Custody medical information
Significant medical events not consistently recorded or made readily accessible to discipline staff in custodial settings.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
81match
Christopher Shapley
Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.
Matched on
terms: custody, information, medical
IOPC learning recommendation
78match
Man died while in police custody – Nottinghamshire Police, June 2017
The IOPC recommends that Nottinghamshire Police amends its custody assessment process to include a specific question about whether the detainee has any allergies. Where a detainee has indicated they have an allergy this information should be visible to all custody staff so that they can ensure that the detainee is only provided with appropriate items of food or...
Matched on
terms: custody, information
PFD report
77match
Thomas McAuley
Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean vulnerable individuals' medical assessments are not consistently reviewed by prison medical staff.
Matched on
terms: custody, medical
IOPC learning recommendation
77match
Recommendation - Essex Police, December 2023
The IOPC recommends that Essex Police should take steps, in partnership with relevant stakeholders, to ensure healthcare services in police custody best meet the needs of detainees. In particular, Essex Police must make sure detainees have access to and receive appropriate clinical attention as soon as reasonably practicable if they appear to be suffering from physical or mental...
Matched on
terms: custody, medical
IOPC learning recommendation
74match
Care and attention for man whilst detained in custody – Thames Valley Police, June 2021
The IOPC recommends that Thames Valley Police reminds police officers that where the arresting officer does not transport the detainee to custody, information they may have about the detainee is also transferred by some other means and passed on to the custody officer. This follows an investigation into the death of a man at a Thames Valley Police...
Matched on
terms: custody, information
PFD report
73match
Nicholas Rowley
Insufficient verbal consultation between medical practitioners and custody staff, coupled with inadequate joint training, led to unclear observation levels and poor management of drug/alcohol risks in detainees.
Matched on
terms: custody, medical
PFD report
73match
Richard Green
Prison medical professionals failed to act on recorded self-harm history in SystmOne due to system usability issues, workload pressure, and a lack of clear display for critical historical information.
Matched on
terms: information, medical
PFD report
73match
Adam Rice
There was poor communication between the hospital and police regarding a patient's self-discharge against medical advice, compounded by inconsistent custody care, staff shortages, inadequate handovers, and a lack of understanding of welfare check protocols.
Matched on
terms: custody, medical
PFD report
73match
Stewart Akins
Critical information about the deceased's repeated suicide intentions recorded in police custody was not relayed to the Magistrates' Court, leading to bail being granted without full awareness of the high self-harm risk.
Matched on
terms: custody, information
PFD report
73match
Tedros Kahssay
Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical emergency protocols.
Matched on
terms: information, medical
PFD report
73match
Robert Brown
Information in central NOMIS records, medical system records, and the security department was not available to all prison staff who may have benefitted from having it.
Matched on
terms: information, medical
PFD report
73match
Ivan Ignatov
A detainee's mental health assessment was missed in police custody, and an act of self-harm was misjudged. Critical risk information, including first-time custody status, was not properly recorded or collated, hindering comprehensive risk assessment.
Matched on
terms: custody, information
PFD report
73match
Amy Cross
There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical records system.
Matched on
terms: information, medical
Article 2 learning point
73match
AA — HMP & YOI Holloway - 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.
Matched on
terms: information, medical
PFD report
69match
Anthony Fraser
Summary medical information was not conveyed to the receiving A&E department upon transfer, and there is no system for ensuring such information is sent; a system needs to be implemented to convey such information for every inmate transferred with an acute illness.
Matched on
terms: information, medical
PFD report
69match
Valdas Jasiunas
Custody risk assessments inadequately screen for alcohol dependency, and the computer system's design leads to frequent errors, further complicated by a lack of multi-language support for safety information.
Matched on
terms: custody, information
Inquiry recommendation
69match
AS-9 - Medical Fitness for Detention Forms
Appropriate forms should be made available to allow a medical examiner to declare a detainee unfit for detention and questioning. The decision as to whether a detainee has been declared unfit for detention and questioning should be readily apparent and the reasons for that decision should be recorded. Any conclusion to the contrary effect should be expressed in...
Matched on
terms: medical
PPO recommendation
69match
The Director at Parc
The Director at Parc should ensure that staff assess risk based on all relevant information, including that held in medical records;
Matched on
terms: information, medical
PPO recommendation
69match
The Governor and Head of Healthcare (HMP Highpoint)
The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: • healthcare staff complete the medical information section of the escort risk assessment, accurately reflecting how the prisoner’s current health and medical condition affects their...
Matched on
terms: information, medical
PPO recommendation
69match
The Governor
The Governor should ensure that prison staff understand that medical information about a prisoner must be sought and properly considered when deciding whether to use restraints and in cases where a medical objection is disregarded or is not obtained the reason is documented.
Matched on
terms: information, medical
PPO recommendation
69match
The Head of Healthcare
The Head of Healthcare should ensure that CGL staff consider all relevant information from a prisoner’s medical and prison record, either by accessing the medical record themselves, or asking a member of the healthcare team to provide this information to them.
Matched on
terms: information, medical
IOPC learning recommendation
69match
Recommendation - West Midlands Police, April 2021
The IOPC recommends that West Midlands Police takes steps to ensure that an appropriate and consistent level of information is included in custody records/Electronic Detention Logs (EDLs) when completing a pre-release risk assessment. This should include considering: Any minimum standards or training should be in line with the guidance contained in the College of Policing Detention and Custody...
Matched on
terms: custody, information
PFD report
65match
Matthew Sargent
Critical information sharing failures occurred as historical prisoner data and ACCT histories were not consistently reviewed or shared with healthcare staff upon reception. Personal officers also lacked regular meetings, limiting their knowledge of individuals.
Matched on
terms: information
PFD report
65match
Natasha Chin
Significant failures in prison medication management, including lack of information sharing with officers, unclear protocols, absent audits for critical processes, inadequate response to previous concerns, and insufficient staff training on withdrawal.
Matched on
terms: information
PFD report
65match
Michael Folley
The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk information pose significant safety concerns.
Matched on
terms: information
IOPC learning recommendation
65match
Man injured during restraint and arrest - Thames Valley Police, March 2018
Recommendation to Thames Valley Police Thames Valley Police should review its training to ensure that it is providing officers with clear advice on what constitutes a head injury and when immediate medical advice must be sought and/or when a detainee must be transferred to hospital. This follows a case where a man appeared to sustain an injury to...
Matched on
terms: custody, medical
PFD report
61match
John Stabler
The Prisoner Escort Record requires review and redesign. Furthermore, medical records systems need to be consistently available in reception and care areas within prisons.
Matched on
terms: medical
PFD report
61match
Jonathan Palmer
There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of contraband (Spice) inflow posed significant health risks within the prison.
Matched on
terms: information
PFD report
61match
Andrew Shirley
HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and did not adequately share information with prison staff. The Duty Governor also failed to make sufficient enquiries regarding health screens.
Matched on
terms: information
PFD report
61match
Benjamin Harrison
Lack of night-time healthcare in prison means untrained officers manage intoxicated prisoners without clear guidance, compounded by inconsistent information sharing policies between healthcare and prison staff regarding medication and risk.
Matched on
terms: information
PPO recommendation
60match
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: • healthcare staff complete the medical information section of the escort risk assessment to say whether the prisoner’s current medical condition affects their mobility...
Matched on
terms: information, medical
IOPC learning recommendation
60match
Recommendations - North Yorkshire Police, August 2024
The IOPC recommends that North Yorkshire Police should create guidance for custody staff to support them in implementing the College of Policing Authorised Professional Practice (APP) and adhering to Code C of thePolice and Criminal Evidence Act 1984(PACE) with regards to the care of detainees with chronic health conditions. The guidance should support custody staff in identifying such...
Matched on
terms: custody, medical
IMB annual report
59match
London short term holding facilities (STHF) (2025)
This report details the operations of London's Short-Term Holding Facilities (STHFs) from February 2024 to January 2025. While positive aspects include safe environments, respectful staff interactions, and improved medical support, significant concerns persist. These include extended detention times in unsuitable conditions, particularly for children, lack of privacy, and inadequate access to medication and reliable translation services. The IMB...
Matched on
terms: custody, medical
PFD report
57match
Jason Basalat
Poor information sharing between police, magistrates' court, and prison meant the prison lacked critical details about a vulnerable prisoner's mental state, and a mental health assessment couldn't be arranged.
Matched on
terms: information
PFD report
57match
Jeroen Ensink
Police failures included not creating mental health alerts, inaccurate record-keeping regarding injuries and force, and failing to inform the forensic medical examiner of mental health concerns or family-reported history.
Matched on
terms: medical
PFD report
57match
Andrew Carr
Critical information on a prisoner's drug history was missed by the receiving prison, while drugs could be passed through the plumbing system, and contraband mobile phones exacerbated substance misuse.
Matched on
terms: information
PFD report
57match
Zak Farmer
Prison healthcare failed to obtain crucial discharge information from the hospital regarding prescribed medication, diagnoses, and care plans for a released prisoner.
Matched on
terms: information
PFD report
57match
Bradleigh Barnes
Date of report: 24/10/2022 Ref: 2022-0332 Deceased name: Bradleigh Barnes Coroner name: Rachael Griffin Coroner Area: Dorset Category: State Custody related deaths | Suicide (from 2015) This report is being sent to: NHS England | Oxleas NHS Foundation Trust | HMPPS | HMP YOI Portland
Matched on
terms: custody
PFD report
57match
Sean Williams
The custody nurse did not adequately assess Mr Williams or record vital signs before prescribing medication. Serco staff showed delays and inadequate first aid response, with concerns raised about their emergency procedures and the sufficiency of their first aid training.
Matched on
terms: custody
PPO recommendation
57match
The Director and Head of Healthcare at Altcourse
The Director and Head of Healthcare at Altcourse should ensure that staff: Have a clear understanding of their responsibilities and the need to share all relevant information about risk. Start ACCT procedures when a prisoner has recently self-harmed or expressed suicidal intent. Complete person escort records fully and accurately with details of a prisoner’s risk and mental health...
Matched on
terms: information
PPO recommendation
57match
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that reception staff thoroughly check the person escort record for all relevant risk information about newly arrived prisoners and where appropriate, clarify risk information with escort staff.
Matched on
terms: information
IMB annual report
56match
North East Midlands, Yorkshire & Humber STHF (2025)
The IMB report for North East Midlands, Yorkshire & Humber STHFs highlights generally positive staff-detainee interactions and a relaxed atmosphere at Swinderby RSTHF, but raises significant concerns across the wider STHF estate. Key issues include inadequate risk identification processes, the inhumane policy of confiscating medication, and the unsuitability of several holding facilities. The Board's ability to monitor effectively...
Matched on
terms: medical
PFD report
53match
Lee MacPherson
Delayed police risk assessments and a lack of common understanding between escort and prison staff regarding critical handover documentation posed significant safety risks during transfers.
Matched on
classifier match
PFD report
53match
Edwin O’Donnell
Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked adequate ACCT training.
Matched on
classifier match
PFD report
53match
Stephen Coster
Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding of emergency transfer protocols, led to significant delays.
Matched on
classifier match
PPO recommendation
52match
The Governor and Head of Healthcare at Risley
The Governor and Head of Healthcare at Risley should ensure that reception staff have a clear understanding of their responsibilities and the need to share all relevant information about risk, and that they consider and record all the known risk factors of a newly arrived prisoner when determining the risk of suicide and self-harm.
Matched on
terms: information
IOPC learning recommendation
52match
Recommendation - Derbyshire Constabulary, April 2026
The IOPC recommends that Derbyshire Constabulary should implement improvements in longer term safeguarding practices within high-risk investigations. This recommendation was raised by the investigating officer as the result of a death or serious injury investigation. Suspects who qualify for a 'Fit to Release' assessment prior to release from custody, should be robustly safeguarded throughout the investigation by the...
Matched on
terms: custody
IOPC learning recommendation
52match
Recommendation - South Wales Police, August 2022
The IOPC recommends that South Wales Police takes steps to ensure that custody staff are aware of how to safely manage detainees who have sleep apnoea. Consideration should be given to: This follows an IOPC review of a Death and Serious Injury (DSI) local investigation where a detainee's sleep apnoea machine stopped working during their detention. The machine...
Matched on
terms: custody
Detention investigation recommendation
52match
Review into the Welfare in Detention of Vulnerable Persons - Rec 50
I recommend that the Home Office, in consultation with NHS England, draw up explicit guidelines as to: • What informed consent looks like • What information can be shared between all parties in the event that informed consent to the release of clinical information is granted by the detainee.
Matched on
terms: information
IOPC learning recommendation
52match
Recommendation - Metropolitan Police Service, March 2024
The IOPC recommends that the Metropolitan Police should update local guidance to reflect that if a detainee is required to be in custody, and is breastfeeding, custody staff should organise a Health Care Professional to see the detainee as soon as possible. This is so that the needs of the detainee can be assessed to avoid any health...
Matched on
terms: custody