State Custody related deaths

Concerns summary Significant delays in transferring prisoners experiencing acute mental health crises to appropriate secure hospitals potentially endanger lives.

Concerns summary Prison healthcare staff lacked training and authorization to administer diazepam, despite having it available, indicating a systemic failure in emergency drug administration protocols for prisoners.

Concerns 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.

Concerns summary A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, jeopardizing emergency response.

Concerns summary The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to his death by ligature.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw that could be easily avoided.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns 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.

Concerns summary The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are detailed.

Concerns summary Prisons are unsuitable environments for individuals with severe mental health issues due to the lack of secure, therapeutic treatment facilities. This systemic failure, highlighted repeatedly over a decade, risks future deaths.

Concerns summary Healthcare staff showed confusion regarding intelligence reports, communication between departments was poor, and systems for reducing illegal substances and managing referrals needed improvement. Record-keeping was also substandard.

Concerns summary A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and healthcare nurses during medical screenings created a risk of significant alerts being missed.

Concerns summary Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number of passive drug detection dogs to control Novel Psychoactive Substances.

Concerns summary A lack of a formal, robust documentary system for referring prisoners to mental health services meant reliance on unreliable telephone conversations, risking delays in crucial assessments.

Concerns summary Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also no mandatory first aid training for existing prison officers.

Concerns summary Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night welfare checks. Intermittent observations are insufficient to detect self-harm, requiring continuous monitoring.

Concerns summary The adequacy of prison intelligence processes, including reporting and analysis, was questioned. A critical internal report on these issues was not shared with relevant staff, indicating a failure to learn lessons.

Concerns summary An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and staff were not informed of previous unnatural death causes, reducing vigilance.

Concerns summary Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable prisoner's mental state, and a mental health assessment couldn't be arranged.

Concerns summary HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. Critical issues also included inadequate medical training and supply restocking.