Themes | Prison & Custody Safety | The Accountability Index

Custody medical information

Significant medical events not consistently recorded or made readily accessible to discipline staff in custodial settings.

191 items 17 sources 1 inquiry
Source spread

Where this theme appears

This theme appears across 17 independent accountability sources, so the source mix matters as much as the headline total.

3 inquiry recs 36 PFD reports 1 committee rec 1 HSSIB rec 27 PPO recs 17 IOPC recs 12 IMB recs 2 IMB reports 18 Scottish FAIs 3 Article 2 learning points 5 detention investigation recs 13 DHR recs 1 PHSO decision 7 LGO/SPSO decisions 8 CJINI reports

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.

17 sources
Inquiry recommendations(3)
AS-9 — Medical Fitness for Detention Forms
Al-Sweady Inquiry
Recommendation: 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 …

Words of: Michael Fallon, Secretary of State for Defence, statement to the House of Commons, 17 December 2014 (HC Deb vol 589, col 1408)

Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted in part
AS-5 — Detainee Capture and Condition Records
Al-Sweady Inquiry
Recommendation: Appropriate procedures should be introduced to ensure that there is an accurate and detailed contemporaneous record of the circumstances relating to the original capture/detention of a prisoner and his general physical condition (including an appropriate photographic record) on arrival at …

Words of: Michael Fallon, Secretary of State for Defence, statement to the House of Commons, 17 December 2014 (HC Deb vol 589, col 1408)

Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted in part
AS-6 — Informing Detainees of Rights
Al-Sweady Inquiry
Recommendation: All detainees should be clearly informed of their rights and obligations as soon as is practicable upon arrival at any detention facility. As a minimum this should include informing the detainee as to the reason(s) for his detention and explaining, …

Words of: Michael Fallon, Secretary of State for Defence, statement to the House of Commons, 17 December 2014 (HC Deb vol 589, col 1408)

Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted in part
Prevention of Future Deaths reports(36)
Lee MacPherson
03 Mar 2014 · London (West)
Concerns: The coroner noted issues with the timely completion and transfer of police risk assessments, alongside a lack of shared understanding between SERCO and prison staff regarding accompanying documentation. Handover details on the Prisoner Escort Record (PER) were also not completed by prison staff.
Overdue
Christopher Shapley
11 Mar 2014 · Cardiff & the Vale of Glamorgan
Concerns: The Person Escort Record form lacked a section for prior hospital treatment and had issues with securely attaching warning documents, hindering information transfer to the prison. Furthermore, prison staff did not always review all available risk information, and efforts to find a suitable cellmate were insufficient.
Overdue
John Stabler
18 Dec 2014 · Central Lincolnshire
Concerns: The coroner noted a need to review and redesign the Prisoner Escort Record. Concerns were also raised about the availability of Wing System medical records in reception areas at HMP North Sea Camp and HMP Lincoln.
Overdue
Nicholas Rowley
15 Apr 2015 · Stoke-on-Trent & North Staffordshire
Concerns: The coroner noted a lack of verbal consultation between medical practitioners and custody sergeants regarding detainee concerns and observation levels. There is a need for joint training on observation levels, precise observation specification, and risks of drug and alcohol abuse in custody.
Response (College of Policing): • The College of Policing stated it would incorporate guidance on verbal consultation between medical practitioners and custody sergeants into the Detention and Custody Authorised Professional Practice. • It confirmed … (AI summary)
Response (Staffordshire Police): • Guidance has been issued to custody staff and medical services providers to ensure verbal updates, which will be incorporated into Force Policy. • A Custody Training sub-group has been … (AI summary)
Response (G4S1): • G4S provides mandatory training to custody officers on setting observation levels, in line with PACE, ACPO, and College of Policing guidance. • G4S provides mandatory first aid training, including … (AI summary)
Responded
Richard Green
02 Nov 2015 · Cumbria
Concerns: Concerns were raised that previous self-harm incidents recorded on SystmOne were not identified by prison medical staff due to insufficient review of records and usability issues with the system, leading to a lack of awareness of the prisoner's risk.
Response (NHS England): • NHS England is re-procuring the SystmOne electronic healthcare system, with improvements planned for sharing risk indicators between healthcare and NOMS. • The implementation of the new SystmOne system will … (AI summary)
Overdue
Imran Douglas
29 Dec 2015 · London Inner (South)
Concerns: The coroner identified concerns regarding the rigid legal handover of placement duties at age 18, which may occur before a young person's Transition Plan is completed. Also noted were gaps in knowledge and interagency working between social care and the secure estate for transition planning.
Responded
Adam Rice
03 Mar 2016 · West Yorkshire (East)
Concerns: The coroner noted that clinicians should inform police about self-discharged patients requiring further investigation, and raised issues regarding West Yorkshire Police custody staff's knowledge of relevant acts and codes, as well as staffing levels during high demand.
Response (Adam Rice): • West Yorkshire Police confirmed that all custody staff receive initial and annual refresher training on relevant legislation and professional practice. • West Yorkshire Police is recruiting additional Detention Officers … (AI summary)
Overdue
Stewart Akins
03 Mar 2016 · Worcestershire
Concerns: The coroner identified inadequate information sharing regarding an individual's repeatedly stated intentions to end his own life between the custody record, the investigating officer, and the Crown Prosecution Service. This led to a significant under-reporting of suicide/self-harm risk during bail consideration.
Response (S Akins): • West Mercia Police conducted a full review into Mr Akins' detention. • West Mercia Police revised its practice to ensure all Prisoner Escort Forms are signed as accurate by … (AI summary)
Responded
Matthew Sargent
07 Apr 2016 · Worcestershire
Concerns: The coroner noted insufficient processes for sharing and reviewing historical prisoner information and risks between staff and healthcare departments. Specifically, healthcare staff were not consistently informed of prisoners with an ACCT history or provided with Prisoner Escort Records upon arrival.
Response (Matthew Sargent): • Care UK will share and roll out its Suicide Prevention Strategy across all sites. • Care UK plans to review the reception screening process to introduce a standard template … (AI summary)
Response (HM Prison and Probation Service): • The prison stated it would remind all staff of the Personal Officer policy through communications including a Safer Custody Bulletin. • A process was established for Offender Management Unit … (AI summary)
Responded
Shalane Blackwood
03 May 2016 · Nottinghamshire
Concerns: The coroner identified a lack of provision for prisoners with complex health needs and insufficient staff for segregation unit regimes. Additionally, concerns were raised about an unclear documentary tool for assessing fitness for segregation and healthcare staff's awareness of physical symptoms masked by mental health issues.
Overdue
Anthony Fraser
08 Jun 2016 · South Yorkshire (East)
Concerns: There is no robust system to ensure that summary medical information from electronic records is conveyed to A&E departments when inmates are referred, which risks delaying diagnosis for other patients.
Response (Nottinghamshire Healthcare NHS Trust): • A collaborative meeting was held to develop a shared system for conveying summary medical information. • A procedure was co-authored, identifying roles and responsibilities for custodial and healthcare staff. … (AI summary)
Responded
Thomas Jordan
10 Aug 2016 · Yorkshire West (East)
Concerns: The coroner identified that medication continued to be administered in prison despite hospital advice to discontinue it, owing to a communication breakdown between the hospital and prison, and discharge correspondence not being immediately available or reviewed by prison healthcare staff.
Response (Care UK): • Care UK's Head of Healthcare at HMP Leeds discussed the matter with the Clinical Director for Urgent Care at Leeds Teaching Hospital. • The Hospital's Clinical Director agreed that … (AI summary)
Overdue
Thomas Gallagher
11 Aug 2016 · Greater Manchester (North)
Concerns: The coroner identified a lack of formal training in child mental health risk assessment, staff disregard for Force policies, and persistently low staffing levels. There were also concerns about unrecorded rationales for resource allocation decisions and unallocated welfare incidents, leading to delays.
Response (Thomas Gallagher): • Greater Manchester Police (GMP) implemented a staff training programme for the Operational Communications Branch (OCB) focused on vulnerability, risk mitigation, and safeguarding. • GMP reviewed and launched the FWIN … (AI summary)
Responded
Tedros Kahssay
06 Dec 2016 · London Inner (North)
Response (Care UK): • Care UK implemented changes to reception screening templates, including mandatory questions for reviewing Person Escort Records and obtaining consent for general practitioner records. • The prescriptive scoring system for … (AI summary)
Overdue
Valdas Jasiunas
08 Mar 2017 · London (East)
Concerns: The coroner raised concerns about the need for a specific alcohol dependency question in custody risk assessments and noted frequent errors in custody records due to system design. There was also a lack of multi-language versions for alcohol withdrawal information leaflets provided to detainees.
Overdue
Jonathan Palmer
31 May 2017 · London Inner (West)
Concerns: The coroner noted no effective system exists for prisoners' families to input relevant health information and ensure its dissemination to prison teams and proper recording. Concerns were also raised about the ineffective measures to control contraband, such as illicit drugs like Spice, entering the prison.
Response (HM Prison Probation Service): • HMPPS issued a Safer Custody Learning Bulletin in October 2016, providing guidance on receiving emergency calls and sharing risk information from families. • HMP Wandsworth implemented a multi-pronged approach … (AI summary)
Overdue
Edwin O’Donnell
13 Jul 2017 · Liverpool & Wirral
Concerns: The coroner identified that the nurse undertaking initial health screening lacked access to pertinent prisoner documentation, including the Prisoner Escort Report and digital medical records. Concerns were also raised about the recording of such documentation and the sufficiency of ACCT training for probation staff.
Response (HM Prison Probation Service): • The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to healthcare staff. • Revised procedures will be implemented to ensure second health screenings … (AI summary)
Responded
Sean Plumstead
09 Aug 2017 · Hampshire (Central)
Concerns: Winchester Prison has inadequate systems for storing and retrieving telephone recordings and staff interview recordings, often providing only summary transcripts. This lack of proper retention of important electronic and documentary evidence with specific prisoner records is a recurring issue, posing a risk for future deaths.
Response (HM Prison Probation Services): • HMP Winchester has assigned temporary staff to transcribe encrypted telephone call recordings and implemented a new protocol for information and evidence gathering. • Recordings of staff interviews have been … (AI summary)
Response (Carillion): • Carillion familiarised itself with PSI64/2011 and its updates to ensure compliance with HMPPS policies. • Carillion contacted HMPPS to support Prison Governors in ensuring staff receive appropriate training. • … (AI summary)
Response (HM Prison Probation Services.2): • The Introduction to Safer Custody course was replaced by the Introduction to Suicide and Self-Harm Prevention (SASH) course in May 2017. • The SASH course is delivered to all … (AI summary)
Responded
Jason Basalat
27 Nov 2017 · Milton Keynes
Concerns: The coroner noted insufficient information sharing from police and magistrates' court to the prison regarding the deceased's behaviour and mental state. There was also a lack of mental health assessment at court and no consideration of appropriate placement for a vulnerable prisoner.
Response (Northampton Police): • A review of the circumstances of the case was conducted and revisited against existing procedures. • Custody officers and staff have been reminded of the guidance for completing Person … (AI summary)
Response (BASALAT): • Magistrates have received training on procedures for identifying vulnerable defendants. • Legal advisers have been issued with an information leaflet and reminded to forward CPNI forms, endorse warrants, and … (AI summary)
Responded
Jeroen Ensink
19 Jul 2018 · London (Inner) North
Concerns: The coroner noted insufficient recording and escalation of mental health concerns for a detainee, which prevented MASH referral and led to a superficial medical examination. Further concerns included inconsistencies in police statements and custody records regarding injuries and use of force.
Overdue
Dean Barrell
11 Oct 2018 · East Sussex
Concerns: The coroner identified a seven-day delay by the Prison and Probation Service in communicating a prisoner's correct release date to HMP Lewes. This prevented timely notification to the prisoner, an issue of particular importance for vulnerable individuals.
Response (Dean BARRELL): • An investigation identified an oversight by administrative staff as the cause of the delay in Mr Barrell's case. • Instructions were reinforced to Public Protection Casework Section (PPCS) staff … (AI summary)
Responded
Thomas McAuley
29 Oct 2018 · London Inner (South)
Concerns: The coroner identified issues with the universal availability and access to Detainee Property and Medical Forms (DPMFs) and other medical records for healthcare staff within the prison system. There was no assurance that medical assessments from custody were consistently seen and considered by prison medical staff.
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) anticipates the introduction of a new Person Escort Record (PER) by April 2019, led by HMPPS, which will include additional health and social care … (AI summary)
Overdue
Natasha Chin
10 Jan 2019 · Surrey
Concerns: The coroner identified issues with medication information sharing between clinical and discipline staff, inadequate opiate and alcohol withdrawal protocols, and a lack of formal audits on medication administration. There were also concerns about the adequacy of staff training.
Response (HM Inspector of Prisons): • HM Inspector of Prisons stated it would place a copy of the Regulation 28 report in its intelligence file to inform future inspections of HMP Bronzefield. • HM Inspector … (AI summary)
Overdue
Andrew Carr
31 Jan 2019 · Birmingham and Solihull
Concerns: Birmingham Prison did not review or record vital information about a prisoner's history of psychoactive substance use upon transfer. The report also highlighted that no solution had been found for five years to prevent drugs being passed through the prison's plumbing system.
Overdue
Heather Birchall
28 Jun 2019 · Wiltshire and Swindon
Concerns: Gaps were identified in G4S healthcare professionals' access to individuals' full mental health background when assessing detainees in police custody, particularly outside of Liaison and Diversion Service (LADS) hours. This limited their ability to make informed decisions regarding further healthcare input, such as formal mental health assessments.
Overdue
Michael Folley
21 Jun 2019 · Hampshire (Central)
Concerns: The coroner identified issues with the police's paper-based Person Escort Record (PER) system, including officers lacking access to previous self-harm risk data from other agencies. Concerns were also raised about Detention Officer training and deficiencies in the PER's completion, checking, and secure handover processes.
Response (Hampshire and Isle of Wight Constabulary): • Hampshire Constabulary will mandate that all Custody Officers and Detention Officers complete an electronic self-learning package on Person Escort Records (PERs). • The force will review its policies and … (AI summary)
Response (CNWL NHS Trust): • The Trust confirmed mandatory ACCT and SASH training for staff, with compliance monitored monthly, and stated it would address any outstanding SASH training. • The Trust has implemented policies … (AI summary)
Overdue
Robert Brown
09 Mar 2020 · Staffordshire (south)
Concerns: Information about prisoners was not consistently available across different prison systems and to all relevant staff, leading the coroner to seek an update on the national development of a unified information system and its implementation timeline.
Response (the Director General of Prisons): • Development work on phase one of a project to automate patient administration data from NOMIS to SystmOne has been partially completed. • Phase three of the project, which includes … (AI summary)
Responded
Zak Farmer
24 Sep 2020 · Essex
Concerns: The coroner noted gaps in CRG's procedures for obtaining information from a secure unit following a prisoner's discharge, which meant the prisoner did not receive prescribed medication or full discharge details including diagnoses and care plans.
Response (CRG Medical): • CRG Medical stated that a member of the mental health team attends all MHA s117 meetings prior to a prisoner's discharge back to HMP Chelmsford, with information discussed at … (AI summary)
Response (EPUT): • The Trust established a separate Crisis Response Service in April 2020, which now actions all crisis referrals. • The EPUT Clinical Guidelines for Community Mental Health Service Users are … (AI summary)
Responded
Bradleigh Barnes
24 Oct 2022 · Dorset
Concerns: The provided document extract contains boilerplate text regarding the duty to respond and general statements about preventing future deaths, but does not detail specific coroner's concerns.
Response (NHS England): • NHS England will require all prison healthcare providers to establish local operating procedures for control and restraint incidents, outlining healthcare roles and responsibilities and mandating vital sign monitoring using … (AI summary)
Response (NHS Oxleas): • A memorandum of understanding has been put in place between healthcare and the prison regarding attendance of healthcare and all planned use of force interventions. • Healthcare staff are … (AI summary)
Response (HM Prison Probation Service): • A memorandum of understanding (MOU) was produced by HMP Portland and Oxleas NHS Foundation Trust, detailing healthcare's role during use of force incidents. • The national use of force … (AI summary)
Response (HM Prison Probation Service): • HM Prison and Probation Service (HMPPS) previously provided a response to the Regulation 28 report in December 2022. • The Governing Governor of HMP Portland contributed information to the … (AI summary)
Responded
Andrew Shirley
27 Jan 2023 · Worcestershire
Concerns: Healthcare and mental healthcare staff at HMP Hewell did not sufficiently identify or reduce Andrew's suicide/self-harm risk, nor did they adequately share information. Concerns also noted the Duty Governor's insufficient enquiries regarding a health screen document.
Response (Midlands Partnership NHS Foundation Trust): • A prison-specific record keeping training session is planned for April 25, 2023, aiming for 100% staff completion, and Mr Shirley's case will be used as a case study. • … (AI summary)
Response (Practice Plus Group): • A cohort of healthcare staff has been identified to deliver ACCT training, and compliance for ACCT training for the healthcare team at HMP Hewell is now 76.8%. • A … (AI summary)
Response (HM Prison and Probation Service): • HMP Hewell is delivering updated Assessment, Care in Custody and Teamwork (ACCT) version 6 and Suicide and Self-Harm Prevention (SASH) training to all staff, with completion expected by July … (AI summary)
Responded
Ivan Ignatov
08 Jun 2023 · Dorset
Concerns: The required face-to-face mental health assessment for the detainee did not take place. The police custody system also lacked a structured way to record a detainee's first arrest and other key risk factors, hindering comprehensive risk assessment.
Response (Dorset and Wiltshire Fire and Rescue): • The Service confirmed its commitment to the Joint Emergency Services Interoperability Programme (JESIP) principles. • It stated that all incident commanders are trained in JESIP doctrine and their application … (AI summary)
Response (Dorset Police): • Dorset Police updated the Niche system to include a dropdown menu for capturing detainee risk factors and is implementing further changes to prompt consideration of detainee risk and vulnerability … (AI summary)
Response (Maritime and Coastguard Agency): • HM Coastguard stated it had substantive plans in place to work with partners locally and nationally to improve safety. (AI summary)
Response (National Fire Chiefs Council): • The National Fire Chiefs Council (NFCC) tracks Prevention of Future Deaths Reports and shares them with its members. • The NFCC will establish a process to provide additional national … (AI summary)
Response (South Western Ambulance Service NHS Foundation Trust): • SWASFT implements Joint Emergency Services Interoperability Principles (JESIP) through regular training for all staff and commanders to improve multi-agency working and clear communication. • The Trust is strengthening relationships … (AI summary)
Response (NHS England): • NHS England noted that Dorset Healthcare Criminal Justice Liaison and Diversion Team and Dorset Police are implementing a new referral form and process, joint training, and a review of … (AI summary)
Response (Associations of Ambulance Chief Executives): • The Associations of Ambulance Chief Executives (AACE) stated it is not constituted to mandate or direct UK ambulance service clinical practice. • AACE noted it is not responsible for … (AI summary)
Response (College of Policing): • The College of Policing stated it would amend the checklist for custody officers regarding detainee assessment and inform forces of this change. • The College noted it has produced … (AI summary)
Response (NicheRMS): • The facts of the report have been circulated to Niche Technology customers. • Views are being sought on changes needed to reduce the chance of a similar occurrence. • … (AI summary)
Response (National Police Air Service): • The Senior Coroner's requested visit to NPAS Bournemouth has been completed. • NPAS and HMCG have agreed to hold joint familiarisation briefings and monthly communication meetings. • Work will … (AI summary)
Response (Royal National Lifeboat Institution): • The Royal National Lifeboat Institution (RNLI) is updating its ResilienceDirect platform page to provide details on its capabilities to emergency services partners. • The RNLI is compiling material to … (AI summary)
Responded
Stephen Coster
04 Jan 2024 · East Sussex
Concerns: The coroner identified inadequate record keeping, healthcare staff failures in observation and assessment, and a lack of care plans and communication protocols between healthcare and prison staff. There was insufficient understanding among prison staff of emergency procedures, leading to delays in hospital transfer.
Response (HM Prison and Probation Service): • HMP Lewes implemented an agreed system clarifying responsibilities for welfare checks and clinical observations between prison and medical staff. • Staff received regular briefings, training, and pocket guides on … (AI summary)
Responded
Benjamin Harrison
19 Jul 2024 · Mid Kent & Medway
Concerns: The coroner identified a lack of night-time healthcare provision and guidance for prison staff assessing prisoners under the influence of substances. Also noted were inconsistencies in policy and practice for sharing essential medication information between healthcare and prison staff.
Response (Oxleas NHS Foundation Trust): • The Trust will conduct a review of out-of-hours GP service calls in Autumn 2024 to assess their frequency and effectiveness. • Healthcare will share relevant information about prisoners with … (AI summary)
Response (HM Prison and Probation Service): • HMP Rochester issued an order to staff detailing the escalation process for concerns about prisoners suspected to be under the influence of illicit substances during night state. • HM … (AI summary)
Responded
Amy Cross
22 Oct 2025 · Avon
Concerns: The coroner identified a lack of a system to ensure important healthcare information, including medication details and physical observations, is passed between different healthcare providers in the criminal justice system during transfers. There is also no standard medical records system accessible by all providers for efficient information transfer.
Response (NHS England): • NHS England stated it would commence pilot schemes in London and West Yorkshire in 2026 to enable Liaison & Diversion Services to directly access and enter health information onto … (AI summary)
Overdue
Sean Williams
· Inner North London
Concerns: The report identifies that a custody nurse did not record vital signs or clinical details before prescribing medication. It also notes Serco staff's delayed first aid response, insufficient training, and unclear emergency protocols, which impacted their ability to provide urgent care.
Response (SERCO): • Serco revised Standard Operating Procedures (SOPs) for prisoner welfare, vehicle escort duties, and responses to death or attempted suicide in custody. • A new mandatory online course on emergency … (AI summary)
Response (Metropolitan Police Service): • Operational reminders were issued to Custody Officers regarding medical requests, and a new 'case finding' protocol was implemented in November 2025. • New SYSTMOne templates, created in April 2024, … (AI summary)
Responded
Alan Whelan
07 May 2026 · West Yorkshire EastThis report is being sent to: The Minstry of Justice | Practice Plus Group
Concerns: A mandatory mental health assessment for a prisoner transferred to the Segregation Unit was not completed within the required 24-hour timeframe. The report notes this breach of a standing instruction.
Response (HM Prison and Probation Service): • A comprehensive review of the segregation policy is currently underway, with a revised framework scheduled for publication later this year. • The Segregation Policy Framework is being aligned with … (AI summary)
Response (Practice Plus Group): • Practice Plus Group's National Mental Health & Psychosocial Lead and Medical Director for Health in Justice reviewed the organisation's mental health policies. • Communication was sent to regional managers … (AI summary)
Responded
Select committee recommendations(1)
HSSIB safety recommendations(1)
PPO death in custody recommendations(27)
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • healthcare staff assess prisoners in reception when they return from hospital; and • there is effective written communication of clinical risks and health needs of prisoners returning from hospital and …
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 …
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.
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;
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 …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that healthcare and security teams share appropriate information and work collaboratively to complete escort risk assessments, to ensure restraints decisions are appropriate.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare input into escort risk assessments is based on up-to-date medical information and is clear and sufficiently detailed.
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 …
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 …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that nurses conducting reception health screenings always have access to the PER.
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 …
The Head of Healthcare
The Head of Healthcare should ensure that all prisoners with multiple NHS numbers have their records merged within 24 hours of arriving at Wandsworth.
The Governor
The Governor should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that authorising managers show that they have taken this information into account when assessing a …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that reception staff: • have a clear understanding of their responsibilities and the need to share all relevant information about risk; • do not rely solely on what a prisoner says or …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that when a prisoner returns from hospital: • their healthcare needs are assessed if they are in any of the categories at paragraph 4 of Annex D of PSI 07/2015; and • …
The Director and the Head of Healthcare at Parc
The Director and the Head of Healthcare at Parc should ensure that SLPs are properly completed and shared with operational staff and are taken into account when providing care to prisoners.
The Head of Healthcare and the Mental Health Services Manager
ensure that healthcare staff share information that may be relevant to a prisoner’s risk of suicide or self-harm with prison staff.
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 …
The Director General of Operations for HMPPS
The Director General of Operations for HMPPS should update PSI 64/2011 to provide instructions on sharing risk information when a prisoner is subject to an unplanned release following a court appearance.
The Head of Healthcare
The Head of Healthcare should ensure that staff completing medication in-possession risk assessments consider all relevant information, including recent drug or alcohol use.
The Head of Healthcare
The Head of Healthcare should ensure that information from the pharmacist is shared with the healthcare team for review and action.
The Governor
The Governor should ensure that staff understand the need to record and share relevant information that may affect a prisoner’s risk.
The Head of Healthcare of HMP Bedford
The Head of Healthcare should ensure that prisoners’ GP records are obtained.
The Operational Security Group Director for HMPPS
The Operational Security Group Director for HMPPS should monitor, over the next three months, how many prisoners at HMP Highpoint are escorted to hospital without restraints (for inpatient admissions and outpatient appointments) and report back to the Ombudsman.
The Heads of Healthcare at Littlehey and Wandsworth
The Heads of Healthcare at Littlehey and Wandsworth should ensure that when a prisoner with complex medical needs transfers to a different prison, relevant medical issues are discussed with the receiving prison.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all relevant information about a prisoner is documented and shared appropriately and that there are robust quality assurances process in place to check this is happening routinely.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review the Swallowed and Secreted Items Policy to include prisoners who have had illicit items taken from them and ensure any information about secreted illicit items is communicated and considered appropriately.
IOPC learning recommendations(17)
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 …
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 …
Man injured during restraint and arrest - Thames Valley Police, March 2018
National recommendation The College of Policing should review the guidance on head injuries in Authorised Professional Practice (APP) to: - provide greater clarity on what constitutes a head injury, including the difference between a traumatic brain injury, other serious injury …
Care and attention for man whilst detained in custody – Thames Valley …
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 …
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: - minimum standards …
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 …
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that Thames Valley Police ensures arrangements are in place for all custody officers, staff and HCPs to receive information about detainees when their shift starts. This follows an investigation into the death of a man at a …
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 …
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: - Updating custody policies and procedures to provide clear …
Recommendation - Lancashire Constabulary, August 2022
The IOPC recommends that Lancashire Constabulary should update their custody policies and procedures to ensure that metal detectors are used as part of all searches when booking detainees into custody (provided it is safe to do so). Consideration should also …
National recommendation - National Police Chiefs' Council, August 2022
The IOPC recommends that the National Police Chiefs' Council (NPCC) shares the learning from IOPC cases with force custody leads, asking them to review their custody policies, procedures and training to ensure that metal detectors are used as part of …
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 …
Recommendations - North Yorkshire Police, August 2024
The IOPC recommends that North Yorkshire Police assures itself that their training for custody officers and staff covers the management of detainees with chronic conditions in line with Authorised Professional Practice (APP) and adhering to Code C of the Police …
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 the Police and Criminal Evidence Act 1984 (PACE) …
Recommendation - Sussex Police, March 2023
The IOPC recommends that Sussex Police should take steps to ensure that details/identity of all officers/custody staff present are documented in the custody record when: A detainee is searched in custody (irrespective of the level of search)A detainee has their …
Recommendation - Suffolk Constabulary, May 2022
The IOPC recommends that Suffolk Constabulary review their custody booking-in procedure to ensure that when two or more detainees are brought into custody with named (boxed) medication, these are separated, booked-in with each respective detainee and recorded on the Custody …
Recommendation - Metropolitan Police Service, January 2023
The IOPC recommends that the Metropolitan Police Service ensures that Digital / Person Escort Record (DPER / PER) forms are completed for all detainees where transportation is required to another Constabulary, Court, Immigration Detention Centre, HMP, HMYOI, and other relevant …
IMB annual reports(2)
IMB individual recommendations(12)
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 Implemented
Heathrow Immigration Removal Centre (2020)
Efforts should be made and training provided as necessary to ensure that the health screening on arrival is a useful tool, ensuring that potential vulnerabilities are identified at the start of a period of detention and can be taken account of.
NHS / Healthcare Provider
Gatwick, Stansted, Luton and Lunar House (2020)
Detained individuals who are held for more than a very short period of time, should have access to a qualified medical practioner.
Home Office
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The Minister is urged to request that the Home Office carry out an urgent assessment of the risks to detained people as a result of the removal of their prescription medications. These risks should then be taken into account when designing a practical strategy for ensuring that detained people receive their appropriate medication. The desired outcome would be that the …
Other
Durham (2023)
How will you ensure that all healthcare staff in reception have access to SASH (suicide and self-harm) and PER (person escort record) documents? (4.2.4)
Governor / Director
Hollesley Bay (2024)
The need for hourly observations of prisoners arriving too late to be seen by the healthcare departments highlights an important need.
HMPPS
Gatwick, Stansted, Luton and Lunar House (2020)
We do not believe that the arrangements for the monitoring of the medical welfare of detained individuals within the holding rooms are adequate and in particular there is potential risk to the health of an individual who needs urgent access to their medication or medical equipment.
Home Office
Heathrow and City airports Short Term Holding Facilities (2021)
The Home Office should ensure that the new system for giving detainees access to their prescription and over-the-counter medication is designed and implemented without further delay.
Home Office
Durham (2023)
What plans will be put in place to achieve an improved and sustained delivery of “secondary health screening within 7 days”? (6.2.3)
Governor / Director
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2020)
That the administration of detainees’ personal prescribed medication, in airport HRs be resolved forthwith.
Home Office
Huntercombe (2021)
To develop a process with healthcare to ensure there is documented sharing of appropriate health information with prison staff (paragraph 6.1.8.).
Governor / Director
Downview (2023)
There seems to be some limitations in communication between HMP Bronzefield and the prison (for example, with regards to transferred prisoners with significant mental health conditions and with missing property and medication issues). Is this because HMP Bronzefield is a private prison, and systems and processes may not be compatible?
HMPPS
Health investigations(21)
Independent investigation: Rodney Ramkissoon, Leeds (2006) — Rec 2
It is recommended that NHS Leeds prison healthcare services reconsider the current design of the form it issues to general practitioners seeking health based information about new inmates. The current form is not particularly directive and does not state clearly the importance of the information provided to enabling the provision …
north_east_yorkshire
Independent investigation: Rodney Ramkissoon, Leeds (2006) — Rec 1
When a service user is arrested and a custodial sentence is passed it is important that the specialist mental health service ensures that the responsible prison healthcare team is aware of any relevant mental health history, including the care plan and risk assessments. This responsibility is held regardless of the …
north_east_yorkshire
Independent investigation: Chloe Fahey, Manchester (2003) — Rec O.2
It is recommended that all persons in custody transferred to hospital be accompanied by a written report from the police (Detained Persons Medical Form), which is to be handed over to the receiving hospital with a receipted copy handed to the police
north_west
Multi-agency systems review to identify the learning following five homicides … — Rec 8
Clinical records should be available to custody healthcare professionals, which includes information about previous contacts, and tracks information requests and responses/outcomes. The Police Healthcare Provider should develop: • electronic clinical records • an auditable process for information requests and responses / outcomes.
south_west Accepted
Multi-agency systems review to identify the learning following five homicides … — Rec 5
HCP assessments should include clarity on the threshold for fitness to detain regarding mental health, and what mental health presentation changes would indicate that a new medical assessment was required and could be requested. Police Healthcare Provider should provide clarity on threshold for fitness to detain and be evident in …
south_west Accepted
Multi-agency systems review to identify the learning following five homicides … — Rec 4
Healthcare professionals providing police custody healthcare should have the skills and knowledge to make effective mental state examinations. The Police Healthcare Provider should ensure mental health knowledge and training is enhanced to include: • how to gather background information, mental state examination, risk assessment and decision making about requesting an …
south_west Accepted
Independent review of the care and treatment received by JW … — Rec R5
The healthcare provider in the prison should ensure that it has robust systems and processes in place to ensure that timely and appropriate information is shared with known relevant health services for a prisoner due to be released, so that the right treatment and support can continue to be delivered …
south_west
Independent review of the care and treatment received by JW … — Rec R17
NHS England’s Health and Justice Team should work with all healthcare provider agencies to ensure that SystmOne functionality is maximised to promote appropriately accessible sharing of important information between prisons and community services when a patient transfers in and out of secure and detained settings. It must be ensured that …
south_west
Independent investigation into the care and treatment of Mr P: … — Rec 2
Lancashire Care NHS Foundation Trust and Mersey Care NHS Trust should review the effectiveness of their systems for receiving information about prisoners from external agencies and entering it into the health care record. The aim should be to ensure that information from other agencies, while subject to the required protection, …
5 Boroughs Partnership NHS Foundation Trust north_west
Independent investigation into the care and treatment of Mr B — Rec 2b
The Trust must ensure when assessments of clients who are in police custody are undertaken, that clinicians obtain a clear history from police staff about the client’s forensic history.
Mr B who committed a homicide in 2012. Mr B was in receipt of services from South London and Maudsley NHS Foundation Trust london Accepted
Independent investigation: Amina Ali, Sheffield (2004) — Rec S11
In addition to this work there may be some merit at the next liaison meeting between the Police Force and the Mental Health Service in establishing precisely what guidance is provided to the Forensic Examiners (Police Surgeons) regarding the appropriate route(s) of contact with the Mental Health Service if information …
north_east_yorkshire
Independent investigation: Rodney Ramkissoon, Leeds (2006) — Rec 4
From time to time service users receiving active input from the trust will be arrested and placed in custody at the direction of the courts pending trial, or as a result of trial and/or sentencing. Where the trust is aware of a service user being awarded a custodial sentence, in …
north_east_yorkshire
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015) — Rec 4
NHS England should ensure that all mental health professionals working in Accident and Emergency departments and crisis teams have access to comprehensive patient records, including those held on SystmOne by prison healthcare providers, to enable informed decision-making during mental health assessments. Where direct access is not immediately feasible, clear and …
north_west
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015) — Rec 3
Mersey Care NHS Trust, in conjunction with NHS England, should review its processes for the transfer of care for individuals with complex mental health needs from prison mental health services to community mental health teams. This review should specifically address the issues identified in this report regarding incomplete information transfer …
north_west
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015) — Rec 2
Sefton Safer Communities Partnership should review and update its multi-agency information sharing protocols to ensure that all relevant information, particularly concerning individuals with complex needs (such as mental health issues and a history of offending), is effectively shared between agencies, including prison mental health services, community mental health teams, probation, …
north_west
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015) — Rec 12
NHS England should review the current guidance and practice regarding the assessment of individuals under Section 136 of the Mental Health Act, particularly when there is a known complex mental health history. This review should ensure that assessing clinicians have immediate access to all relevant historical mental health information, including …
north_west
Independent review of the care and treatment received by JW … — Rec R4
Consideration should be given to developing an information sharing process that could establish multi-agency meetings where an offender in prison is on short-term remand and considered to be considered at significant risk to the public but are not currently a MAPPA subject.
south_west
Multi-agency systems review to identify the learning following five homicides … — Rec 14
There should be structures in place to include the Police Healthcare Provider in local Memoranda of Understanding and information sharing agreements. The Police Healthcare Provider should be included as a partner in custody/health Memoranda of Understanding and information sharing agreements related to custody settings.
south_west Accepted
Multi-agency systems review to identify the learning following five homicides … — Rec 11
The overall sharing of information with the Police Healthcare Provider will be sufficient to ensure they can provide the best service possible with the maximum amount of information available. Develop a Protocol between Devon and Cornwall Police in relation to Potentially Dangerous or Mentally Disordered Persons, which includes the Police …
south_west Accepted
Multi-agency systems review to identify the learning following five homicides … — Rec 10
All agencies involved are aware of the individual PACE conditions and any changes of a detained person in custody. Police should ensure that when there is a need for multi-agency healthcare input, all agencies involved are aware of the individual PACE conditions and any changes.
south_west Accepted
Multi-agency systems review to identify the learning following five homicides … — Rec 1
There should be appropraite available L&D cover in each custody suite in agreed daytime hours. The L&D service should be designed and delivered in a way that meets contractual expectations.
south_west Accepted
Scottish Fatal Accident Inquiries(18)
Xi Biao Huang
(i) All medical assessments, and particularly clinical examinations should be carried out with the use of a professional interpreter where the detainee does not speak fluent English. Whilst the nature of the establishment may mean that it would not be possible or practicable to use professional interpretation services for every interaction with a detainee, the use of fellow detainees and/or …
Apr 2023 Custody 14 recs
Alison Aikman Duguid
Recommendations When officers are advised of the need for medication, they should get it. The system of classification of calls should be more sophisticated and there should be a more sophisticated grading system. Grampian Police themselves are contemplating having five gradings rather than four and that would result from a splitting of Grade 2. The calls in the higher grading …
Jul 2003
John James McKelvie
Consideration should be given to the provision of supervised accommodation to which persons arrested or detained under the influence of alcohol might be admitted. Consideration should be given to defining circumstances when the police should inform a police surgeon that a vulnerable person is in custody. c. Where it is possible, all relevant information should be recorded in an Ambulance …
Jan 2006
Daniel Thomas Crew
[9] There are no recommendations for changes to practices or procedures which could have altered the course of events. The following matters, however, should be given consideration:- (1) Whether clarification is required about the use of the addiction assessment form in HM Prison, Edinburgh in relation to alcohol detoxification. (See paragraphs 61 and 62.) (2) Further training or instructions in …
Aug 2007
Lee Russell
In terms of Section 6(1)(e) of the said Act, that the following were further facts relevant to the circumstances of the death namely, in the event of a person who is in custody being seen by a medical practitioner, the reasons for that person being seen by that practitioner and any treatment and medication received by that person should be …
May 2009
Angela Smith
[51] Although I do not find established that system failures contributed to Angela Smith’s death, I consider the evidence which emerged in this long inquiry should be examined by the police service and NHS to ensure at-risk prisoners are flagged up with all relevant information known about the risk. Where a nursing assessment is indicated this should be carried out …
Dec 2009
Martin Jamieson
a) that all personnel, both police officers and civilian staff, involved in the initial processing of a person in custody must ensure that all relevant information about the person is communicated to the Custody Officer; b) that Custody Officers must ensure that during initial processing they undertake a risk assessment of the person based on all relevant information provided to …
Feb 2010
Angus MacDonald Malone
Oct 2009
Alan Irvine
However as the Chief Constable was a party to the Inquiry and the suggestion was moved by the Procurator Fiscal, I hope that consideration will be given to such a proposal which is, I was advised, in place elsewhere.
Jan 2013
James Birnie Milne
Consideration should be given by Police Scotland to including, as an appropriate risk assessment question for persons presented at the charge bar, whether he or she has any medical or dental implants or plates.
Sep 2015
Andrew Hamilton
1. That a number of defibrillator machines are made available in HMP Dumfries for emergency use by prison staff when the prison medical centre is closed. 2. That Scottish Prison Service (SPS) install and maintain a system of individual cell emergency alarms which is effective at all times. 3. That consideration should be given by SPS to enabling a prison …
Sep 2016
Raygen Merchant
I would express a hope that such information, provided it is significant and relevant to the care of a prisoner in custody, would be communicated to those who are responsible for the prisoner’s care. Further, it seems to me that if the prison authorities have information which is potentially relevant to the care of a prisoner either because of the …
Aug 2018
Thomas James Strain
I recommend that the wording of the form be changed to read: “The following reports are attached. … (circle/tick as appropriate)…”. I recommend that staff charged with carrying out risk assessments and case conferences should be instructed to take all reasonable steps to obtain copies of any potentially relevant medical or psychiatric report which is identified in respect of a …
Sep 2010
Daryl Malcolm Shearer
But the point here is that it could easily have been avoided if Dr Campbell had written, or better still printed or typed, clear instructions in duplicate to the police to the effect that Mr Shearer should be taken to Raigmore Hospital the following morning to have his cheek x-rayed. But I should have thought that a single form incorporating …
Jul 2011
Michael Peter Cameron
However, if they have information which they consider could be safely shared then, in my view, they ought to be reminded that such information can and should be entered into the prison computer system PR2.
Jun 2006
Jason Jackson
9. In terms of section 6(1)(e) of the said Act, that other facts which are relevant to the circumstances of the death of Jason Jackson are that a standardised approach, such as that set down in the SEWS scale or the Glasgow coma scale, be employed to assess the condition of a prisoner who was suspected of taking drugs. 10. …
Jul 2017
Clark James Isard
It seems to me that consideration should be given to ensuring a copy of that form accompany a prisoner to prison.
Jul 2008
Dylan Evan Brian Stickle
I realise that the doctor’s ACT risk assessment is but a part of a general health assessment but recommend that consideration be given to making the PER together with any accompanying information relevant to the issue of suicide or self harm (such as social work department or procurator fiscal letters) available to the examining doctor at least in cases where …
Oct 2009
Article 2 learning points(3)
Detention investigations(5)
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.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R29
The SMT must ensure that all prison files of time-served foreign national offenders are examined for relevant security information, including risk profiles, in a timely fashion. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R28
G4S should work with the Home Office to ensure that all time-served foreign national offenders arriving at Brook House are accompanied by prison escort records that identify matters affecting their risk profile. (To be completed as a matter of urgency)
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 49
The Home Office and NHS England should promote the self-‐administration of drugs where risk assessments support that approach.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 55
The Home Office and NHS England should conduct a clinical assessment of the level and nature of mental health concerns in the immigration detention estate.
Immigration Detention
Independent reviews(16)
Harris Review: Deaths in Custody — Rec 105
CQC should undertake regular inspections of health provision in prisons and YOIs and these should include an assessment of whether initial health screening and the 48 hour multi-disciplinary holistic needs assessment is occurring, and how well healthcare is engaging and leading in the SAVRAS work.
Justice & Legal
Harris Review: Deaths in Custody — Rec 39
NOMS should introduce a robust assurance process for the safe transfer of every prisoner. As part of the preparations for transfer and on completion of transfer there must be a mandatory obligation on both the sending and the receiving establishments to ensure that the full details of a prisoner’s record, …
Justice & Legal
Corston Report — Rec 42
The NHS should provide health care services to police custody suites; in busy areas this will require a 24-hour presence and ideally be a registered mental health worker.
Justice & Legal
Shaw Detention Review — Rec 50
Recommendation 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; and …
Immigration
Angiolini Review — Rec 31
Forensic Medical Examiners and other medical services within police stations should be brought within NHS commissioning, in order to introduce minimum standards of medical care in police custody and so that medical records of the individual are quickly available to the doctor.
Policing & Security Accepted
Angiolini Review — Rec 10
HMIC should include a focus on inspection of observation regimes for intoxicated detainees within its Expectations of Police Custody (updated April 2016). HMIC should monitor police forces’ internal inspection procedures for observation regimes.
Policing & Security Accepted
Harris Review: Deaths in Custody — Rec 82
Guidance from health organisations should be considered to reflect the duties of the State to protect life in custodial settings, with appropriate guidance given as to the disclosure and sharing of health information in such settings (including in those instances where consent is not provided).
Justice & Legal
Harris Review: Deaths in Custody — Rec 79
Department of Health, Home Office and the Ministry of Justice need to issue joint guidance to the effect that when consent to sharing medical information has been given by a person in custody, then the assumption is that that consent remains valid (unless withdrawn) throughout the criminal justice journey of …
Justice & Legal
Harris Review: Deaths in Custody — Rec 78
Any health assessment (both physical and mental) produced at the police station by the liaison and diversion practitioner and others at the start of a prisoner’s journey through the criminal justice system should be shared amongst specified CJS organisations (e.g. CPS, legal team, NOMS, HMPS) in order to assist them …
Justice & Legal
Harris Review: Deaths in Custody — Rec 68
There should be a consistent approach throughout the criminal justice system to requesting consent to share medical information, which should happen at the first point of contact with the health services in a CJS setting, whether that be at a police station or at a prison, and that that consent …
Justice & Legal
Angiolini Review — Rec 84
Comprehensive and standardised mandatory police training is required across forces for custody sergeants, officers and civilian detention staff on the dangers associated with intoxication. This should include medical input.
Policing & Security Accepted
Angiolini Review — Rec 12
Police forces should include medical input in the risk assessment process at the point of release, provided by the NHS (assuming medical services within police stations are brought within NHS commissioning).
Policing & Security Accepted
Jones: Patronising Disposition Review — Rec 16
It has been submitted to me that the medical evidence presented at the fresh inquests may make a useful contribution to the content of additional training for police officers, prison staff and others whose job can involve the restraint of others – in particular in order to reduce the incidence …
Policing & Security
Harris Review: Deaths in Custody — Rec 80
An appropriate consent form should be available which reflects the above, and in particular requesting of such consent should be a standard part of any prison reception assessment.
Justice & Legal
Corston Report — Rec 36
All magistrates' courts, police stations, prisons and probation offices should have access to a court diversion/Criminal Justice Liaison and Diversion Scheme in order to access timely psychiatric assessment for women offenders suspected of having a mental disorder. These schemes should be integrated into mainstream services and have access to mental …
Justice & Legal
Angiolini Review — Rec 9
CCTV should be introduced in police vans nationally to allow monitoring of restrained detainees, in conjunction with vigilant supervision of welfare and safety during transport. Failure to maintain and ensure its proper functioning should be a disciplinary issue. Unforeseen CCTV failures should not result in a van being taken out …
Policing & Security Accepted
PHSO casework decisions(1)
LGO / SPSO decisions(7)
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
201403808 — Scottish Prison Service
Mr C complained that the prison inappropriately ignored instructions issued by the prison health centre. He said he was to be provided with a suitable chair and orthopaedic mattress because of back pain. The prison said they checked with the health centre who confirmed that there was no medical requirement …
SPSO (Scottish Public Se… Prisons Not Upheld Mar 2015
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
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
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
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
Domestic Homicide Reviews(13)
Kent — recommendation 7
Referral pathways between Court Diversion/Custody Liaison Service and DIP should be formalised and agreed. In particular, it will be important to ensure that appropriate information protocols are in place to support the correct diagnosis and treatment of individual service users.
Court Diversion/Custody Liaison Service | DIP
Liverpool — recommendation 4
When a person has been remanded to the custody of the courts and there is information available indicating that the person may be a suicide risk, then that information should be fully documented under the risk section of the Person Escort Record (PER) form that accompanies them to court and …
Merseyside Police Merseyside Police
Sheffield — recommendation C
DACT alerts NHS England and the National Offender Management Service (NOMS) to the issues identified in this report in relation to the sharing of patient information between GPs and prison health providers and requests they consider to what extent national policies and procedures can be improved
DACT
Lincoln — recommendation i)
The Trust to review how known risks and risk management plans identified within the Police custody environment translate from the CJL&D ‘Assessment of Needs and Outcomes’ into the ‘Clinical Risk Framework’ (where other LPFT services are involved or later become involved) to ensure the Clinical Risk Framework is a complete …
Lincolnshire Partnership NHS Foundation Trust Lincolnshire Partnership NHS Foundation …
Norfolk — recommendation 3
That the Ministry of Justice and HM Prison Service establish that all commissioned Prison Health Services are required to provide a timely written discharge report with a transfer of notes to community services and primary care prior to or on release from custody. There should also be a requirement that …
Ministry of Justice | HM Prison … Ministry of Justice
Norfolk — recommendation Q
To improve communication and process between the criminal justice system and the general medical services in Norfolk at the point of release from prison including registration at a new practice, timely transfer of medical records and communication regarding ongoing physical and psychological needs as well as repeat medication.
Norwich GP
Norfolk — recommendation C
Review of safeguarding hand over in Primary Care specifically for post-prison registrations with a GP including history of violent offending, mental health and substance misuse.
Hackney ICB for General Practitioner (GP)
Swindon — recommendation 16
Operational officers will be reminded of Force Policy that if either drugs or alcohol are key factors in an offence for which an individual has been arrested, the arrested person should be signposted to a substance abuse support service and this should be recorded on the Custody Record.
Wiltshire Police Wiltshire Police
Solihull — recommendation 6
That West Midlands Police and Hertfordshire Constabulary in the light of section 9 of the Care Act 2014, consider and demonstrate that they understand local policies and procedures for Local Authority or Healthcare services; especially where it is believed a detainee has such care and support needs. That West Midlands …
West Midlands Police | Hertfordshire Constabulary West Midlands Police
Rochdale — recommendation v
In order to help practitioners understand the perpetrator’s behaviour when he committed this offence it will be helpful at the appropriate stage to provide the institution where he is detained and receiving treatment with a copy of this report.
the institution where the perpetrator is …
Aylesbury Vale — recommendation 1 (TVP)
The Pre-Release Risk Assessment (PRRA) section concerning issues raised in custody to be altered from being a statement to being clear questions which are required to be addressed.
Thames Valley Police Thames Valley Police
Croydon — recommendation 9
Prisoners should be interviewed at the earliest opportunity, and all decisions must be documented in the custody record around not interviewing / rest periods and showing all efforts to contact an Appropriate Adult.
Metropolitan Police Metropolitan Police Service
Croydon — recommendation 8
Through training, ensure that all custody sergeants when granting bail without conditions provide a full rationale around their decision on the subject’s custody record.
Metropolitan Police Metropolitan Police Service
CJINI inspection reports(8)
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