Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to healthcare records, heightening risk for vulnerable individuals.