Custody medical information
35 items
2 sources
Significant medical events not consistently recorded or made readily accessible to discipline staff in custodial settings.
Cross-Source Insight
Custody medical information has been flagged across 2 independent accountability sources:
3 inquiry recs
32 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (3)
AS-5 — Detainee Capture and Condition Records
Recommendation: Appropriate procedures should be introduced to ensure that there is an accurate and detailed contemporaneous record of the circumstances relating to the original capture/detention of a prisoner and his general physical condition (including an appropriate photographic record) on arrival at …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
AS-6 — Informing Detainees of Rights
Recommendation: All detainees should be clearly informed of their rights and obligations as soon as is practicable upon arrival at any detention facility. As a minimum this should include informing the detainee as to the reason(s) for his detention and explaining, …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
AS-9 — Medical Fitness for Detention Forms
Recommendation: Appropriate forms should be made available to allow a medical examiner to declare a detainee unfit for detention and questioning. The decision as to whether a detainee has been declared unfit for detention and questioning should be readily apparent and …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted
PFD Reports (32)
Amy Cross
Concerns: There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical records system.
Response: NHS England plans to commence a 'proof of concept' trial around February/March 2026 in specific regions, enabling healthcare providers to access the Digital Person Escort Record (DPER) system to improve …
Overdue
Benjamin Harrison
Concerns: Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent information sharing policies between healthcare and prison staff regarding medication and risk.
Responded
Stephen Coster
Concerns: Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding of emergency transfer protocols, led to significant delays.
Responded
Ivan Ignatov
Concerns: A detainee's mental health assessment was missed in police custody, and an act of self-harm was misjudged. Critical risk information, including first-time custody status, was not properly recorded or collated, hindering comprehensive risk assessment.
Responded
Zak Farmer
Concerns: Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans for a released prisoner.
Responded
Robert Brown
Concerns: Critical prisoner information from different systems (NOMIS, medical, security) was not consistently accessible to all prison staff, highlighting a systemic failure in information sharing.
Responded
Heather Birchall
Concerns: Healthcare professionals assessing detained persons lack full access to mental health records, especially out-of-hours, due to confidentiality issues, hindering informed decisions for appropriate care.
Overdue
Michael Folley
Concerns: 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.
Overdue
Andrew Carr
Concerns: 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.
Overdue
Natasha Chin
Concerns: 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.
Overdue
Thomas McAuley
Concerns: 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.
Overdue
Dean Barrell
Concerns: 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.
Pending
Jeroen Ensink
Concerns: Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner of mental health concerns or family-reported history.
Overdue
Jason Basalat
Concerns: 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.
Responded
Sean Plumstead
Concerns: Winchester Prison has inadequate systems for storing electronic material and creating transcripts, leading to missing crucial evidence. This recurring issue raises a risk of future deaths due to poor record-keeping.
Responded
Edwin O’Donnell
Concerns: Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked adequate ACCT training.
Responded
Jonathan Palmer
Concerns: There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of contraband (Spice) inflow posed significant health risks within the prison.
Overdue
Valdas Jasiunas
Concerns: Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further complicated by a lack of multi-language support for safety information.
Overdue
Tedros Kahssay
Concerns: Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical emergency protocols.
Overdue
Thomas Gallagher
Responded
Thomas Jordan
Concerns: Communication breakdown and failure to review discharge correspondence at the prison led to continued, incorrect drug administration after hospital clinicians requested discontinuation. Electronic discharge summaries could prevent such errors.
Overdue
Anthony Fraser
Concerns: A significant systemic failure exists in conveying inmates' summary medical information from prison to A&E departments, potentially delaying crucial diagnosis and treatment.
Responded
Shalane Blackwood
Concerns: The prison lacks adequate provision for complex health needs, has insufficient staff for prisoner regimes, faces rife NPS use, and has unclear decision-making tools and staff awareness for physical symptoms alongside mental health issues.
Overdue
Matthew Sargent
Concerns: Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers also lacked regular meetings, limiting their knowledge of individuals.
Responded
Stewart Akins
Concerns: Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' Court, leading to bail being granted without full awareness of the high self-harm risk.
Responded
Adam Rice
Concerns: There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, and a lack of understanding of welfare check protocols.
Overdue
Imran Douglas
Responded
Richard Green
Concerns: Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack of clear display for critical historical information.
Overdue
Nicholas Rowley
Concerns: Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks in detainees.
Overdue
John Stabler
Concerns: The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in reception and care areas within prisons.
Overdue
Christopher Shapley
Concerns: Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.
Overdue
Lee MacPherson
Concerns: Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
Overdue