Prison cardiac screening
Omission of questions about family history of sudden cardiac death in prison reception health screens.
41 items
5 sources
Source spread
Where this theme appears
Prison cardiac screening has been flagged across 5 independent accountability sources:
25 PFD reports
3 committee recs
9 PPO recs
1 IOPC rec
3 IMB reports
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
PFD Reports (25)
Redmond Johnson
Concerns: 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.
Overdue
Jason Lawson
Concerns: 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.
Overdue
James Colton
Concerns: 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.
Response (Worcestershire Health Care NHS): The trust held study sessions reviewing the case notes of Mr. Colton, increased the consultant psychiatrist's sessions at HMP Long Lartin, appointed a clinical director for offender healthcare, and formalised …
Overdue
Hayden Norton
Concerns: 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.
Response (Dorset Healthcare University NHS Foundation Trust): The Trust has implemented new policies and procedures to improve service provision and provides a AAA screening programme. HMP Dartmoor now has an emergency code protocol in place.
Overdue
Greg Revell
Concerns: 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.
Response (Leicestershire Partnership NHS Trust): Leicestershire Partnership NHS Trust has implemented a robust system for seeking clinical information and has a flowchart identifying team member responsibilities. However, following review of the case notes, it was …
Response (HM Prison and Probation Service): HM Prison and Probation Service has reinforced local policies to ensure ACCTs are opened on reception after a self-harm attempt, launched a new Safer Prisons strategy, provided training on recording …
Responded
Luke Myers
Concerns: 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.
Response (Ministry of Justice): HMP Liverpool has reviewed sentence calculations and found no other miscalculated sentences. First aid training is being provided to all Custodial Managers who carry out orderly officer duties, and Operational …
Responded
Carl Smith
Concerns: 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.
Response (Dorset Healthcare University NHS Foundation Trust): Dorset HealthCare NHS Trust implemented new policies and procedures to improve the quality of service in Devon Prisons. An education package has been put in place for all staff regarding …
Overdue
Steven May
Concerns: 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.
Response (Steven May): HMP Ranby reminded staff about comprehensive record-keeping for ACCT interviews, reinforced elements of its Local Security Strategy regarding night-time incidents, and provided access to the LSS with annual knowledge testing. …
Response (Nottingham Healthcare NHS Trust): The Trust has already addressed concerns by obtaining additional funding from NHS England for new posts at HMP Ranby to meet healthcare demands.
Overdue
Samuel Blair
Concerns: 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.
Response (London Ambulance Service NHS Trust): The London Ambulance Service updated its Computerised Gazetteer to include multiple entrances to HMP Pentonville, and included specific reference to HMP Pentonville in refresher training for EOC staff, requiring confirmation …
Response (Care Uk): Care UK refers to the response provided by BEH-MHT for some concerns, and states they will collaborate with them to ensure their action plan is implemented. They have implemented a …
Response (HM Prison and Probation Service): NOMS states that the local risk assessment at Pentonville is up to date, and there is a sufficient number of staff trained in first aid. Prison control room staff have …
Overdue
Alan Stead
Concerns: Delays in taking and testing blood samples from prisoners at HMP Dovegate were identified, which could have serious clinical consequences.
Response (Care UK): Care UK implemented a training program for nurses and HCAs in phlebotomy at HMP Dovegate, completed in March 2016, to ensure timely blood tests. The Governance team also shared learning …
Responded
Haydn Burton
Concerns: 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.
Response (HM Prison and Probation Service): HMP Winchester is providing local ACCT refresher training and Safety Awareness training, including lessons learned from previous deaths in custody. Wing Supervising Officers are informed of ACCT post closure reviews, …
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.
Response (Care UK): Care UK has changed the reception screening template to include mandatory PER review, seeks consent for GP records during screening, and reinforced Code Red/Blue training with staff and displayed posters. …
Overdue
Mark Doyle
Concerns: 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.
Response (Care UK): Care UK has reflected on the inquest and reviewed healthcare processes, embedding Local Operating Procedures (LOPs) with senior management audits, to ensure relevant risks and triggers are identified and shared …
Overdue
Robert Richards
Concerns: 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.
Overdue
Martin Haines
Concerns: 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.
Response (Department of Health and Social Care): 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 …
Response (NHS England): 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 …
Response (HM Prison and Probation Service): 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 …
Responded
Justin Gallagher
Concerns: 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.
Response (Department of Health and Social Care): 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 …
Response (NHS England): 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 …
Response (HM Prison and Probation Service): 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 …
Responded
David Bird
Concerns: 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.
Overdue
Khairul Rahman
Concerns: 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.
Response (Practice Plus Group): Practice Plus Group has begun a service improvement project to encourage the appropriate use of NEWS2 scoring and embedding this into practice, including a ‘Back to Basics’ workshop on ‘Identifying …
Overdue
Connor Hoult
Concerns: 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.
Response (HM Prison and Probation Service): HMP Wakefield issued a Governor’s Order in January 2020 regarding verbal responses during roll checks and unlocking procedures. The Governor has now circulated a Notice to Staff reminding them to …
Responded
Joseph Price
Concerns: 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.
Response (NHS England): NHS England acknowledges the concerns and is refreshing the secondary health screening template to include a specific prompt for users to ask relevant questions relating to family history. All reports …
Responded
Amarjit Singh
Concerns: 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.
Response (HM Prison and Probation Service): HMPPS issued emergency response guides and pocket cards to all prisons. Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in …
Response (Practice Plus Group): Practice Plus Group has changed procedures to ensure cell sharing risk assessments are completed effectively, including long term conditions monitoring, and provide the HMP Pentonville prison team with a list …
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.
Response (HM Prison and Probation Service): HMP Lewes reviewed record-keeping practices, clarified responsibilities for welfare checks and clinical observations, regularly briefs staff on emergency codes, and reviewed hospital escort procedures. Custodial managers now oversee Code Blue/Red …
Responded
Russell Irvine
Concerns: 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.
Response (HM Prison and Probation Service): While stating existing policy covers monitoring food refusals, HMPPS will write to all Governors to remind staff of their role in early identification of food and/or fluid refusals, and to …
Pending
Colin Lovett
Concerns: 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.
Response (HM Prison and Probation Service): HMPPS does not believe it's necessary or appropriate to require all operational prison staff to undertake specific diabetes awareness training. However, following discussion with the Governor, the healthcare provider at …
Response (Department of Health and Social Care): NHS England will share the details of this case and concerns raised with all regional health and justice commissioning teams, along with links to NICE guidance and the National Diabetes …
Responded
Ryan Harding Prevention of future deaths report
Concerns: Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.
Responded
Committee Recommendations (3)
#12 — Review mental health services specification for competent professional screening of prisoners
Recommendation: 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.
Gov response: HMPPS is committed to listening to its staff to better understand how to improve their wellbeing and provide a fulfilling and safe workplace where they feel valued and supported. To promote positive wellbeing, HMPPS has …
Under Consideration
#11 — Identify reasons for delayed prisoner health screenings and implement remedial action plans
Recommendation: 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.
Gov response: The mental health of prisoners remains a priority for this Government as it has done throughout the pandemic. The MoJ, HMPPS, DHSC, NHS England and NHS Improvement are working closely together to ensure that offenders …
Under Consideration
#10 — Racial disparity exists in identifying mental health conditions during prisoner health screenings
Recommendation: 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 …
Gov response: HMPPS recognises that its staff, who interact with prisoners every day, are a vital part of creating an environment that supports good mental health for all prisoners. HMPPS is committed to ensuring that all staff …
Accepted
PPO Death in Custody Recommendations (9)
The Head of Healthcare
The Head of Healthcare should ensure that all patients who present with chest pain have an electrocardiogram (ECG) undertaken in accordance with NICE guidelines NG95 Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis.
The Head of Healthcare
The Head of Healthcare should ensure that all new prisoners receive secondary health screens within seven days, in line with NICE guidelines and PSO 3050, Continuity of Healthcare for Prisoners.
The Head of Healthcare
If an initial health screen cannot be carried out on the day of arrival, it is carried out the next day.
The Head of Healthcare
The Head of Healthcare should ensure that staff follow the NICE guidelines [CG181] on cardiovascular disease: risk assessment and reduction, including lipid modification, and that: patients with high cholesterol have annual lipid checks; and patients with cardiovascular disease have a …
Manx Care
Manx Care should ensure there is a long-term conditions monitoring register and clinic.
The Head of Healthcare
The Head of Healthcare should ensure all new arrivals and transfers to prison should receive a second stage health assessment within 7 days of arrival.
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.
The Head of Security, Procedures and Capability in the Security …
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; …
The Head of Healthcare
The Head of Healthcare should ensure that any prisoners with elevated blood pressure readings are monitored in accordance with NICE guidelines.
IMB Annual Reports (3)
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, and the impact of early release schemes on resettlement and accommodation provision.
PRISON
Key concerns
Bedford (2024)
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, and high levels of assaults on staff, although recent improvements are noted. The Board also raises concerns about the unaddressed needs of its large remand population, the lack of digital infrastructure, and disproportionate adjudications.
PRISON
Key concerns
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 clarity surrounding external service provider contracts, calling for action from the Minister, Prison Service, and Governor.
PRISON
Key concerns