Prison cardiac screening

Omission of questions about family history of sudden cardiac death in prison reception health screens.

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Jan 2023 · County Durham and Darlington

Prison healthcare failed to routinely inquire about and record family history of sudden cardiac death during reception health screenings, missing opportunities to identify and screen at-risk inmates.

Matched on terms: cardiac, prison, screening

Dec 2016 · London Inner (North)

Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical emergency protocols.

Matched on terms: prison, screening

Committee recommendation

#12 - Review mental health services specification for competent professional screening of prisoners

Justice Committee

The NHS should review its mental health services specification so that mental health screening is always carried out by a competent mental health professional with experience of the criminal justice system.

Matched on terms: prison, screening

Committee recommendation

#11 - Identify reasons for delayed prisoner health screenings and implement remedial action plans

Justice Committee

The NHS should identify why some establishments have difficulties screening prisoners within 24 hours of arrival and should put in place action plans with the healthcare providers at those establishments to remedy this.

Matched on terms: prison, screening

Committee recommendation

#10 - Racial disparity exists in identifying mental health conditions during prisoner health screenings

Justice Committee

It is unacceptable that one in 12 prisoners do not have a health screening appointment within 24 hours of arrival and that Black, Asian, and other Minority Ethnic prisoners who have a mental health condition are less likely to have that identified than their white counterparts.

Matched on terms: prison, screening

PPO recommendation

The Head of Healthcare

The Head of Healthcare should ensure that prisoners with a raised blood pressure reading at first or second stage reception screening have an appropriate follow up arranged.

Matched on terms: prison, screening

Redmond Johnson

Jun 2014 · Suffolk

Prison healthcare lacked robust processes for gathering detainee medical history, conducting medication reviews, documenting test results, and assessing fitness for transfer, risking inadequate care for those with complex needs.

Matched on terms: prison

Mar 2016 · Nottinghamshire

Prison healthcare suffered from reception nursing staff failing to consult medical notes, lacking mental health expertise, and incomplete ACCT documents. Inadequate First Aid/CPR training and poor weekend/Bank Holiday healthcare access also posed significant risks.

Matched on terms: prison

Justin Gallagher

Aug 2019 · East Sussex

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.

Matched on terms: prison

May 2025 · Dorset

Prison staff lack essential diabetes training and understanding of critical attacks. Non-24/7 healthcare and poor awareness among staff risk delayed care and future deaths for insulin-dependent prisoners.

Matched on terms: prison

Jan 2015 · Rutland & North Leicestershire

Welfare checks failed to identify a deceased prisoner. Prison healthcare lacked a computer-driven system to track missed and lapsed prescriptions, and there was no policy for constant medical supervision for high-risk prisoners.

Matched on terms: prison

Jan 2015 · Worcestershire

Prison healthcare staff failed to correctly diagnose and treat Mr Colton, missing his developing cancer due to not revisiting the initial diagnosis. There was also inadequate pain management, poor continuity of care, and communication failures.

Matched on terms: prison

Apr 2015 · Exeter & Greater Devon

After the deceased arrived at HMP Dartmoor, there was no record that his blood pressure was monitored, or that he had been informed of a screening test for aortic aneurysm; furthermore, there was a delay in calling an emergency ambulance because HMP Dartmoor lacked an emergency code protocol.

Matched on terms: screening

Apr 2015 · Leicester (City & South)

Ineffective suicide prevention measures were evident, with a prisoner not placed on ACCT despite clear risk and a culture of avoiding such measures. Healthcare information systems were insufficient, leading to missed opportunities for vital medication and treatment.

Matched on terms: prison

Jul 2015 · Liverpool

HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff lacked current first aid training, raising concerns for lone working officers.

Matched on terms: prison

May 2016 · London Inner (North)

Prison healthcare failed to adequately assess mental health, record vital information, or continue prescribed antidepressants. Delays in emergency response included slow 999 information, a nurse failing to acknowledge radio calls, and not immediately bringing a defibrillator.

Matched on terms: prison

Dec 2017 · London Inner (North)

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.

Matched on terms: prison

Aug 2019 · East Sussex

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.

Matched on terms: prison

Jul 2021 · Inner London North

The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.

Matched on terms: prison

Jan 2024 · East Sussex

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.

Matched on terms: prison

Ryan Harding Prevention of future deaths report

Feb 2026 · South Wales Central

Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.

Matched on terms: prison

Jul 2015 · Exeter and Greater Devon

Custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing related to these checks was deficient.

Matched on terms: prison

Jul 2016 · Staffordshire (South)

Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.

Matched on terms: prison

Oct 2016 · Hampshire (Central)

Prison staff failed to implement ACCT plans effectively and observations were inadequate. Confidentiality rules for Listeners were unclear regarding active suicide plans, and the NOMIS database inadequately records past ACCT information.

Matched on terms: prison

Nov 2021 · West Yorkshire (Eastern)

Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing asleep, risking missed signs of distress or concerns.

Matched on terms: prison

Sep 2023 · Inner North London

There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance for prisoners on how to respond to a cellmate having a fit.

Matched on terms: prison

Jul 2024 · Durham & Darlington

Prison staff failed to escalate or monitor a prisoner's reported refusal of food and fluids, highlighting a national absence of formal policy for monitoring prisoner meal collection.

Matched on terms: prison

Jun 2019 · Bedfordshire & Luton

Custody officers received inadequate training in interpreting detainee behavior, leading to misjudgments of vulnerability. There were also failures to ensure vulnerable detainees saw a Health Care Practitioner before release, despite identified risks.

Matched on classifier match

PPO recommendation

The Head of Security, Procedures and Capability in the Security Directorate of HMPPS

The Head of Security, Procedures and Capability in the Security Directorate of HMPPS should amend the guidance on completing the initial segregation health screen to: make assessment of a prisoner’s physical health as important as assessment of their mental health; make it mandatory for the nurse completing the health screen to check the prisoner’s clinical record for the...

Matched on terms: prison

Robert Richards

Nov 2017 · London Inner (West)

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.

Matched on classifier match

IMB annual report

Altcourse (2024)

HMP Altcourse experienced a contract transfer to Sodexo in June 2023, leading to initial staffing challenges that have largely been addressed. The Board commends staff for maintaining safety amidst population pressures and notes improvements in mental healthcare and a successful reading strategy. Key concerns include the kitchen's inadequacy, lack of education in CSU, delays in mental health transfers,...

Matched on terms: prison

IMB annual report

HMP Bedford, a Category B YOI, continues to face significant challenges including persistent overcrowding and an inconsistent induction process, despite some improvements in wing cleanliness and key worker implementation. The report highlights serious concerns regarding healthcare, characterized by poor communication and a decline in drug rehabilitation services. Security remains an issue with illicit items readily entering the prison,...

Matched on terms: prison

IMB annual report

Holme House (2021)

HMP Holme House experienced a year dominated by Covid-19 restrictions, yet saw notable improvements in overall ambiance, cleanliness, and reduced violence. While healthcare services generally improved and key worker compliance increased, significant concerns persist regarding unacceptable dental waiting times, inadequate education provision, and unscreened toilets in cells. The Board highlights issues with property transport and the lack of...

Matched on terms: prison

PPO recommendation

Manx Care should ensure there is a long-term conditions monitoring register and clinic.

Matched on classifier match

IOPC learning recommendation

Recommendations - Humberside Police, January 2022

The IOPC recommends that Humberside Police use this case, within; officer training, force communications and policy/guidance, to highlight the need to maintain effective supervision of a detainee, especially prior to the completion of a search. This follows a Death or Serious Injury (DSI) incident whereby a detainee was able to hide a razor blade within a copy of...

Matched on classifier match

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