Prison healthcare best practice
Absence of clear national replication or sharing of critical learning and improved practices in prison healthcare.
649 items
10 sources
Source spread
Where this theme appears
Prison healthcare best practice has been flagged across 10 independent accountability sources:
107 PFD reports
6 committee recs
27 PPO recs
1 IOPC rec
17 IMB reports
380 IMB recs
90 Article 2 learning points
2 detention investigation recs
4 PHSO decisions
15 LGO/SPSO decisions
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 (107) — showing 50 strongest matches
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 (Worcestershire Health Care NHS): The trust reiterated expectations regarding ACCT documents for prisoners arriving at HMP Hewell, and reviewed Prison Service Instruction 64/2011 to identify and address areas of non-compliance.
Response (HM Prison and Probation Service): HMP Bristol introduced a system to contact receiving establishments about prisoners on open ACCTs, and HMP Hewell issued a notice reminding staff to report information indicating a change in a …
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 (Department of Health): The Department of Health acknowledges the concerns regarding undiagnosed breech presentations but states that after consulting with the RCOG and taking account of existing research and guidance, it considers that …
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 (Department of Health): The Secretary of State acknowledges the concerns and states that the National Offender Management Service (NOMS), NHS England and Public Health England (PHE) are due to meet to discuss governance …
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
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.
Response (HM Prison and Probation Service): Cameras have been removed from cells in the healthcare centre and any prisoner assessed as requiring high levels of observation is located in a constant observation cell. A system is …
Overdue
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
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.
Response (HM Prison and Probation Service): HMP Woodhill reviewed the local ACCT process in December 2013, revised the case review process, and issued guidance to staff. A governor grade is appointed to manage the case of …
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
Satheeskumar Mahatheaven
Concerns: Failures in information sharing, multi-agency communication procedures, and inadequate training contributed to an accident within prison services.
Response (HM Prison and Probation Service): HMP Pentonville and HMP Thameside have implemented local policies to ensure appropriate information sharing and effective communication between prison staff and healthcare providers. Community GP records are now routinely requested …
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
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.
Response (Serco): Serco states that they were the healthcare provider at HMP Norwich at the time of the death but no longer provide any services there and thus cannot implement the recommendations. …
Response (Ministry of Justice): HMP Norwich acknowledges the coroner's concerns regarding CPR training, outlines the current legislation and risk assessment process for first aid needs, and states that there is no requirement to provide …
Response (Virgin Care Services Limited): Virgin Care, the current healthcare provider at HMP Norwich, has instituted changes to its procedures, including a local induction process and checklist, and guidance for resuscitation in a joint protocol …
Responded
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
Laurence Boyens
Concerns: Healthcare professionals appeared to misunderstand guidelines for managing drug dependence in adult prison settings, particularly around monitoring blood pressure before administering methadone or buprenorphine, and some nurses did not know when to withhold medication or escalate concerns.
Response: Following the PFD report, the GMC commenced a review of their earlier decision not to proceed with a complaint about the doctor's care. They have obtained the doctor's comments and …
Response: The Nursing and Midwifery Council acknowledges receipt of the referral and states that it will go through an initial assessment process to determine how to proceed and will then write …
Overdue
Anthony Dwyer
Concerns: The guidance provided to the Trust for the general management of long-term tracheostomy patients with complex medical needs was inadequate.
Response (Department of Health): The Department of Health acknowledges the concerns and states that adequate guidance already exists for tracheostomy management through the UK National Tracheostomy Safety Project and other resources, with NHS England …
Responded
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.
Overdue
Daniel Byrne
Concerns: There were repeated failures to identify and assess suicide risk in newly arrived prisoners, with nursing staff notably absent from initial health screenings and reviews.
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
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.
Response (Department of Health): The Department of Health acknowledges concerns regarding mini tracheostomy procedures, and includes a joint response from the Faculty of Intensive Care Medicine (FICM) and the Royal College of Anaesthetists (RCOA). …
Response (The Royal College of Anaesthetists): The Faculty of Intensive Care Medicine and Royal College of Anaesthetists reviewed information about a death following a minitracheostomy, but state the provided data is inadequate to answer questions definitively …
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
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
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
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.
Response (Care UK): Care UK will remind staff to check they have had sight of the core record and any accompanying information including the PER, relating to history, index offence, sentence status, clinical …
Overdue
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.
Response (Care UK): Leeds Teaching Hospital has agreed to issue an electronic summary with all patients who transfer back to HMP Leeds following discharge. IT personnel from both the Hospital and Care UK …
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.
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.
Response (Response Dept of Health): The Department of Health acknowledges the coroner's report and notes NICE's decision not to update its guidelines at this time, but that the information will be looked at when the …
Response (N.I.C.E): NICE acknowledges the coroner's concerns about awareness of haemorrhage risk in renal failure patients with head injuries. While they believe their existing guideline covers this adequately, they have logged the …
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
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.
Response (NHS England): NHS England states that Care UK circulated a document with contact details of medical staff who can sign Mental Health Assessment documents, and a new provider will deliver healthcare at …
Response (Essex Partnership NHS Trust): Essex Partnership NHS Trust has submitted its admissions protocol for regional review by the Secure Services Catchment Group for East of England and will inform the coroner of the outcome; …
Response (Care UK): Care UK developed a new Mental Health Pathway, formally signed off on 28 March 2017, and is rolling it out across all Care UK sites via mental health workshops to …
Overdue
Daniel Dunkley
Concerns: The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.
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.
Response (Association of Ambulance): The Association of Ambulance Chief Executives will request that JRCALC review the UK ambulance service clinical practice guidelines for the management of renal patients, specifically in relation to fistula bleeds. …
Response (the JRCALC): JRCALC clarifies it is not responsible for setting health education requirements for paramedics. AACE and NASMeD will provide the full response to the PFD.
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.
Response (Bedfordshire Police): The BCH APU is no longer using the un-bonded 5.56mm ammunition which was used in the present case and has amended its system of record-keeping to ensure that all decisions …
Overdue
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.
Response (Care UK): Care UK acknowledges receipt of the report but states they ceased providing healthcare at HMP Chelmsford on 26 May 2017 and therefore will not be filing a substantive response.
Overdue
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.
Response (NHS England): NHS England details a service specification refresh completed in March 2018, with Spectrum benchmarking against these specifications, and revisions to approaches for secure hospital transfers, including a ten-point plan "Right …
Response (HM Prison Probation Service): HMPPS acknowledges concerns about healthcare provision at HMP Liverpool and highlights that responsibility for healthcare provision transferred to Spectrum Community Health CiC in partnership with Mersey Care NHS Foundation Trust …
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.
Responded
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.
Response (Shropshire Community Health NHS Trust): The trust describes current practices for observing prisoners using illegal substances and referring them to support services. It notes that Forward Trust's access to medical records is under discussion with …
Response (HM Prison Probation Service): An updated drug strategy has been launched at the establishment, and staff were reminded of communication protocols for prisoners at risk from repeated use of psychoactive substances. By April 2019, …
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.
Response (HM Prison and Probabtion Service): HMPPS piloted a revised version of ACCT and will roll out a new version nationally in early 2020, and two on-site first aid trainers will deliver first aid training to …
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
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.
Response (The British Psychological Society): The British Psychological Society will emphasize Pica training and management in Clinical Psychology doctoral programmes and actively support the development and dissemination of multi-professional guidelines relating to the management of …
Overdue
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.
Response (Care UK): Care UK updated its Local Operating Procedure in February 2019 to ensure a member of healthcare staff attends planned ACCT reviews daily. In-possession risk assessments are completed at various points …
Response (HM Prison Probation Service): HMP Bullingdon implemented a new ACCT case management system with a case manager assigned to each case. The prison issued guidance stating in-possession medication is a topic for ACCT reviews, …
Response (Midlands NHS Trust): The Trust has reminded staff to update Medication In Possession risk assessments, ensuring updates feed into the ACCT. Staff were reminded that changes in presentation regarding serious self-harm should trigger …
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.
Response (North Middlesex Hospital): The hospital will conduct an education and awareness event at the next Orthopaedic Governance Meeting, introduce an additional step to the electronic discharge procedure, publish a VTE risk assessment template/flyer, …
Overdue
Trevor Oakley
Concerns: Night staff at the prison may not be immediately aware of which prisoners are due in court the following morning, potentially overlooking increased self-harm risks among these prisoners.
Response (Wye Valley NHS Trust): • The use of thromboprophylaxis to surgery has been relaunched and clarified to all pertinent staff, particularly the time period before which it should be withheld. • All speciality specific …
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.
Response (National Institute for Health and Care Excellence): NICE's guideline on epilepsies (CG137) is being updated, with a draft consultation expected in November 2020 and publication planned for June 2021. The update will consider the effectiveness of new …
Response (the Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns regarding annual reviews and highlights the Social Care Act 2014. They note that a LeDeR review is being conducted and that …
Response (Stockport Metropolitan Borough Council): Stockport Council is creating a dedicated review team of six social workers and a team manager to address the backlog of annual reviews in the Learning Disabilities Service, with an …
Responded
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.
Response (Care UK): Care UK has offered additional refresher ACCT training to all staff, to be provided by the prison within 12 weeks. They are also implementing a system to ensure senior oversight …
Response (HMP Dovegate): Care UK has offered additional refresher ACCT training to all staff, to be provided by the prison within 12 weeks. They are also implementing a system to ensure senior oversight …
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.
Response (Central and North West London Foundation Trust): Central and North West London NHS Foundation Trust has made changes to healthcare services at HMP Winchester, including internal training on SystmOne, Mental Health risk assessments and a joint learning …
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.
Response (Birmingham and Solihull Mental Health Trust): Birmingham and Solihull Mental Health Trust has provided pharmacists with additional training on Clozapine, will build further education into the Post Graduate Medical Education programme and is drafting a safety …
Response (Dept Health and Social Care): The Department of Health and Social Care notes that Birmingham and Solihull Mental Health NHS Foundation Trust has responded to the report by undertaking a review and update of its …
Responded
Alvin Black
Concerns: The report identifies concerns about the poor state of cleanliness at the prison's Health Care Centre, potentially increasing the risk of infection for prisoners; it also notes a missed opportunity to consider anti-coagulation therapy, with the system not picking up on this error.
Overdue
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.
Response (Practice Plus Group): Practice Plus Group has implemented measures to improve ambulance response times, including updating training materials to emphasize upgrading calls to category one when CPR is in progress. They have also …
Response (HM Prison and Probation Service): HMP Long Lartin updated local policies and issued Governor's notices regarding emergency incident reporting to the Emergency Control Room (ECR) and ambulance services. They created a checklist for ECR staff …
Responded
Corin Bonaparte
Concerns: An ACCT was not opened despite the patient seeking help from the mental health department at HMP Dartmoor and revealing recent self-harm, suggesting inadequate training; the ambulance was kept waiting 8 minutes at the main gate, suggesting inadequate arrangements for swift ambulance departure in emergencies.
Response (HM Prison and Probation Service): HMPPS has briefed staff and issued a Governor's order reinforcing the Local Security Strategy requirements for ambulance escorts. They also plan to work with the ambulance service on a contingency …
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
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
Committee Recommendations (6)
#8 — Charging bodies would benefit from improved sharing of best practice and expert advice.
Recommendation: We heard charging bodies would value more signposting of where to go for expert advice and support and to learn from others’ experience. DVLA told us that more can be done to share good practice and that it is important …
Gov response: 1. PAC conclusion: The Treasury is not doing enough to actively support government bodies in managing their fees and charges effectively, resulting in inconsistent and poor practices across departments. 2 1. PAC recommendation: Alongside its …
No Published Response
#43 — Prisoners are not receiving equivalent healthcare services compared to the wider population
Recommendation: Given the acute needs of those in prison, particularly regarding mental health, it is imperative that prisoners have access to good health and wellbeing services to assist them in properly engaging with rehabilitative programmes. However, despite the principle of equivalence, …
Gov response: Accept. The Government is committed to ensuring that people in prison have access to an equivalent standard, range and quality of health care in prisons to that available in the wider community. This is reflected …
Accepted
#25 — Support neighbourhood pilot sites to address digital interoperability challenges and share best practice.
Recommendation: In order for the neighbourhood pilots to realise the potential of the innovative model of care they are trialling, the Government should support the pilot sites to address challenges with digital interoperability, for example through sharing of learning and best …
No Published Response
#1 — Unmet need for mental illness treatment in prisons remains surprisingly high
Recommendation: While there have been improvements in prison mental healthcare, provision is still not adequate. The high unmet need for treatment for mental illness in prisons is surprising and disappointing. Around 10% of prisoners were recorded as receiving treatment for mental …
Gov response: NHS England and NHS Improvement has commissioned the Centre for Mental Health to conduct a National Mental Health Needs Analysis. This piece of work will give a good understanding of how current provision meets the …
Accepted
#35 — Direct College of Policing to collate and share best practices in modern slavery investigations.
Recommendation: In collaboration with the National Police Chiefs’ Council, the Home Office should direct the College of Policing to collate learning from forces that are effective in pursuing and investigating modern slavery and human trafficking and work with the Crown Prosecution …
Gov response: 37. Ofcom is operationally independent of Government. As set out in the Online Safety Act 2023, Ofcom has a tough suite of enforcement powers to use against companies who fail to fulfil their duties. This …
Under Consideration
#15 — HMPPS prioritises staff investment through pay and development to improve probation officer retention.
Recommendation: HMPPS told us it is seeking to improve the conditions of service for existing staff to assist with staff retention. It has implemented a new three-year pay deal and increased its focus on staff development and wellbeing. We asked whether …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented. 3.2 HMPPS will take a number of additional steps to retain and incentivise experienced staff over the next 12-18 months. 3.3 The agency will: • …
Accepted
PPO Death in Custody Recommendations (27)
The Head of Healthcare
The Head of Healthcare should ensure that clinical checks on prisoners who are refusing food and/or fluids are carried out and recorded appropriately to ensure risks are managed.
The Governor
The Governor should implement a process for monitoring food collection, to ensure follow up action can be taken where necessary.
The Head of Healthcare
The Head of Healthcare should ensure that staff are aware of their responsibilities under the food refusal policy, including sharing information with prison staff and completing an incident report.
The Director and Head of Healthcare
The Director and Head of Healthcare should remind staff that compassionate release applications on medical grounds may be made for prisoners who are incapacitated, and not only for those who are terminally ill.
The GP provider
The GP provider should review the prison GP wait times to ensure all is being done to bring it in line with community access to GPs.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff complete the medical risk assessment in full, including signing and dating the form.
The Governor
carry out fresh risk assessments for each escort when/if the prisoner’s condition changes to establish the appropriate level of restraints when travelling to and from hospital; and
The Head of Healthcare at Lewes
The Head of Healthcare at Lewes should ensure that a formal clinical handover is arranged for all complex mental health prisoners before transfer to a new prison.
Manx Care
Manx Care should ensure there is a dedicated lead pharmacy provision at Isle of Man Prison and there is a prescriber available every day, even if that is for remote prescribing.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are aware of the circumstances in which resuscitation is inappropriate.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners are kept informed of the status of their referrals to healthcare services, particularly when referrals are rejected. Information about repeated referrals should be clearly recorded and identify follow-up action.
The Governor
The Governor should ensure that there is an effective key worker scheme which provides meaningful and ongoing support to prisoners.
The Head of Healthcare
The Head of Healthcare should ensure that staff carry out a proper assessment of a prisoner after a use of force incident.
The Head of Healthcare
The Head of Healthcare should ensure that staff understand when they should make referrals under the suspected cancer pathway.
The Head of Healthcare
The Head of Healthcare should ensure that there is a robust blood test monitoring system in place so that samples that are lost, insufficient or mislabelled are reviewed and, if necessary, repeated.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff adhere to NICE Guidance [NG28] for patients presenting with raised blood glucose levels.
The Head of Healthcare of HMP Holme House
The Head of Healthcare should ensure that prisoners have access to appropriate therapy services, such as physiotherapy and occupational therapy, following major surgery.
The NHS Commissioner for Northeast and Yorkshire Region
The NHS Commissioner for Northeast and Yorkshire Region should write to the Ombudsman, setting out how they intend to improve mental health care at Wakefield, within twelve weeks of receiving our initial report.
The Head of Healthcare
The Head of Healthcare should ensure that there is an effective recall system for patients receiving regular injections such as Prostap.
The Head of Healthcare of HMP Holme House
The Head of Healthcare should ensure that prisoners with complex pain management needs have access to a local specialist pain service.
The Governor and Head of Healthcare
The Governor and Head of Healthcare will wish to consider this.
The Head of Healthcare
The Head of Healthcare will wish to consider this.
The Ministry of Justice’s Release Policy Team
The Ministry of Justice’s Release Policy Team should amend the ROTL Policy Framework to include that healthcare staff are consulted when there is information available to indicate concerns about a prisoners ability to comply with ROTL.
The Governor of HMP Manchester
It is important that Manchester continues to strive to meet its obligations in the matter.
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should review the disclosure of DNACPR instructions to custodial staff. Custodial staff should be aware of those who wish not to be resuscitated and have access to a DNACPR instruction form (which can …
The Governor
Ensure there is a robust quality assurance process in place to check that escort risk assessments properly consider the appropriateness of restraints based on the prisoner’s age, health and mobility.
The Director General of HMPPS and Prison Group Directors
The Director General of HMPPS should issue guidance to ensure that prisons are clear about their responsibilities to ensure that prisoners who attend court by video link are assessed for their risk of suicide and self-harm and seen by healthcare …
IOPC Learning Recommendations (1)
IMB Annual Reports (17)
Altcourse (2020)
HMP Altcourse maintained safety and humane treatment during the COVID-19 pandemic, with low levels of self-harm and violence. Staff and prisoner morale remained high due to positive staff attitudes and good communication, despite severe regime restrictions. Key concerns include the challenges of housing an aging prison population, delays in mental health transfers, and persistent issues with prisoner property and food quality.
PRISON
Key concerns
Bronzefield (2024)
Bronzefield faced significant challenges in the reporting year, primarily due to severe staff shortages impacting all aspects of the regime, leading to prisoners being locked up for extended periods and missing activities. Healthcare delivery was suboptimal due to lack of staff and poor coordination, resulting in medication delays and cancelled appointments. The prison also grappled with a high incidence of self-harm and challenges in managing complex, mentally unwell prisoners, compounded by external bed shortages.
PRISON
Key concerns
Youth estate (2020)
Pre-COVID, Boards raised concerns about high levels of violence, gang activity, and inadequate mental health resources, calling for cross-governmental action. During the first national lockdown, young people endured exceptionally restrictive regimes, locked in rooms for over 22 hours daily with minimal activity, severely impacting their mental and physical health and education. The pandemic exposed and exacerbated existing systemic problems, particularly in mental health, education, and progression, with an increased remand population further compounding issues.
PRISON
Key concerns
Highpoint (2021)
HMP Highpoint is a male Category C training and resettlement prison. The reporting year saw a positive reduction in self-harm and violence, with staff commended for humane Covid management. Key concerns include persistent issues with property transfers, under-resourcing in contracted services like mental health and education, poor maintenance by GFSL, and the ongoing security vulnerability from unrepaired netting.
PRISON
Key concerns
Aylesbury (2023)
HMP Aylesbury underwent a challenging transition from a Young Offender Institution to a Category C prison, which significantly impacted the regime, staffing, and healthcare provision. Staffing levels remained critically low, leading to limited purposeful activity and complaints about time spent in cells. Healthcare services experienced a chaotic start with a new, unprepared provider, though improvements were initiated by year-end. Despite a reduction in violence, concerns persisted regarding prisoner safety, drug use, and the prison's capacity to support resettlement for the 65 prisoners released directly from Aylesbury.
PRISON
Key concerns
Durham (2023)
HMP Durham, a Reception and Resettlement Prison for adult and young adult men, holds a significant population of unsentenced prisoners (75.6%). The past year has seen a notable increase in self-harm incidents (596) and total assaults (340), including those on staff (77), alongside 8 deaths in custody. Despite these challenges, 92% of prisoners report feeling safe, and the Board commends staff de-escalation techniques and efforts to reduce illicit item supply.
PRISON
Key concerns
Drake Hall (2023)
Drake Hall continues to provide a largely safe and humane environment, with commendable support for vulnerable women and effective management of challenging behaviours, although self-harm and violence have increased. Key concerns persist regarding the poor condition of Richmond and Plymouth houses, systemic issues with property, and healthcare resources being outstripped by the increasing complexity of the population's needs. The Board also highlights issues around staffing, regime restrictions, and the halting of planned capacity improvements.
PRISON
Key concerns
The Verne (2024)
HMP The Verne is a Category C training prison for sex offenders, holding 605 prisoners with an operational capacity of 608. The IMB noted generally good staff-prisoner relationships and effective healthcare, but raised significant concerns about the deplorable state of the healthcare building and kitchen roof. Key issues also include the barely functioning key worker scheme, a backlog in OASys assessments, and increased bullying linked to the prison's more moderate regime.
PRISON
Key concerns
Dovegate (2024)
HMP Dovegate, a privately run Category B training prison for men aged 21 and over, operated at or near its 1160 operational capacity during the reporting year. The Board observed generally calm wings with good staff-prisoner relationships and commended improvements in education. Key concerns include three deaths in custody, long healthcare and mental health transfer waiting times, persistent issues with lost property during transfers, and regime restrictions due to tight staffing levels exacerbated by a more complex prisoner population.
PRISON
Key concerns
Risley (2024)
HMP Risley, a large Category C training and resettlement prison with a complex population including PCoSOs and foreign nationals, faced significant challenges during the 2022-2024 reporting period. The Board noted extremely high and increasing self-harm rates, poor estate maintenance exacerbated by contractor issues, and insufficient purposeful activity spaces. Positive observations included well-managed mental health provision, improved resettlement planning for some groups, and a well-regarded chaplaincy team, but critical concerns remain regarding safety, infrastructure, and regime provision for the diverse prisoner population.
PRISON
Key concerns
Berwyn (2023)
HMP Berwyn faced staffing shortages and a more challenging prisoner cohort, impacting regimes and increasing violence in early 2023, despite overall reductions in self-harm and staff assaults. The Board noted positive staff-prisoner relationships, comprehensive resettlement services, and strong education/work provisions. However, significant concerns remain regarding healthcare (medication restrictions, mental health transfers, appointment attendance), estate maintenance, and the need for improved staff training and activity for vulnerable groups.
PRISON
Key concerns
Coldingley (2023)
HMP Coldingley, a Category C training prison, maintains a relatively open regime and positive staff-prisoner relationships, contributing to low self-harm levels. However, the Board notes a concerning rise in violence, use of force, and illicit substances, often linked to population pressures and insufficient new arrival checks. Significant challenges remain, including dilapidated older wings lacking in-cell sanitation, a struggling kitchen, and persistent issues with lost property and perceived disproportionality in treatment for some ethnic minority groups.
PRISON
Key concerns
Belmarsh (2023)
HMP Belmarsh operates as a Category A men's prison, holding approximately 650 prisoners with an operational capacity of 814. The report highlights both positive developments, such as improved induction processes, a new employment hub, and dedicated staff supporting vulnerable prisoners, alongside significant concerns. Key issues include persistent property loss, prolonged waits for mental health transfers, a restricted regime limiting purposeful activity for many, and staffing challenges impacting key worker provision and educational opportunities. The IMB urges HMPPS and the Governor to address these long-standing issues and improve the daily life and progression pathways for prisoners.
PRISON
Key concerns
Bristol (2023)
HMP Bristol faced significant challenges in the reporting year, marked by an increase in deaths in custody (9), self-harm, and violence, alongside persistent overcrowding at over 50% capacity in single cells. Staffing shortages severely impacted regime delivery, leading to increased time in cell and reduced access to purposeful activity. The Board expressed concern that the HMIP Urgent Notification Action Plan did not adequately address systemic issues such as occupancy levels or substantive staff numbers, hindering effective prisoner care and safety improvements.
PRISON
Key concerns
Bure (2023)
HMP Bure, a Category C prison primarily for older prisoners, maintains a calm and safe environment with good staff-prisoner relationships and effective healthcare, including a fully staffed mental health team. Key concerns include insufficient purposeful activity, inconsistent key worker engagement, and the significant impact of not having formal medical care on-site at night. Persistent estate maintenance issues and a call for the re-sentencing of IPP prisoners highlight areas requiring urgent attention from both the prison and the Ministry of Justice.
PRISON
Key concerns
Exeter (2023)
HMP Exeter faced another challenging year, operating under an Urgent Notification due to high levels of violence and self-harm, alongside significant staffing instability, particularly in healthcare. Major refurbishment projects continued, impacting operational capacity and regimes, compounded by persistent overcrowding and unsuitable conditions in the temporary Care and Separation Unit. While improvements were noted in induction processes and use of force governance, critical issues like security vulnerabilities, challenges in purposeful activity due to high turnover, and deficiencies in property management remained key concerns.
PRISON
Key concerns
Bronzefield (2023)
HMP/YOI Bronzefield is a privately run local prison for female remand and sentenced prisoners, with an average population of 471 and Certified Normal Accommodation of 542. The reporting year saw concerns over staffing shortages impacting regime, increased healthcare complaints following a contract change, and a significant number of prisoners released without safe accommodation. Positive developments included the implementation of PPO recommendations, a new Employment Hub, and re-established gardening team.
PRISON
Key concerns
IMB Recommendations (380) — showing 50 strongest matches
Drake Hall (2021)
Additionally, during the year the prison had to deal with a prisoner experiencing difficulties associated with an eating disorder. However, no facility existed that could provide specialist services for this individual. As a result, the prison was forced to manage the situation without specialist support. This constitutes a service deficit (see section 6.3).
HMPPS
Whatton (2022)
Will the Prison Service, once again, consider substantial refurbishment or replacement of the healthcare facilities so that they match those expected in the community?
HMPPS
Long Lartin (2023)
Healthcare Centre (HCC). What full programme of measures is planned to provide an acceptable level of care for inpatients?
HMPPS
Lincoln (2025)
The Board recommends that provision is put in hand to deal with the problems arising from the Victorian infrastructure for the increasing numbers of frail older people, particularly those with dementia, end of life care and disabled prisoners.
HMPPS
Portland (2020)
The provision of healthcare services has suffered for lack of a psychologist and psychiatrist at times during the reporting period. The appointment and retention of psychologists and psychiatrists to posts in Portland have been problematic since the contract transferred from the local health authority. It would be helpful if the reasons for this could be explored and, where possible, addressed.
Governor / Director
Featherstone (2020)
While the performance of healthcare staff appears adequate, there are a number of concerns: attendance at segregation reviews and use of force incidents; the monitoring of self-dispensing of medication held by prisoners; the operation of the healthcare complaints procedure; the thoroughness of mental health reviews and the reporting relationship with general healthcare. Can the Governor discuss these shortcomings with the …
Governor / Director
Drake Hall (2020)
The Board is interested in how the prison will mitigate the long-term impact of the pandemic on some prisoners’ mental health.
Governor / Director
Dovegate (2021)
Accelerate plans for the conversion of the in-patient unit in healthcare to provide consultation and treatment rooms adequate for the number of residents in the prison. Should it be decided not to proceed with the above, then urgently upgrade the inpatient bath/shower room.
Governor / Director
Altcourse (2021)
The transfer of seriously mentally ill prisoners to appropriate healthcare facilities continues to be a problem, with one particular prisoner spending over 300 days in segregation this year. This case was escalated to a national level. In addition we are concerned about the long-term legacy of the pandemic on prisoners’ mental health. Altcourse is already seeing more seriously ill men …
Ministry of Justice
Whitemoor (2022)
Will the minister please secure the cooperation of the Department of Health and other interested parties to conduct a wide-ranging review of the role and capacity of the secure hospitals and their relationship with the prison service?
Ministry of Justice
Peterborough (Men) (2022)
Because of the widespread perception among prisoners that all Healthcare services (Clinical, Mental, and substance misuse) are not up to the standard expected, going forward the prison should prioritise the review and monitoring of Complaints to Healthcare e.g. in the Monthly Clinical Governance Meeting, to ensure that standards are maintained and improved.
Governor / Director
Gartree (2022)
Therefore, can the Prison Service confirm to the Board that the integrated health services at Gartree are achieving the outcomes expressed in various commissioning documents, and that the healthcare is equivalent to the local wider community (i.e. the Market Harborough district)?
NHS / Healthcare Provider
Durham (2022)
How will you ensure that all prisoners in reception receive healthcare screening before moving to first night centres (4.1.6)?
Governor / Director
Buckley Hall (2022)
Ensure an effective and valued healthcare provision.
Governor / Director
Thameside (2023)
We urge the Minister to look at the problem of transferring mentally ill prisoners to a secure hospital setting again, as the establishment of the Transfer Time Limit Working Group (TTLWG) has not improved the situation for mentally ill prisoners at HMP Thameside.
Other
Swinfen Hall (2023)
Can the Minister liaise with other departments to create a detailed and funded plan for sufficient spaces in secure mental health units to reduce the number of seriously mentally ill being held in prison, especially in segregation units?
Ministry of Justice
Liverpool (2023)
The Board has repeatedly raised concerns around the inhumane length of time prisoners experiencing mental health illness are kept segregated whilst waiting for transfer to an appropriate mental health establishment. A recent example is a prisoner who spent 377 days in the CSU waiting for a transfer, which the Board view as completely inhumane. What immediate action will the Minister …
Other
Hollesley Bay (2023)
The need for hourly observations over prisoners arriving too late to be seen by the healthcare department highlights an important need. Those responsible for transport should be aware of those prisons without 24-hour healthcare provision.
HMPPS
Gartree (2023)
We ask the Minister to explain how the Ministry of Justice perceives the performance of prisoner healthcare at HMP Gartree when compared against the performance specification in the contract.
Ministry of Justice
Eastwood Park (2023)
Women with mental health issues and complex needs would be better treated in the health system rather than the criminal justice system. Women with complex needs continue to have delays in transferring to a secure hospital. Are there plans to address this concern?
Ministry of Justice
Downview (2023)
As commented on last year, the considerable rise in the number of prisoners being transferred to the prison, often from HMP Bronzefield, who exhibit more challenging mental health symptoms and consequent behavioural issues is causing safety concerns. Prison is not an appropriate environment for these women and staff do not have the appropriate training to manage them. The Board is …
Other
Dovegate (2023)
Ensure there is enough staff to make sure all health care appointments are attended.
Governor / Director
Dartmoor (2023)
The commitment by the new healthcare provider, Oxleas NHS Foundation Trust, to provide overnight care at a category C prison in Devon - which will be a pathway available to prisoners at HMP Dartmoor - has not yet materialised. What is the progress on this initiative and when will it be introduced?
NHS / Healthcare Provider
Ashfield (2023)
With the large number of elderly prisoners in the custodial estate (particularly in prisons such as Ashfield), cases of dementia and terminal illness requiring 24-hour care are increasing. The specific needs of these prisoners cannot be adequately met in normal prison conditions. What plans does the Prison Service have for addressing this issue through the creation of specialist custodial centres?
HMPPS
Wealstun (2024)
As referenced in our previous report, what steps will the Minister take to ensure that prison is not used to house severely mentally ill people whilst they await a place in a suitable institution?
Ministry of Justice
The Verne (2024)
HMPPS to ensure funding for an alternative accommodation for the healthcare unit.
HMPPS
The Mount (2024)
The Prison Service should consider what can be done with existing resources to better support IPP prisoners (see §7.3.1).
HMPPS
The Mount (2024)
The continued detention of prisoners long after they have served the punitive part of their sentence can only be morally justified if they are given all the support they need to become ready for release and if the conditions for such release are clear and objective. This should not be conditional on their being able to demonstrate that they are …
Ministry of Justice
Thameside (2024)
The Board would like the new Minister to look at the continued lengthy delays in transferring mentally ill patients from a custodial setting to a secure hospital setting, an issue highlighted by this Board and the majority of other IMBs across the country for several years. In the Board’s view, these delays are not only inhumane for the patients involved …
Ministry of Justice
Nottingham (2024)
Again, the Board raises its continuing concern about prisoners who are seriously mentally unwell being held in prison and frequently having to be detained in the Care and Separation Unit. Prison is not the appropriate environment for prisoners who are severely mentally unwell. We again ask for greater provision to be made available for such prisoners so they can be …
HMPPS
Northumberland (2024)
What measures can be implemented to ensure mental health support is available within a reasonable timeframe to prisoners who require it?
Ministry of Justice
New Hall (2024)
What will the Minister do to help accelerate the process of transferring prisoners with mental health issues to secure units?
Other
Long Lartin (2024)
Healthcare centre (HCC): what full programme of measures is planned to provide all necessary facilities (including end of life) for in-patients?
HMPPS
Leicester (2024)
What actions will the Minister take, together with colleagues in health commissioning, to ensure there are sufficient secure hospital places to cope promptly with the demand?
Ministry of Justice
Leeds (2024)
The IMB has seen no improvement in the extent to which prisoners who have been assessed as requiring treatment in secure mental health facilities are quickly removed to those facilities. Does the Prison Service agree that, whilst the prison may be a safe place to hold those prisoners, it is not an appropriate place to do so and what is …
HMPPS
Lancaster Farms (2024)
When will the Minister increase the number of specialist secure prison settings for prisoners with complex and/or enduring mental health conditions?
Ministry of Justice
High Down (2024)
The Government should address the physical needs of the ageing prison population, including social care provision, accessibility, purposeful activity for retired prisoners and end of life care.
Ministry of Justice
Featherstone (2024)
Issues with low numbers of healthcare staff have, on occasion, meant that the regime has been disrupted because of delays dispensing medication. This has been an ongoing issue and consideration should be given as to whether the system can be changed to increase its reliability and consistency.
Governor / Director
Featherstone (2024)
Mental illness is a serious issue within prisons. The compassionate answer appears to be to locate some of these prisoners in isolation in the CSU, where largely untrained staff attempt to deal with them in a humane way. This is not acceptable and there needs to be a way of speedily transferring these prisoners to more appropriate accommodation that can …
HMPPS
Exeter (2024)
Given the high proportion of prisoners with mental ill health, will the Prison Service ensure the delivery of standalone mental health training for all officers?
HMPPS
Exeter (2024)
When will the non-statutory independent role, referred to in the Minister’s response last year, improve the timely transfer of prisoners with serious mental health conditions?
Ministry of Justice
Altcourse (2024)
Can an assurance be given that the provision of hospital escorts will be prioritised?
Governor / Director
Usk and Prescoed (2025)
HMPPS should consider specific measures to address the increased demand for general and palliative healthcare, additional resources and funding (e.g., expanded weekend services, more staff for hospital escorts), and the unsuitability of HMP Usk's current infrastructure for older individuals, ensuring plans meet complex needs in the medium to long term.
HMPPS
Nottingham (2025)
As referenced in our previous report, we again raise with the Minister the issue of the wellbeing of prisoners who are severely mentally ill. The Board remains concerned at the length of time it takes for suitable places in secure mental health hospitals to become available. This means that severely unwell prisoners are having to be detained in the care …
Other
Moorland (2025)
What more will the Governor do to improve the quality of health care provided?
Governor / Director
Leicester (2025)
What pathways can be developed for prisoners with severe dementia to meet their needs in specialist facilities in prison or community facilities?
Other
Bure (2025)
Are there plans to provide specialised units for dementia and geriatric healthcare, given the increasing age profile and fragility of many prisoners? This is especially required in those prisons like HMP Bure that do not have 24/7 healthcare on site.
NHS / Healthcare Provider
Ashfield (2025)
Inadequate social care, including end-of-life and dementia care, for people convicted of sexual offences. With an increasing older population, what additional measures will be taken to assist prisons such as HMP Ashfield?
Other
Lancaster Farms (2022)
Given concerns expressed above to invite Department of Health colleagues to work with the Minister to review the capacity associated with the provision of mental health services across the prison estate for those prisoners with severe and enduring mental illness.
Other
Whatton (2020)
The standard of the accommodation in the healthcare centre remains a significant concern, as indicated in our letter to the minister in April 2020 (see paragraphs 6.1.8 to 6.1.11). Will the Prison Service consider substantial refurbishment or replacement of the healthcare facilities, now that more capital funding has been made available?
HMPPS
Article 2 Learning Points (90)
— LP 1
I recommend that, those responsible for healthcare governance at HMP Lincoln and HMP Ranby: identify the requirements of good practice in the specific areas identified below, in the light of the problems that occurred in this case and taking account of NHS and NOMS policies; review their current arrangements and …
HMP Lincoln, HMP Ranby
— LP 2
I recommend that NHS England and NOMS: take note of the findings in Chapter 11, and consider jointly in the light of this investigation whether the lessons of this investigation have a wider application; in particular, that they consider whether they are satisfied that adequate arrangements are now in place …
NHS England, NOMS
— LP 4
We recommend that people presenting with multiple complex symptoms, in particular in the context of a serious episode of self-harm, should have a full diagnostic psychiatric and suicide/self-harm risk assessment, highlighting triggers for self-harm and likely high risk times, with contingency planning.
HMPPS
Accepted
— LP 2
We recommend that across the Prison Service Estate nationally there is enhanced provision for the assessment and treatment of alcohol misuse and dependence disorders.
HMPPS
Accepted
— LP 17
To make better use of pre‐existing information, we recommend that psychiatric assessment guidelines used on HMP Pentonville’s Healthcare unit reference the need to source and consider the results of medical and psychiatric assessments that may have been conducted by other institutions.
PPG
Accepted
— LP 15
We recommend the ongoing use of the record‐keeping audit tool being used on HMP Pentonville’s Healthcare unit, whilst ensuring that it continues to make a tangible difference and informs decision‐making, rather than being seen as a paper‐filling exercise. Showing staff exactly how it is making a difference should further encourage …
PPG
Accepted
— LP 12
We recommend that HMP Pentonville’s Healthcare unit reviews its use of ‘Special Observation forms’ and clarifies what value, if any, they are adding to the care and management of a prisoner who is on an observation regime.
PPG
Accepted
— LP J
When a prisoner is identified as requiring assessment by a psychiatrist, he should be escorted to that appointment where necessary. If, for whatever reason, such an appointment is missed, medical staff should ascertain the reasons for the missed appointment on the same day.
HMPPS and PPG
— LP H
A much more robust system should be in place to account for missed medical appointments. This system should explore reasons for non-attendance, emerging patterns of non-attendance and identify vulnerable prisoners. As happened with the Substance Misuse Team, two consecutive failures to attend GP appointments should trigger a visit to the …
HMPPS and PPG
— LP F
Drug Dependence Reviews of dual diagnosis patients should consider the range of medication prescribed to a patient.
PPG
— LP E
In a case where a prisoner has both substance misuse and mental health problems – so-called dual diagnosis – a joint assessment by a mental health and a substance misuse specialist should be carried out.
PPG
— LP C
In the period between an assessment by the Mental Health Outreach Team and a decision about whether to accept a prisoner on to the caseload, a pending case should be subject to a provisional zoning priority. A system of monitoring and auditing compliance with the zoning protocol should be in …
PPG
— LP B
The Medical Record should be properly updated within 24 hours of any action taken or decisions made.
PPG
— LP 5
We recommend that policy on the sharing of medical information in the prison setting is clarified and a training programme established to ensure staff understand its implications.
HMPPS
Accepted
— LP 8
I recommend to NOMS that: An inquiry into an incident of life-threatening self-harm should always include an examination of healthcare as well as the actions of the discipline staff. Findings and conclusions should take account of both aspects considered jointly.
NOMS
— LP 8
HMPPS should ensure that liaison between Article 2 investigators and prisons is improved by ensuring that the member of staff in an establishment appointed to liaise: a) understands the nature of the Article 2 process, and b) is of sufficient seniority to direct staff and resources to facilitate the investigation.
HMPPS
Accepted
— LP 7
HMPPS takes steps to reduce the time between incidents and the commission of Article 2 Investigations.
HMPPS
Accepted
— LP 6
As the impact on staff well-being of traumatic incidents may not be immediately apparent, all staff should be actively encouraged by their managers to access staff care services following such incidents.
HMPPS
Accepted
— LP 5
As a considerable time may pass before an Article 2 investigation is commissioned, HMPPS should clarify whether the prison is responsible for completing a full investigation where serious harm to an individual has been sustained.
HMPPS
Accepted
— LP 4
HMP Durham should review the minimum staffing level needed to safely oversee prisoners taking part in association.
HMP Durham
Rejected
— LP 3
In order to reduce congestion in and around showers and make observation easier HMP Durham should introduce a prisoner reservation booking system for the use of showers.
HMP Durham
Partially Accepted
— LP 2
In order to reduce the risk of violence to prisoners the Violence Reduction Strategy should be monitored by managers to ensure that all prisoners to whom it applies are included and steps taken to reduce their likelihood of potential violence.
HMP Durham
Accepted
— LP 1
In order to reduce the risk of harm posed by prisoners to other prisoners’ Cell Sharing Risk Assessments should be better recorded and steps to mitigate risk of harm clearly stated. In addition, there should be a system for retrieval of the document upon request.
HMP Durham
— LP 5
We invite the Governor to examine whether the 12 minutes from arrival at the prison to attending a patient on K wing is unavoidable or whether the process of accessing the wings in emergencies can be made more efficient.
HMPPS
Accepted
— LP 4
We recommend that the Governor of Stocken (locally) and HMPPS (nationally) review the present arrangements for communications with the ambulance services to examine whether current policy and practice appropriately reflects the ambulance services’ system of allocating priorities.
HMPPS
Accepted
— LP 3
We recommend that PPG review their protocols for supplying data for the investigation of a suspected crime where the alleged victim has no capacity to give or withhold consent. Any request to disclose information to the police should be recorded, with a note of the reasons for the decision to …
PPG
— LP 2
We recommend that the prison takes note of the problems that occurred in this case and ensures that where the police are investigating an incident in the prison, clear arrangements are made for a single point of contact in the prison and for another staff member to deputise if they …
HMPPS
— LP 11
We recommend that in the Prison Service nationally, for prisoners with complex and serious medical conditions, the need for ongoing use of handcuffs should be regularly reviewed, with a full assessment of risk to the public and of absconding, and that this should be clearly documented in the case notes.
HMPPS
Accepted
— LP 9
We recommend that Doncaster Prison develops a robust system for testing and ensuring that all medical devices, including defibrillators, are in full working order.
The Governor
Accepted
— LP 3
We recommend that across the Prison Service Estate there is more focus on conducting full psychiatric and psychological assessments of prisoners, particularly those with complex needs. This should include the gathering and assimilation of all relevant previous records. This process should be followed by a full psychological formulation with longitudinal, …
HMPPS
Accepted
— LP 1
We recommend that across the Prison Service Estate nationally there is a review of psychological therapy provision and an audit of the use of antipsychotic medication for agitation, in the absence of a diagnosis of psychosis. There should be enhanced provision of psychological therapies nationally and cessation of inappropriate use …
HMPPS
Accepted
— LP 3
HMP Featherstone should comply with the mandatory action contained in Prison Service Order 1300 – ‘Investigations’ that a formal investigation is completed when there is serious harm to any person.
HMP Featherstone
Accepted
— LP 2
HMP Featherstone should review its procedures so that families are informed of a prisoner’s illness with a minimum of delay.
HMP Featherstone
Accepted
— LP 1
HMP Featherstone and the health care providers in the prison should explore how to maximize information-sharing between Health Care and Security so that both of these components of care can work together to reduce the ingress and use of illicit substances in the prison. This includes the completion of agreed …
HMP Featherstone, Midlands Partnership NHS …
Accepted
— LP 3
I recommend that all prisoners should have a mental health assessment within 72 hours of entering custody, for case-finding. Prison Service Instruction (PSI) 74/2011 Early Days in Custody – Reception In, First Night in Custody, and Induction to Custody indicates that all prisoners should have a health review within a …
HMP Altcourse and HMPPS
Partially Accepted
— LP 19
We recommend that officers’ attendance at ward rounds is embedded as a norm on HMP Pentonville’s Healthcare unit, if this is not already the case. This should help further improve understanding and promote a sense of collegiate working among discipline and clinical staff.
PPG
Accepted
— LP 3
We recommend that HMP Pentonville’s Healthcare unit keeps a log of temporary staff who have received a prison induction, whether they be booked through NHS Professionals or otherwise. We think it’s important that this log is easily accessible and made visible to help promote ownership for the provision of these …
PPG
Accepted
— LP 1
At an organisational and cultural level, we recommend that further measures are taken to close the perceived gap between the main prison and the Healthcare unit at HMP Pentonville. This should help create a greater sense that HMP Pentonville is functioning as one organisation, comprised of staff and managers working …
HMPPS
Accepted
— LP 13
Prisoners on Level A of the Safe Supervision of Prisoners (in-patients) policy should be reviewed on a daily basis in accordance with that policy and these reviews should be documented.
The Governor
Accepted
— LP 3
As a considerable time may pass before an Article 2 investigation is commissioned, HMPPS should clarify whether the prison is responsible for completing a full investigation where serious harm to an individual has been sustained.
HMPPS
Accepted
— LP 2
The in-reach team should consider whether an algorithm based on risk presentation that is high, medium or low, would help to dictate time-frames for specific actions to be taken.
Central and North-West London NHS …
Accepted
— LP 1
The psychiatric in-reach service at HMP High Down should consider the delay in completing the actions arising from the assessment on GN in October 2015 and describe the current arrangements for avoiding such delays.
Central and North-West London NHS …
— LP 12
We recommend that GEOAmey review the staff training modules on mental health awareness and interpersonal skills in the light of Dr Craissati’s advice in paragraphs 5.42 to 5.46, noting in particular her focus on behaviours likely to be encountered in a prisoner population, and in developing skills in listening, exploring, …
GEOAmey
Accepted
— LP 11
We recommend that GEOAmey puts in place express policy for aftercare for staff involved in a serious incident through immediate informal support from managers, and further recognition over a longer period, as well as access to independent counselling for staff who wish to use it.
GEOAmey
Accepted
— LP 10
We recommend that GEOAmey and HMPPS consider how friends and families of prisoners at risk can be encouraged and enabled to pass on any concerns about risk of self-harm. Protocols may be required as to how to reconcile requirements of privacy and requirements of safe custody that may be in …
GEOAmey and HMPPS
Accepted
— LP 1
We recommend that PECS and GEOAmey review the number of custody officers required in the Southampton Magistrates’ Court custody suite and how they are deployed.
PECS and GEOAmey
Accepted
— LP Healthcare 7
An auditable system should be implemented to monitor completion of annual resuscitation training updates for staff within the healthcare team.
Healthcare Provider
— LP Healthcare 6
Individual staff log-in details should not be shared or used by other members of the healthcare team to make entries to the electronic Patient Record.
Healthcare Provider
— LP Healthcare 5
Paper documentation which is generated and subsequently scanned to the electronic Patient Record should clearly identify the location, date, time and author along with their designation.
Healthcare Provider
— LP Healthcare 4
The date and time of an individual’s transfer to secondary care and discharge back to prison should be documented in the clinical record. This should include any required actions which are identified on discharge from secondary care.
Healthcare Provider
Detention Investigations (2)
Assessment of government progress in implementing the report on the … — Rec 4
I remain concerned about the position of detainees held in the prison estate and recommend that a policy be developed to equate to Detention Centre Rule 35.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 3
The Home Offce should establish a joint policy with HMPPS on provision for those held in prison under immigration powers.
Immigration Detention
PHSO Casework Decisions (4)
P-003496 — An independent provider in the Isle of Wight …
Mr K complains about his care and treatment between February and June 2023. He complains he was unable to attend some medical appointment because nobody sent for him, he has not had dental treatment since May 2023 and he is not allowed to hold medicine in his cell.
NHS in England
Apr 2025
P-003565 — Oxleas NHS Foundation Trust
Mr R complains about the care and treatment he received from two prisons. Mr R says he did not receive appropriate pain management or care in relation to his mental health.
NHS in England
Not Upheld
Dec 2024
P-003123 — Oxleas NHS Foundation Trust
Mr A complains about the Trust’s decision to transfer him back to prison without properly considering his mental health.
NHS in England
Nov 2024
P-004363 — An independent provider in the Wychavon area
Claimed failings: Mr F complains between 13 June 24 to 24 June 24 he was refused access to healthcare as the prison would not transport him to A&E after sustaining an injury to his hand. Mr F also tells us he was not given the pain medication he required and …
NHS in England
Nov 2025
LGO / SPSO Decisions (15)
201304654 — Scottish Prison Service
Mr C complained that a prison manager had refused to contact the on-call doctor after Mr C was sick and got something stuck in his throat, causing him chest pain. Mr C said that the prison did not act in accordance with the prison rules because a healthcare professional must …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Feb 2015
201507736 — Scottish Prison Service
Mr C complained to the Scottish Prison Service (SPS) about the time it took prison staff to escort him to the health centre located within the prison. Mr C, who has diabetes, was unhappy it took two hours to receive assistance with his insulin pen. He also felt the SPS's …
SPSO (Scottish Public Se…
Prisons
Upheld
Jul 2016
PSOW-202403715 — Cwm Taf Morgannwg University Health Board
Mr A complained that he had to write 3 letters to Cwm Taf Morgannwg University Health Board before it responded to his concerns about his son’s healthcare in prison. Mr A was dissatisfied with the Health Board’s complaint response, the handling of his complaint, and the provision of information. Mr …
PSOW (Public Services Om…
Health
Jan 2025
201508349 — Scottish Prison Service
Ms C complained that the Scottish Prison Service (SPS) failed to take reasonable action after she reported feeling unwell. She was also dissatisfied with the way in which the SPS dealt with her complaint. We did not reach a decision on Ms C's complaint as she was released from prison …
SPSO (Scottish Public Se…
Prisons
Dec 2016
NIPSO-202004929 — South Eastern Health and Social Care Trust
A man claimed that prison authorities unfairly denied him treatment for his opioid addiction. We did not uphold the complaint but made observations on the case for the Trust to consider going forward.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Dec 2024
PSOW-202105815 — Betsi Cadwaladr University Health Board
Mr J complained about the lack of care and treatment provided by Betsi Cadwaladr University Health Board (“the Health Board”) from May 2021 in response to concerns he raised about experiencing chest pain, blood in his stools and knee pain. The Ombudsman’s investigation concluded that Mr J’s presenting symptoms, which …
PSOW (Public Services Om…
Health
Upheld
Dec 2022
201102802 — Scottish Prison Service
Mr C, who is a prisoner, complained because he was unhappy with the delay in him being able to access the smoking cessation programme. Our enquiries with the prison confirmed that prisoners are selected onto the programme in line with their liberation date and because of that, we were satisfied …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Feb 2012
201101364 — Scottish Prison Service
Mr C, who is a prisoner, complained because he felt the prison were failing to issue privileged mail to prisoners with a reasonable time in accordance with published standards. Privileged mail is mail sent to a prisoner from their legal representative, the courts and other organisations, such as SPSO. Our …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Dec 2011
201404480 — Scottish Prison Service
Mr C complained to us that the Scottish Prison Service (SPS) had appointed a person to carry out an assessment who did not meet the stated criteria specified in the tender document. We took independent advice from one of our medical advisers, who is a consultant psychiatrist. We found that, …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jan 2016
201709050 — Scottish Prison Service
Mr C complained that the Scottish Prison Service (SPS) stopped his Special Escorted Leave (SEL). He also complained about the handling of his complaint. We found that the prison did not stop Mr C's access to SELs but, within their authority under the relevant legislation, they questioned Mr C's need …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Jan 2019
201200020 — Scottish Prison Service
Mr C, who is a prisoner, complained that the Scottish Prison Service (SPS) unreasonably failed to comply with their statutory and procedural duties to him as a disabled prisoner. However, Mr C was freed from prison whilst we were investigating his complaint and did not provide us with a contact …
SPSO (Scottish Public Se…
Prisons
Jan 2013
201303091 — Scottish Prison Service
Mr C, who is a prisoner, complained because he said the prison failed to take reasonable steps to improve television reception. He said his in-cell signal was poor and although repair work had been carried out, the problem was not fixed. The prison told us that the repair work indicated …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Mar 2014
201304894 — Scottish Prison Service
Mr C complained that the prison he was in failed to make adequate arrangements for the provision of halal food. He said that he wanted the imam for the prison to taste random halal meals, as he considered that the halal goods brought into the prison were not halal by …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jan 2015
201407669 — Scottish Prison Service
Mr C alerted staff in the prison that he was experiencing chest pain, and it was agreed that he should attend hospital. However, Mr C decided not to attend and staff agreed to carry out regular observation checks on him throughout the night. Mr C complained because he said staff …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jul 2015
201504160 — Scottish Prison Service
Mr C complained that there was inadequate choice to meet his food preferences in prison. For example, he liked plain food, rather than curried or spicy food. We considered the relevant prison rule about the provision of food in prison and looked at sample menus. The prison also explained how …
SPSO (Scottish Public Se…
Prisons
Not Upheld
May 2016