Prison healthcare best practice
100 items
1 source
Absence of clear national replication or sharing of critical learning and improved practices in prison healthcare.
Cross-Source Insight
Prison healthcare best practice has been flagged across 1 independent accountability source:
100 PFD reports
This theme has been identified in one data source. As more data is added, cross-references may emerge.
PFD Reports (100)
Rajwinder Singh
Concerns: HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
Pending
Edward Hands
Concerns: Confusion and differing policies between prison and healthcare staff regarding prisoners under the influence led to inadequate observation, failed recognition of clinical deterioration, and delayed medical assessment.
Pending
Josh Tarrant (2)
Concerns: Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Pending
Gareth Chumber-Kelly
Concerns: Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature deaths.
Pending
Josh Tarrant (3)
Concerns: Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Pending
Mia Lucas
Concerns: A lack of national guidance for clinicians on considering and diagnosing Autoimmune Encephalitis creates a risk of missed diagnoses and future deaths.
Response: The Royal College of Psychiatrists has established a national expert working group that has developed national guidance on the neuropsychiatric presentation of autoimmune encephalitis and autoimmune psychosis. This guidance is …
Response: The Department for Health and Social Care noted the concerns regarding national guidance for Autoimmune Encephalitis, but concluded that these are more appropriately addressed by NHS England, which will provide …
Responded
Pippa Gillibrand
Concerns: A critical lack of national guidance exists for home births, covering midwife training, competency, staffing, equipment, and transfer thresholds, alongside an absence of outcome data collection.
Pending
Mark Turner
Concerns: There is a critical absence of local or national guidance for managing the steps to be taken when a high serum level is returned in patients being monitored for clozapine.
Pending
Antonio Galisi-Swallow
Concerns: There is an absence of national guidance for the use of propofol for short-term sedation in children and young people in paediatric intensive care units.
Response: NICE declines to develop national guidance on propofol use for sedation in children, stating it is not the appropriate organisation. They advise that existing product information contains contraindications and local …
Responded
Samuel Stewart
Concerns: No action was taken by prison or healthcare after a prisoner tested positive for non-prescribed drugs on a "drug free" wing, missing an opportunity for support and policy enforcement.
Response: HM Prison and Probation Service confirms that following a positive drug test on an ISFL wing, prison staff are required to refer the prisoner to the Forward Trust, who then …
Response: Practice Plus Group clarifies that healthcare was not informed of the positive drug test, which prevented them from taking action. They then detail their existing process for managing positive drug …
Overdue
Jennifer Cahill and Agnes Cahill
Concerns: There is a critical absence of national guidance for home births, particularly for high-risk pregnancies, leading to inconsistent midwife practice, insufficient risk discussions, and inadequate midwife training.
Response: NHS England is developing national home birth guidance for consultation by Q2 2026 and will work with UKMIDSS to improve national data collection. An updated Neonatal Life Support (NLS) course …
Response: NICE clarifies that home birth is covered in its existing intrapartum care guideline (NG235) and midwifery staffing guideline (NG4). They commit to reviewing their guidance to define high and low-risk …
Response: The RCOG notes the concerns and refers to existing NICE guidelines (2025) on intrapartum care and place of birth, and points to NHS England/DHSC or RCM/NMC as best positioned to …
Response: The RCM notes the concerns, refers to existing NICE guidelines and RCM/NMC position statements, and states they will continue to advocate for clearer guidelines, training funding, and safe staffing through …
Response: The NMC plans to engage with the Royal College of Midwives and NHS England to explore developing a national framework for home births and will consider strengthening their Code regarding …
Response: The Association of Ambulance Chief Executives has amended the JRCALC Postpartum Haemorrhage guideline to clarify the reconsideration of other bleeding causes if a firm uterus persists. They confirmed existing guidance …
Responded
Louisa Walker (1)
Concerns: There is a lack of national guidance and relevant training for the increasingly common obstetric emergency of impacted fetal head during caesarean sections.
Responded
Declan Carr
Concerns: Inadequate national policy for sharing information on psycho-social support for substance misuse during prisoner transfers risks continuity of care and future deaths.
Response: NHS England confirmed that a national pathway for transferring non-clinical healthcare information, including psycho-social support, between prisons was implemented on 24 November 2025. They also conducted an audit confirming 100% …
Responded
Luke Chatterton
Concerns: Significant delays in accessing advanced life support in a mental health hospital and a lack of national guidelines for managing antipsychotic-induced bowel obstruction in emergency departments were identified.
Overdue
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.
Responded
Christian Hobbs
Concerns: Key recommendations to improve cardiogenic shock care, including staff awareness, out-of-hours echocardiography access, and defined pathways, are not adequately funded or implemented across healthcare systems.
Responded
Marta Vento
Concerns: No formal process exists for prisons to share critical in-prison behavioural and mental health information with sentencing courts. Additionally, national guidance is lacking for ensuring continuity of care for released prisoners with mental health needs.
Responded
Nicholas J’Dourou
Concerns: A lack of national guidance for psychiatric medication cross-titration leads to inconsistent and potentially unsafe practices, while the discontinuation of electronic patient observation on wards raises concerns about insufficient monitoring.
Responded
Amelia Ridout
Concerns: A lack of national guidelines and standardized procedures for bone marrow aspirate and trephine biopsy, coupled with no database for recording outcomes, suggests inconsistent practice and missed learning.
Responded
Haydar Jefferies
Concerns: HMP Coldingley lacked systems for recording welfare information, collating prisoner details, checking mental health referrals, and providing out-of-hours clinical mental health support, leading to inadequate crisis management.
Overdue
Kayleigh Melhuish
Concerns: HMP Eastwood Park staff lack mandatory training on neurodiversity, ACCT procedures, and constant supervision. Healthcare staff also show deficiencies in ACCT review training. Additionally, a specific ligature point was identified in Residential Unit 3.
Overdue
Wayne Bayley
Concerns: National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across all UK prisons, posing a risk that lessons learned are not widely applied.
Responded
John Eyre
Concerns: There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare concerns are unaddressed by consultants.
Responded
Rachel Gibson
Concerns: Unclear responsibilities for checking and administering local anaesthetics, along with inconsistent prescription methods and wide national variations in practice, create significant safety risks.
Responded
Jeffrey Marshall
Concerns: A lack of national guidance on when to recommence anticoagulation after a traumatic head injury and no requirement to discuss risks with patients creates uncertainty and impacts informed decision-making.
Responded
Sean Davies
Concerns: Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper training or adhered to it.
Overdue
Kevin McDonnell
Concerns: Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.
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.
Responded
Frazer Williams
Concerns: A high-risk mental health patient was inappropriately transferred to a prison with limited healthcare and no effective handover. The absence of a national directory for prison healthcare facilities exacerbated risks for prisoners with complex needs.
Overdue
Alan Davies
Concerns: Critical failures included poor communication between healthcare and prison, inadequate discharge planning, lack of staff escort during transfer, and insufficient prison resources or policies for complex patient needs. Staff were also fatigued and felt unable to raise concerns.
Responded
Trevor Monerville
Concerns: The prison failed to adequately monitor and manage a patient's epilepsy with no seizure care plan or effective communication between healthcare and prison staff, compounded by a lack of staff training.
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
John Pace
Concerns: A new methadone detoxification discharge pathway for prisoners lacks formal documentation, policies, or written procedures. This absence prevents consistent implementation and monitoring, posing a risk to future prisoners' safety.
Overdue
Manoel Santos
Concerns: Delays in notifying foreign national offenders of immigration detention and inadequate access to legal advice are compounded by poor inter-agency communication and a lack of specialist prison staff for immigration matters.
Overdue
Reginald Bourn
Concerns: There is a critical lack of national guidance and training for the safe insertion and placement confirmation of nasogastric decompression tubes, unlike feeding tubes, risking fatal misplacement.
Responded
Finley May
Concerns: There is a need for increased awareness of complications associated with Keilland's forceps and guidance on maintaining skill levels or providing clear alternative methods if abandoned, to manage obstetric problems.
Responded
Mackenzie Cooper
Concerns: A community defibrillator was supplied in a non-workable state due to missing parts, highlighting inadequate maintenance systems and poor staff communication. A national system for defibrillator status is also lacking.
Responded
Stephen Beadman
Concerns: A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short of "equivalence of care" and risking insufficient specialist support for long-term inmates.
Overdue
Sandra Lomax
Concerns: Lack of national guidance for oesophageal stricture management, absence of a commissioned specialist service, and poor communication within multi-disciplinary teams led to suboptimal patient care.
Responded
Richard Kew
Concerns: Other hospital Trusts may lack policies and training for safely managing central venous catheter lines during patient mobilisation, risking inadvertent uncapping errors.
Responded
Jason Williams
Concerns: Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor prison staff record-keeping due to insufficient refresher training, compromised care.
Responded
John Henderson
Concerns: There was no clear process for sharing critical medical information about prisoners with chronic conditions with frontline staff, leaving officers unaware of potential medical emergencies and appropriate responses.
Overdue
Liridon Saliuka
Concerns: There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.
Responded
Robert Evans
Concerns: HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately captured after a death, hindering investigations and preventing lessons from being learned.
Responded
Idris Habib
Concerns: Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' actions.
Responded
Thomas Moffett
Concerns: Persistent communication failures between prison healthcare staff and emergency control rooms during medical emergencies, a recurring issue across multiple prisons, indicate a potential national systemic problem.
Overdue
Martin Brown
Concerns: Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and ambulance services, and communication between emergency responders and the control room was inadequate.
Responded
Anthony Clacher
Concerns: A national lack of guidance for welfare checks and monitoring prisoners under the influence of psychoactive substances poses significant risks of physical and mental health deterioration, including death.
Responded
Colin Blackburn
Concerns: Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient observations, exacerbated by high demands and inadequate training, leading to significant risks of suicide/self-harm.
Overdue
James Nowshadi
Concerns: Mental health practitioners lack national guidance on specific suicide method risks and their antidotes, while Serious Incident Reviews fail to adequately learn lessons, risking future fatalities.
Responded
Joanna Daly
Concerns: Prison staff conducting welfare checks on vulnerable first-night prisoners lack specific guidance, raising concerns about the quality and effectiveness of these critical observations.
Responded
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.
Responded
Lola Sheldrake
Concerns: There are no national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn, especially regarding post-treatment and discharge care.
Overdue
Corin Bonaparte
Concerns: HMP Dartmoor failed to open a mandatory ACCT for a self-harming prisoner, indicating inadequate training, and an ambulance was dangerously delayed at the prison gate during an emergency.
Responded
Richard Ormond
Concerns: A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information about the patient's condition to emergency services, highlighting a gap in following emergency protocols.
Responded
Alvin Black
Concerns: Poor hygiene in non-clinical prison healthcare areas creates infection risks. A systemic failure allowed a senior house officer to miss a critical post-surgery VTE risk assessment, indicating a broader protocol adherence issue.
Overdue
Ian Allen
Concerns: The Trust failed to act on high clozapine levels due to poor monitoring systems and a lack of understanding regarding its importance. National guidance is needed for monitoring frequency and practitioner education on clozapine.
Responded
Andrew Goldstraw
Concerns: The SystmOne computer system hindered mental health nurses from identifying critical suicide risk information due to search difficulties, unpopulated summary sections, and a non-functional keyword search.
Overdue
Marlon Watson
Concerns: Healthcare staff at HMP Dovegate demonstrated an inadequate understanding of the ACCT process, which is a significant concern for managing prisoner welfare and suicide risk.
Responded
James Wheeler
Concerns: There is a critical lack of national guidance for monitoring refractory epilepsy, particularly for assistive technology. Additionally, a local authority failed to consistently conduct legally required annual Care Act reviews due to resource constraints.
Responded
Trevor Oakley
Overdue
James Frankish
Concerns: Healthcare professionals lacked understanding of Pica's dangers, and there is no national guidance for its identification, assessment, management, or monitoring for complications like bezoars.
Overdue
Joseph Charles
Concerns: There are no national guidelines or recommendations for preventing DVT and pulmonary embolus specifically for upper limb surgery, despite clear guidance for lower limb procedures.
Overdue
Xander Curran-Pass
Concerns: Lack of national sharing for improved Induction of Labour processes, insufficient guidance on prolonged reduced fetal movement, and failure to advise a mother to return for further monitoring for ongoing concerns were identified.
Overdue
Ryan Trimmer
Concerns: The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid training.
Responded
Daniel Davey
Concerns: Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration between prison and healthcare services.
Responded
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
Jerome Jones
Concerns: 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.
Responded
Anthony Paine
Concerns: The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are detailed.
Responded
Timothy Shaw
Concerns: 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.
Overdue
Terrence George
Concerns: Most Trusts lacked local guidance for timely gallstone surgery post-pancreatitis despite international recommendations. Management did not prioritise this, indicating a need for national guidelines to ensure consistent, timely treatment.
Overdue
Pamela Keech
Concerns: A critical lack of national guidance and A&E/paramedic training on predicting and managing fatal graft/fistula haemorrhage results in inadequate escalation of patients with bleeds for specialist review.
Overdue
Richard Davies
Concerns: A police armed policing unit used unbonded ammunition which did not align with national recommendations and lacked a clear bullet mass retention specification.
Overdue
Daniel Dunkley
Concerns: The provided text outlines the circumstances of the deceased being found hanging in his cell and his subsequent death, but details no specific systemic failures or coroner's concerns.
Overdue
Dean Saunders
Concerns: Serious systemic issues include a rigid protocol preventing mentally disordered individuals' transfer from police custody, unclear hospital transfer processes, and inadequate staff training in the ACCT process, compounded by insufficient psychiatric cover in prisons.
Overdue
Karnel Haughton
Concerns: Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support for parents, risking further injuries and deaths.
Overdue
Dildar Shariff
Concerns: There is a critical lack of national awareness and NICE guideline inclusion regarding the increased haemorrhage risk in haemodialysis or uremia patients, potentially leading to future deaths.
Overdue
Thomas Jordan
Concerns: Communication failures between the hospital and prison healthcare resulted in continued administration of a discontinued drug, as discharge information was not promptly reviewed by prison staff.
Pending
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
Terence Adams
Concerns: Inadequate checking and sharing of prison risk assessments, healthcare staff unawareness of risk score protocols, and failure to follow up on missed appointments contributed to a lack of care.
Overdue
Peter Seale
Concerns: The absence of national guidance for monitoring patients with pleural plaques leads to inconsistent follow-up, risking delayed diagnosis and treatment.
Overdue
Steven Trudgill
Concerns: HM Prison Service lacked standardised treatment programs for fire setters with complex mental health issues, and a suggested therapeutic community option for the deceased was not implemented.
Overdue
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
Helen Patton
Concerns: Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines exacerbates these risks.
Responded
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.
Overdue
Ian Emsley
Concerns: Inadequate formal guidance for healthcare staff on assessing re-offending and escape risk contributed to delays in compassionate release or transfer decisions for terminally ill prisoners.
Pending
Anthony Dwyer
Concerns: The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs was inadequate.
Responded
Laurence Boyens
Concerns: Systemic failure in adhering to drug administration guidelines, including inadequate blood pressure monitoring, poor record-keeping, and insufficient staff training and awareness regarding signs of patient deterioration for patients on Methadone/Buprenorphine.
Overdue
Paul Hardy
Concerns: Healthcare staff failed to follow instructions for obtaining blood/urine samples for cancer investigation, neglected recommendations for INR monitoring, and did not conduct a Significant Event Analysis.
Overdue
Darren Wright
Concerns: Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent CPR training among prison officers due to resource limitations.
Responded
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
Satheeskumar Mahatheaven
Concerns: Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
Responded
Wilfred Aspinwall
Concerns: Healthcare provider at HMP Liverpool did not receive critical PPO and Clinical Review reports, hindering effective implementation of recommendations for prison fatalities.
Overdue
Kevin Scarlett
Concerns: The prison service and healthcare failed to assess the deceased's suicide risk, as staff lacked access to proper risk assessment tools or protocols.
Responded
Matthew Simmonds
Concerns: An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that other Clinical Commissioning Groups may not adopt it.
Overdue
Andrew Hall
Concerns: Inadequate communication and documentation of mental health risks, failure to administer prescribed medication, and insufficient patient observation within the prison healthcare unit were identified. Training gaps for staff in risk assessment and ACCT procedures also contributed to concerns.
Overdue
Lee Curran
Concerns: PPO recommendations for high cholesterol and loss of consciousness protocols were not fully implemented, with NICE guidelines ignored by doctors. Additionally, prison staff lacked training in accurate medical note-taking, leading to incorrect entries.
Overdue
Zeeyad Hamadi
Concerns: Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private healthcare policies, and delays in securing bed watch cover.
Response: The Department of Health acknowledges the concerns regarding prisoner healthcare but states that responsibility for these matters now rests with NHS England. They have forwarded the report to NHS England …
Overdue
Leo Deady
Concerns: A significant proportion of breech presentations go undiagnosed nationally, yet there are no national guidelines for routine late-pregnancy scans to detect them, despite high risks.
Response: The Department of Health, following consultation with the RCOG and review of existing research, concludes there is no benefit to developing a national system of routine late-pregnancy scanning. However, the …
Overdue
Reggie John
Concerns: Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse not accessing or updating crucial risk documents.
Response: Following the inquest, the Lead for Offender Health set out clear expectations to all healthcare staff at HMP Hewell regarding ACCT documents for arriving prisoners, ensuring they are available to …
Response: NOMS reports that HMP Bristol has introduced a system to contact receiving establishments via email and phone for prisoners on open ACCTs, and escort contractors are also informed. HMP Hewell …
Overdue