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).

Response Status
Responded 263 No Response 11 Historic 80 Pending 2
AI Classification
Action Taken 58%
Action Planned 27%
Noted 14%
Disputed 0%
Based on 401 classified responses
Reports by Quarter
PFD Reports
357 results
Trevor Oakley
All Responded
2019-0495 26 Nov 2019 Hampshire
HM Prison and Probation Service
Concerns summary (AI summary) Night staff at the prison may not be immediately aware of which prisoners are due in court the following morning, potentially overlooking increased self-harm risks among these prisoners.
Action Planned (AI summary) • The use of thromboprophylaxis to surgery has been relaunched and clarified to all pertinent staff, particularly the time period before which it should be withheld. • All speciality specific thromboprophylaxis guidelines are being reviewed.
Shaun Dewey
All Responded
2019-0398 19 Nov 2019 Avon
HM Prison and Probation Service
Concerns summary (AI 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.
Action Planned (AI summary) HM Prison and Probation Service will review and update lists of risks and triggers as part of replacing PSI 64/2011 with a policy framework on prison safety, considering the risks posed by remand status. They will also revise the Introduction to Suicide and Self Harm Prevention training.
Darren Williams
Historic (No Identified Response)
2019-0375 6 Nov 2019 Milton Keynes
HMP Woodhill
Concerns summary (AI 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.
Neville McNair
Partially Responded
2019-0380 5 Nov 2019 East Sussex
HM Prison and Probation Service NHS England NHS Improvement
Concerns summary (AI 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.
Action Planned (AI summary) The Forward Trust provides substance misuse services at HMP Lewes and has a protocol for opioid overdose, with staff trained in naloxone administration. NHS England has developed a quality assurance framework to ensure quality standards are met in secure estate establishments and discussed concerns at the HMP Lewes Quality Board. HMPPS is preparing a pilot project to train prison staff in a number of prisons in the north of England to administer naloxone, and is considering the use of alternatives to intramuscular naloxone, such as nyxoid.
Robert Ginn
Partially Responded
2019-0372 30 Oct 2019 London Inner (North)
Care UK HMP Pentonville
Concerns summary (AI 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.
Noted (AI summary) Care UK expresses condolences and addresses the coroner's concerns regarding first aid quality at HMP Pentonville. They discuss training, national changes to resuscitation procedures, and staff safety, but ultimately do not support bodycams for nurses due to concerns about patient trust and rapport.
David Kirsch
All Responded
2019-0362 30 Oct 2019 Worcestershire
HMP Long Lartin
Concerns summary (AI 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.
Action Taken (AI summary) HMPPS has revised training for ACCT case managers, emphasising consistency, Caremap completion, and information sharing, with guidance sent to existing case managers at Long Lartin and training for all Band 4 and 5 staff by June 2020. They have also reviewed the ACCT process and devised a new version of the form and associated guidance, piloted in ten establishments in 2019.
Harold Uzomechina
Historic (No Identified Response)
2019-0351 21 Oct 2019 London (West)
HMP Wormwood Scrubs
Concerns summary (AI 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.
Mark Jarvis
Historic (No Identified Response)
2019-0304 19 Sep 2019 Suffolk
NHS England SystemOne TPP Ltd
Concerns summary (AI 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.
Imran Mahmood
All Responded
2019-0355 4 Sep 2019 Staffordshire South
HM Prison and Probation Service
Concerns summary (AI 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.
Action Planned (AI summary) HMPPS is considering alternative vape devices, including one using vapourless valve technology, to mitigate risks associated with e-cigarettes in prisons, but is constrained by cost and commercial availability.
Amir Siman-Tov
Historic (No Identified Response)
2019-0302 28 Aug 2019 London (West)
CNWL NHS Trust Hillingdon Hospital NHS Trust Home Office +2 more
Concerns summary (AI 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.
Justin Gallagher
All Responded
2019-0491 16 Aug 2019 East Sussex
Department of Health and Social Care MOJ NHS England
Concerns summary (AI 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.
Action Planned (AI summary) Following the death, NHS England has moved to a single provider model for healthcare in prisons to negate communication issues and ensure a single database system. Care UK was awarded the contract in October 2019, with services being mobilized for an April 2020 delivery date and oversight via contract review meetings. The DHSC refers to the National Prison Partnership Board, which published a Principle of Equivalence in October 2019 to ensure equitable healthcare outcomes for prisoners. NHS England and NHS Improvement have taken steps to review and strengthen its quality assurance and contract performance systems. HMP Lewes is committed to providing resources for external escorts to medical appointments and currently makes sufficient staff available for three external hospital escorts each weekday. There is a daily meeting between prison and healthcare staff at which important information is shared.
Martin Haines
All Responded
2019-0486 16 Aug 2019 East Sussex
Department of Health and Social Care HM Prisons and Probation Service NHS England
Concerns summary (AI 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.
Action Planned (AI summary) The Department of Health and Social Care states that providers of healthcare services are responsible for the quality and safety of the care they provide and expects the healthcare providers at HMP Lewes to consider improvements. The National Prison Partnership Board published a Principle of Equivalence in October 2019. NHS England reports that it has reviewed its commissioning contract performance and quality assurance systems following the death. Improvements include a revised governance structure with a Quality Board and Serious Incident Panel, and the appointment of a dedicated Quality Assurance Team. HMPPS published the Prisons Drug Strategy in April 2019 and each prison has responsibility for reviewing their own local substance misuse strategy. A notice is now displayed in the control room to serve as a visual reminder to staff of the need to call an ambulance immediately upon receiving an emergency code and the prison also issues notices to all staff regularly to remind them of the importance of using the emergency codes correctly.
William Vickers
All Responded
2019-0255 26 Jul 2019 Milton Keynes
HMP Woodhill South Central Ambulance Services
Concerns summary (AI 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.
Action Taken (AI summary) HMP Woodhill updated contingency plans to expedite emergency vehicle access, including immediate contact with ambulance services, staff reporting to the prison to await the ambulance, and training for Operational Support Grades (OSGs). All Custodial Managers will have had the opportunity to test these new arrangements. CNWL NHS Trust has implemented new AEDs with data cards, introduced an Offender Care Resuscitation Review Group, and commissioned an external review of emergency response practices. A 'Train the Trainer' course was also completed to enable regular local emergency response training.
Darren McGuin
Historic (No Identified Response)
2019-0221 26 Jun 2019 South Yorkshire (East)
MOJ
Concerns summary (AI 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.
Marcus McGuire
All Responded
2019-0209 23 Jun 2019 Birmingham and Solihull
HMP Birmingham, MOJ, G45
Concerns summary (AI 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.
Noted (AI summary) HMP Birmingham has trained additional case managers, monitors compliance with the single case manager model daily, reviews it monthly, and has introduced further quality assurance of every ACCT document. G4S states that actions at HMP Birmingham are not within its remit as the prison is now operated and managed by HMPPS, but they reflect on every death in custody and consider lessons learned to inform best practice across their establishments.
Ryan Trimmer
Partially Responded
2019-0215 21 Jun 2019 East Sussex
HMP Lewes HM Prison and Probation Service
Concerns summary (AI 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.
Action Planned (AI summary) HMPPS piloted a revised version of ACCT and will roll out a new version nationally in early 2020, and two on-site first aid trainers will deliver first aid training to staff as part of the prison’s monthly training provision.
Michael Folley
Partially Responded
2019-0230 21 Jun 2019 Hampshire (Central)
Central & North West London NHS NHS Tru… GEOAmey Hampshire Police Constabulary +2 more
Concerns summary (AI 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.
Action Planned (AI summary) Hampshire Constabulary will mandate electronic self-learning packages on Prisoner Escort Records for Custody Officers and Detention Officers, review the content annually, and raise the issues in the Regulation 28 Notice at the next HM Courts and Tribunal Service working group meeting. CNWL NHS Trust details existing ACCT and SASH training, reception screening processes with standardized training being rolled out, twice-yearly care records audits, and staff supervision policies including discussion of care plans and risk assessments.
Daniel Davey
Partially Responded
2019-0267 16 May 2019 Oxford
Care UK Midlands Partnership NHS Foundation Tru… HM Prison and Probation Service +1 more
Concerns summary (AI 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.
Action Taken (AI summary) Care UK updated its Local Operating Procedure in February 2019 to ensure a member of healthcare staff attends planned ACCT reviews daily. In-possession risk assessments are completed at various points and random spot checks are undertaken to reduce the risk of stockpiling. The Safer Custody Governor is recommending awareness of in-possession medication risks is included in case manager training. HMP Bullingdon implemented a new ACCT case management system with a case manager assigned to each case. The prison issued guidance stating in-possession medication is a topic for ACCT reviews, with risk assessments informed by healthcare. A safety briefing on in-possession medication has been distributed and ACCT case manager training will cover stockpiling medication. The Trust has reminded staff to update Medication In Possession risk assessments, ensuring updates feed into the ACCT. Staff were reminded that changes in presentation regarding serious self-harm should trigger opening an ACCT. The case was reviewed with involved staff, and learning shared.
Bernard O’Flynn
Historic (No Identified Response)
2019-0488 8 May 2019 London Inner (South)
Oxleas NHS Trust
Concerns summary (AI 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.
Tarek Chowdhury
Historic (No Identified Response)
2019-0131 2 Apr 2019 London (West)
HM Prison & Probation Service Home Office NHS England
Concerns summary (AI 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.
John Wright
All Responded
2019-0175 21 Mar 2019 Oxfordshire
Healthcare Care UK HM Prison and Probation Service
Concerns summary (AI 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.
Action Taken (AI summary) HMPPS details actions taken including; NHS England Commissioners, Mountain Healthcare, and the liaison and diversion service have been informed of the process for contacting the prison healthcare team. The courts that serve HMP Bullingdon and the escort contractors (GEO Amey) have been reminded that safety concerns should be recorded on the Person Escort Record. Care UK provides details of actions taken including; Healthcare staff attending prison morning meetings, maintaining a register of staff who have completed SASH training and providing ASIST training to all patient-facing staff.
Meirion James
Historic (No Identified Response)
2019-0460 4 Mar 2019 Pembrokeshire & Camarthenshire
Dyfed Powys Police Hywel Dda Health Board National Police Chief’s Council
Concerns summary (AI 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.
Kelvin Speakman
Partially Responded
2019-0074 27 Feb 2019 Worcestershire
HMP Hewell HM Prison Service
Concerns summary (AI 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.
Action Planned (AI summary) HMPPS will deliver coaching sessions to ACCT case managers at HMP Hewell, emphasizing information sharing and accurate recording. A updated ACCT case management system is being piloted and will be rolled out nationally in early 2020.
Christopher Moss
Historic (No Identified Response)
2019-0066 26 Feb 2019 Staffordshire South
MOJ
Concerns summary (AI 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.
Matthew Hamilton
All Responded
2019-0050 14 Feb 2019 County Durham and Darlington
HMP Durham
Concerns summary (AI summary) Individuals released from custody are unaware that reduced drug tolerance post-abstinence risks fatal overdose if pre-custody consumption levels are resumed.
Action Taken (AI summary) HMP Durham's Drug and Alcohol Reduction Team (DART) has updated their guidance pack to be offered to all prisoners on discharge, is offering Naloxone to prisoners at risk of opiate overdose, and has a trained prisoner (DART Mentor) to offer additional harm reduction advice.