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).
PFD Reports
357 resultsBranko Zdravkovic
All Responded
2019-0047
13 Feb 2019
Dorset
Home Office
Concerns summary (AI 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.
Action Planned
(AI summary)
The Home Office will write to all parties in IRCs by the end of April 2019 to reiterate the requirements for sharing information on detainees being managed under ACDT procedures. They will use learning from the HMPPS pilot to improve suicide and self-harm prevention guidance and procedures.
Andrew Carr
Historic (No Identified Response)
2019-0038
31 Jan 2019
Birmingham and Solihull
G4S
HM Prisons and Probation
MOJ
Concerns summary (AI 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.
Tyrone Givans
Partially Responded
2019-0028
23 Jan 2019
London Inner (North)
Care UK
HMP Pentonville
National Offender Management Service
Concerns summary (AI 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.
Action Planned
(AI summary)
Care UK provides healthcare services at HMP Pentonville, and they are committed to working with partner agencies in tackling illicit substance supply and trading. A new Health and Wellbeing model was implemented on May 14, 2018, acting as an additional safety net for patients coming into prison. HMPPS published a national Prison Drugs Strategy in April and is revising and republishing its local drug strategy. A new equality policy framework with guidance on reasonable adjustments will be published in June, and a resource tool is being developed to digitally collect more personalized information from prisoners, aiming for implementation in June/July 2019.
Ricardo Holgate
Partially Responded
2019-0012
11 Jan 2019
Birmingham and Solihull
G4S
HM Prisons and Probation Service
MOJ
Concerns summary (AI 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.
Noted
(AI summary)
G4S states that HMP Birmingham is currently being managed by HMPPS and decisions regarding actions/equipment are not within their remit, but they agree with the need for CCTV and airport-style scanners and state that the governor's appointment has been extended.
Natasha Chin
Partially Responded
2019-0011
10 Jan 2019
Surrey
Chief Inspector of Prisons
Care Quality Commission
MOJ
+1 more
Concerns summary (AI 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.
Noted
(AI summary)
HM Inspectorate of Prisons acknowledges the report and will place a copy in their intelligence file to inform future inspections of HMP Bronzefield. They are unable to direct the prison service to take any specific action.
Nicky Reilly
All Responded
2019-0014
4 Jan 2019
Manchester (North)
Greater Manchester Mental Health & Soci…
HM Prisons and Probation Service
Concerns summary (AI summary)
The provided text is incomplete and does not detail specific concerns regarding future deaths, primarily describing the deceased's history and transfer.
Action Taken
(AI summary)
Prison psychology teams can request access to patient's clinical records and have been informed how to gain access. A rewritten guidance document for staff addresses patients who are non-concordant with medication, referencing actions for staff during weekdays and weekends; it was circulated to staff in December 2018. HMPPS provides a Care and Management Plan for prisoners managed by the Managing Challenging Behaviour Strategy (MCBS). They are rolling out 'Working with Challenging Behaviour' training, have developed a toolkit to help staff meet the needs of those with Learning Disabilities and Challenges (LDC), and are opening a dedicated unit for prisoners with autism at HMP Wakefield.
Michal Netyks
Partially Responded
2018-0393
19 Dec 2018
Liverpool & Wirral
Home Office
MOJ
Concerns summary (AI 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.
Action Taken
(AI summary)
HMP Altcourse has updated NOMIS with a record of risk assessment conversations and issued a notice to staff reminding them to use the Big Word translation service. The MoJ Estates Directorate has agreed to carry out a review of balcony design, expected to be completed in the autumn.
John Delahaye
Partially Responded
2018-0388
18 Dec 2018
Birmingham and Solihull
Birmingham and Solihull Mental Health N…
Birmingham Community NHS Trust
G4S
+2 more
Concerns summary (AI 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.
Action Planned
(AI summary)
NHS Digital began rolling out a new mandated coding system called SNOMED CT coding from April 2018 to replace all other coding systems; and SNOMED CT has been introduced as an alternative coding system into the prison general practice electronic medical records; SystmOne since 14 January 2019.
John Mayhew
Historic (No Identified Response)
2018-0381
11 Dec 2018
County Durham and Darlington
HM Inspector of Prisons
Independent Advisory Panel on Deaths in…
National Offender Management Service
Concerns summary (AI 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.
Thomas Nicol
Partially Responded
2018-0375
30 Nov 2018
Hertfordshire
Ministry of Health
MOJ
NHS England
Concerns summary (AI summary)
Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.
Action Planned
(AI summary)
NHS England is reviewing the Good Practice Guidance 2011 on prisoner transfers under the Mental Health Act, aiming for more clinically informed timescales. A revised document has been developed with stakeholders and is currently being prepared in readiness for public consultation anticipated in early 2019. NHS England is conducting service reviews across all adult high, medium, and low secure services, considering service capacity, security levels, gender, service types, and geographical location. It is also reviewing prison transfer and remission guidance and implementing a new service specification for integrated mental health services in prisons.
Bradley Brown
Partially Responded
2018-0374
30 Nov 2018
Manchester (North)
MOJ
NHS England
Concerns summary (AI 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.
Action Taken
(AI summary)
HMP Buckley Hall has instructed governors not to accept transferred prisoners on Fridays, pending healthcare changes. First night procedures have been strengthened with 72-hour monitoring and welfare checks. Healthcare staff must notify the orderly officer if prisoners miss appointments. Staff at HMP Haverigg were reminded to confirm transfers with healthcare so records are reassigned promptly.
Daniel Stokes
Historic (No Identified Response)
2018-0346
5 Nov 2018
South Yorkshire (East)
NHS England
Concerns summary (AI summary)
Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to drug abuse incidents.
Thomas McAuley
Partially Responded
2018-0309
29 Oct 2018
London Inner (South)
Serco Ltd
Metropolitan Police Service
Oxlea NHS Trust
+1 more
Concerns summary (AI summary)
Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean vulnerable individuals' medical assessments are not consistently reviewed by prison medical staff.
Action Planned
(AI summary)
The MPS is working to implement a communication network (N3) and hardware into all custody suites, to provide healthcare professionals with access to NHS Summary Care Records and is required for an EMRS, anticipated within a year. A new PER will be introduced in April 2019 and the MPS will introduce the EMRS platform within one year.
Nicola Lawrence
All Responded
2018-0318
23 Oct 2018
West Yorkshire (East)
National Offender Management Service
Concerns summary (AI summary)
A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, jeopardizing emergency response.
Noted
(AI summary)
HM Prison & Probation Service acknowledges concerns about CPR training at HMP New Hall. They state that the governor has reviewed staff training and considers the current number of trained staff sufficient based on a first aid risk assessment, referring to PSI 29/2015.
Robert McLoughlin
Historic (No Identified Response)
2018-0320
19 Oct 2018
West Yorkshire (East)
HMPPS
Concerns summary (AI summary)
The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.
Dean Barrell
All Responded
11 Oct 2018
East Sussex
Prison and Probation Service
Concerns summary (AI summary)
A seven-day delay in communicating a vulnerable prisoner's actual release date to HMP Lewes contributed to his suicide, highlighting unacceptable communication delays for vulnerable individuals.
1 response
from Dean BARRELL
Jerome Jones
Partially Responded
2018-0369
1 Aug 2018
Shropshire, Telford & Wrekin
Forward Trust
HMP Stoke
Shropshire Community Health NHS Trust
Concerns summary (AI summary)
Insufficient specific checks and a lack of policy for prisoners with multiple NPS use, combined with poor communication of medical risks and drug workers' limited access to medical records, posed significant dangers.
Noted
(AI summary)
The trust describes current practices for observing prisoners using illegal substances and referring them to support services. It notes that Forward Trust's access to medical records is under discussion with NHS England. An updated drug strategy has been launched at the establishment, and staff were reminded of communication protocols for prisoners at risk from repeated use of psychoactive substances. By April 2019, Forward Trust will have access to SystmOne to improve communication with prison and healthcare staff.
Andrew Craig
Partially Responded
2018-0194
25 Jun 2018
Dorset
Care UK
HMP Guys Marsh
HM Prisons and Probation Service
Concerns summary (AI summary)
Illicit prescription drug transfer in prison is facilitated by chaotic medication dispensing, lack of swallowing checks, and an ongoing drug problem despite previous warnings.
Action Taken
(AI summary)
The plan to upgrade the cell windows has now been approved and is provisionally on Ministry of Justice programme for delivery in 2019/20. Additionally, a number of measures to reduce prisoner access to non-prescribed medication have been introduced including assigning responsibility for medication queue management to one person, marking the dispensary floor for security and privacy, using CCTV, providing staff with attendee lists, and implementing a medication management practice where certain drugs are dispensed by healthcare. Care UK provides healthcare services at HMP Guys Marsh. In response to concerns about drug use, they have provided first aid training by prison staff and sourced posters highlighting the risks of NPS. They state a commitment to implementing lessons across Care UK's services.
Andrew Crane
Historic (No Identified Response)
2018-0158
22 May 2018
Northamptonshire
HMP Ryehill
Concerns summary (AI summary)
Unclear guidance for prison officers on initiating emergency calls for chest pain, and failure to update ambulance services with critical changes in patient condition, compromised emergency response.
Michael Berry
Historic (No Identified Response)
2018-0157
22 May 2018
Bedfordshire & Luton
HM Prison Bedford
Concerns summary (AI summary)
A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw that could be easily avoided.
Michalla Sweeting
Historic (No Identified Response)
2018-0165
21 May 2018
Avon
Bristol Community Health
Concerns summary (AI summary)
Concerns were raised about inadequate handover procedures for detox patients, including nurses' record review responsibilities and the timing of observations relative to medication administration.
Stephen Tidey
All Responded
2018-0140
8 May 2018
Surrey
Surrey & Borders Partnership NHS Trust
Surrey County Council
Surrey Police
Concerns summary (AI summary)
Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on high-risk MASH referrals following a critical trigger event.
Noted
(AI summary)
Surrey Police explains how Multi Agency Safeguarding Hub (MASH) reports are processed upon receipt and graded for risk. They state that they do not monitor partner agency responses and suggest forwarding one question to SABP and Adult Social Care. The Trust has already implemented a standardised log for Single Combined Assessment of Risk Forms (SCARF) across Community Mental Health Recovery Service (CMHRS) teams. They have also devised a new checking system between the MASH and the CMHRS teams and set up an automated email reply from the Mental Health/Drug & Alcohol inbox within the MASH.
Paul James
Partially Responded
2018-0254
27 Apr 2018
Mid Kent & Medway
HMP Elmley
THE SECRETARY OF STATE FOR JUSTICE
Concerns summary (AI summary)
A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and safety protocols for vulnerable individuals.
Action Planned
(AI summary)
HM Prison & Probation Service will issue a learning bulletin on managing razor blade risks, pilot a revised ACCT case management process prompting consideration of razor blade access, and consider broader options for managing the issue.
Anthony Paine
Partially Responded
2018-0088
28 Mar 2018
Liverpool and Wirral
HM Prison and Probation Service
Ministry of Justice
The Chief Coroner of England and Wales
Concerns summary (AI summary)
The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are detailed.
Action Planned
(AI summary)
NHS England details a service specification refresh completed in March 2018, with Spectrum benchmarking against these specifications, and revisions to approaches for secure hospital transfers, including a ten-point plan "Right Care, Right Place, Right Time", are being developed. HMPPS acknowledges concerns about healthcare provision at HMP Liverpool and highlights that responsibility for healthcare provision transferred to Spectrum Community Health CiC in partnership with Mersey Care NHS Foundation Trust on April 1, 2018, aiming for a consistent approach to care continuity.
Emily Hartley
Partially Responded
2018-0063
2 Mar 2018
West Yorkshire (East)
Department for Health
HM Prison Service
Concerns summary (AI summary)
Prison was not the appropriate environment for someone with the deceased's mental health problems, and there is a need for secure, therapeutic environments for prisoners with similar mental health needs.
Action Planned
(AI summary)
The Government is developing a strategy to improve outcomes for women in the community and in custody. A project is piloting to work with women who are prolific self-harers and who do not meet the criteria for other services. NHS England has developed a Ten Point Plan for Mental Health which will describe how the secure care pathway can be improved to ensure it works more effectively and efficiently.