Jonathan Thornton

Dear Ms Pountney

RE: Regulation 28 Report Concerning Jonathan Mark Thornton

We write in response to your Prevention of Future Deaths Regulation 28 (‘Report’) dated 8 April 2026 concerning the death of Jonathan Mark Thornton on 12 July 2024. Before responding to the matters of concern you have included within your Report, I would like to express my condolences to Mr Thornton’s family and loved ones. From your Report, we understand that you have concerns about information sharing between the community forensic and prison healthcare teams; information sharing between the prison healthcare team and operational prison staff; and categorisation and visibility of alerts on National Offender Management Information System / Digital Prison Services (NOMIS / DPS). You have asked The Trust to either provide details of action taken, or proposed to be taken, setting out the timetable for action. Otherwise, the Trust must explain why no action is proposed. Please find below our response to your concerns detailing the actions being taken.

Cont’d/…

Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW

Information sharing between the Community Forensic Team and Prison Healthcare

We agree with your statement in your Report that the handover of information between Community Forensic Team and Prison Healthcare is vital for the risk assessment and management of prisoners who are known to the Community Forensic Team.

As you know, since Mr Thornton’s death, the responsibility for Community Forensic and Prison Healthcare teams has changed. Northamptonshire Healthcare NHS Foundation Trust now runs the Prison Healthcare team at HMP Nottingham and Nottinghamshire Healthcare NHS Foundation Trust continues to run the local Community Forensic Team.

We have put practical arrangements in place between the Community Forensic Team and the Prison Healthcare Team at HMP Nottingham to make sure information is shared smoothly when someone comes into custody. This includes holding named contacts in each team.

The national SEAT template is completed for everyone arriving at HMP Nottingham. It prompts conversations about their mental health, any current concerns, and whether they have been involved with community services. This helps the prison healthcare team quickly connect with the right services and gather any information needed to support the person’s care.

While forensic services use a different patient record system to that used by community and prison healthcare services (SystmOne), the arrangements we have put in place mean that information is now passed on more reliably and people receive better-connected care when they come into custody. If information has already been recorded on SystmOne, the team at HMP Nottingham can see this straight away when the person arrives, which helps avoid delays.

Information sharing between Prison Healthcare and Operational Prison Staff

From our experience providing prison healthcare services across the wider East Midlands and East of England regions, we understand the importance of effective communication and working relationships between Prison Healthcare and Operational Prison staff in maintaining the health and safety of prisons and staff at HMP Nottingham. Cont’d/…

Trust Headquarters: St. Mary’s Hospital, London Road, Kettering, NN15 7PW

Since taking over responsibility for healthcare services at HMP Nottingham on 19 November 2025, we have put in place regular and consistent ways of sharing information within the prison. This includes routine contact through daily morning briefings, SIM meetings, drug strategy discussions, and ongoing conversations with colleagues in reception, healthcare, and across the house blocks.

Alongside these planned touchpoints, staff also speak with each other by phone and email whenever concerns arise or when advice and support are needed. This mix of structured meetings and day-to-day communication helps ensure that important information is shared quickly and that any issues can be picked up and acted on without delay.

Categorisation and visibility of alerts on NOMIS/DPS

Your Report acknowledges that the Ministry of Justice (MoJ) is responsible for the NOMIS/DPS and states that you have sent a copy of this report to the Ministry of Justice for their response. We shall therefore defer to the MoJ in responding to your concerns about alerts within NOMIS/DPS.

To the extent that our involvement is required, we shall collaborate with both the MoJ and Governor of HMP Nottingham in making the necessary changes to NOMIS/DPS to address the concerns you raised in your Report.

I hope the content of this letter fully addresses the concerns you raised in your Report and provides assurance on the steps we have taken. Please contact me if you have any questions about this letter or require further information.

Dear Ms Pountney

Regulation 28 Response: Mr. Jonathan Thornton

| write in response to the inquest which was concluded on 17 February 2026 into the death of Mr. Thornton and the Regulation 28 Report to Prevent Deaths received on 8 April 2026. We extend our sincere condolences to the family of Mr Thornton. The Trust is committed to learning from this case and ensuring that the issues identified by the coroner are addressed in full to reduce the risk of future deaths.

Please find below the Trust response in relation to the relevant matter of concern and actions taken.

Information sharing between the Community Forensic Team (CFT) and Prison Healthcare

The coroner found that:

e There were barriers to information sharing between the CFT and Prison Healthcare.

e There was no formal system for handover at the time of the death or at the conclusion of the inquest.

e Prison Healthcare staff were often unavailable or uncontactable for handover discussions.

e The lack of structured information sharing created a risk of future deaths, particularly given the complexity and risk profile of individuals known to the CFT.

The Trust accepts these findings. Actions Taken to Date
1. Introduction of a Formal Information-Sharing Guidance Document (December 2025)

The Trust developed and implemented a formal guidance document titled: Community Forensic Services — Quick Reference Guide: Sharing information following transfer to prison. The document sets out the process for staff to follow in the event a patient is remanded or sentenced to prison and requires that staff share relevant risk and clinical information with the receiving healthcare professionals in the custodial setting.

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2. Guidance Embedded Within the CFT Internal Working Instruction

This guidance now forms part of the CFT Internal Working Instruction and is therefore embedded within the team’s core operational framework. It is subject to annual review, ensuring that the process remains current, robust, and aligned with national standards and local operational needs.

3. Guidance Shared with all CFT Staff

The guidance has been circulated to all Community Forensic Team staff, discussed in team meetings, and incorporated into supervision and induction processes to ensure consistent understanding and application. :

4. Guidance Agreed with Northamptonshire Healthcare NHS Foundation Trust

As Prison Healthcare at HMP Nottingham has now transferred to Northamptonshire Healthcare NHS . Foundation Trust, the guidance has been shared with and agreed by the new provider. This ensures continuity and shared expectations across organisational boundaries.

5. Guidance Shared across HMP Reception Prisons

Although the inquest related specifically to HMP Nottingham, the Trust has also extended the guidance.with HMP Lincoln, recognising that it is another reception prison where Nottinghamshire residents may be transferred. Extending the guidance ensures that the same standards of information sharing apply across both sites. Prison Healthcare at HMP Lincoln has now also transferred to Northamptonshire Healthcare NHS Foundation Trust.

6. Clear Requirements for When and How Information Must Be Shared The guidance mandates:

Immediate liaison with Prison Healthcare upon remand or sentence

Prioritisation of contact when transfers occur outside normal hours

Use of secure email and telephone confirmation

Password-protected documents and separate password transmission

Recording the purpose and rationale for information sharing in the Electronic Patient Record

7. Standardised Documentation for Handover The following documents must now be shared as standard:

CORE Assessment

Risk and Safety Assessment

Summary and Care Plan

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Medication Card and current prescriptions Family or carer contact information

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Escalation Routes

Where contact cannot be made, staff must escalate to Service Managers and the Operational Manager, ensuring that communication failures are addressed promptly.

Actions Planned or Underway

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Appointment of a Dedicated CFT Link Worker

A Community Forensic Team Link Worker has been appointed as an additional, consistent point of contact for Prison Healthcare teams. This role is a qualified and registered mental health nurse

(RMN) and will: e Have oversight of information-sharing activity e Ensure timely responses to enquiries e Provide continuity when other staff (care Co-ordinators) are unavailable e Actas a reliable interface between services

The Link Worker will also arrange and chair a bimonthly interface meeting ‘with Prison Healthcare teams at HMP Nottingham. These meetings will:

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Review shared cases

Address communication issues

Monitor adherence to the guidance

Identify and escalate emerging risks to senior operational leads within respective organisations

Strengthen collaborative working

Embedding the Guidance Through Training and Supervision

The guidance is being embedded through:

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Team briefings Clinical supervision Induction for new staff

Joint Working with Prison Healthcare Providers

The Trust is working with Northamptonshire Healthcare NHS Foundation Trust to ensure:

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Quarterly Audit and Reporting

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A quarterly audit will monitor:

e Timeliness of information sharing e Completeness of documentation e Evidence of escalation where contact was not achieved

Findings will be reported to: e Community Forensic Services Quality Safety and Experience and Performance and Accountability Group

5. Development of Read-Only RIO Access for Prison Healthcare Teams

Nottinghamshire Healthcare NHS Foundation Trust is actively exploring the feasibility of enabling read-only access to RIO Local for the Prison Healthcare mental health teams. This work is being developed collaboratively with colleagues at Northamptonshire Healthcare NHS Foundation Trust, the new provider of healthcare services at HMP Nottingham.

If achievable, this development will significantly strengthen the availability and timeliness of clinical and risk information for mental health practitioners operating within the prison environment. It will also reduce reliance on manual information-sharing processes and further support safe continuity of care for individuals transferring from the community into custody. :

This work remains in development, and the Trust will continue to progress it as a priority area for system improvement.

Assurance

The Trust recognises the critical importance of robust information sharing between community forensic services and prison healthcare. The introduction of the formal guidance, its integration into the Community Forensic Team Internal Working Instruction, its agreement with the new Prison Healthcare provider, its extension to HMP Lincoln, and the appointment of a dedicated Community Forensic Team Link Worker and the potential development of read only access collectively represent a significant strengthening of communication and risk-sharing arrangements. We are confident that these actions will materially reduce the risk of future deaths arising from gaps in information sharing.

It is hoped that this response provides you, Mr. Thornton’s family and the other parties involved with reassurance in terms of the ongoing plans to improve this important area of patient care moving forward