Prison cardiac screening
Omission of questions about family history of sudden cardiac death in prison reception health screens.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
87match
Joseph Price
The coroner noted the absence of questions on reception health screens regarding family history of sudden cardiac death. Adding this to screening templates could help identify predispositions and prevent similar deaths.
Matched on
terms: cardiac, screening
Committee recommendation
77match
#12 - Review mental health services specification for competent professional screening of prisoners
The NHS should review its mental health services specification so that mental health screening is always carried out by a competent mental health professional with experience of the criminal justice system.
Matched on
terms: prison, screening
Committee recommendation
77match
#11 - Identify reasons for delayed prisoner health screenings and implement remedial action plans
The NHS should identify why some establishments have difficulties screening prisoners within 24 hours of arrival and should put in place action plans with the healthcare providers at those establishments to remedy this.
Matched on
terms: prison, screening
Committee recommendation
77match
#10 - Racial disparity exists in identifying mental health conditions during prisoner health screenings
It is unacceptable that one in 12 prisoners do not have a health screening appointment within 24 hours of arrival and that Black, Asian, and other Minority Ethnic prisoners who have a mental health condition are less likely to have that identified than their white counterparts.
Matched on
terms: prison, screening
PPO recommendation
68match
The Head of Healthcare
The Head of Healthcare should ensure that prisoners with a raised blood pressure reading at first or second stage reception screening have an appropriate follow up arranged.
Matched on
terms: prison, screening
PFD report
65match
Luke Myers
HMP Liverpool miscalculated a prisoner's extended sentence, which was a likely factor in their death, and the coroner questions if other prisoners sentenced during that period might also have incorrect sentences. Additionally, two prison discipline staff members had significantly outdated first aid training.
Matched on
terms: prison
PFD report
65match
Steven May
The coroner identified insufficient mental health training and medical note review by reception staff, alongside deficiencies in the ACCT process. Further concerns included inadequate First Aid training and emergency response by prison staff, and limited weekend healthcare access for inmates.
Matched on
terms: prison
PFD report
65match
Samuel Blair
The coroner highlighted a lack of comprehensive mental health assessment and proper record-keeping regarding Mr Blair's medication upon prison reception. Also noted were delays in emergency response, including communication of ambulance gate location and difficulties in accessing resuscitation equipment.
Matched on
terms: prison
PFD report
61match
James Colton
The coroner noted inadequate diagnosis and treatment of Mr Colton's developing cancer at the prison, insufficient provision of pain medication, and a lack of continuity of care and communication among healthcare staff, exacerbated by GP workload.
Matched on
terms: prison
PFD report
61match
Hayden Norton
The coroner noted a lack of blood pressure monitoring and no record of informing the patient about aortic aneurysm screening at HMP Dartmoor. There was also a delay in calling an emergency ambulance due to the absence of an emergency code protocol.
Matched on
terms: screening
PFD report
61match
Mark Doyle
Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also no mandatory first aid training for existing prison officers.
Matched on
terms: prison
PFD report
61match
Robert Richards
The coroner identified inadequate management of bullying and vulnerable prisoners at HMP Wandsworth, due to staffing, communication, and cell allocation. Deficiencies also included resuscitation training, medical supply restocking, and communication between healthcare and prison.
Matched on
terms: prison
PFD report
61match
Martin Haines
The coroner noted fragmented healthcare responsibility in the prison, with insufficient communication and separate IT systems between providers. This affected the monitoring of the deceased's medical conditions and the establishment of clear protocols for emergency response.
Matched on
terms: prison
PFD report
61match
Khairul Rahman
The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.
Matched on
terms: prison
PFD report
61match
Stephen Coster
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.
Matched on
terms: prison
PFD report
61match
Colin Lovett
The coroner notes a lack of diabetes training and awareness among Prison Service staff regarding hypoglycaemic or hyperglycaemic attacks. This, combined with limited healthcare operating hours, could delay vital care for diabetic prisoners.
Matched on
terms: prison
PFD report
61match
Ryan Harding Prevention of future deaths report
Prison windows and the gatehouse require upgrading to reduce the entry of illicit materials. Additionally, scheduled morning welfare checks were missed due to a lack of staff, a recurring issue.
Matched on
terms: prison
PFD report
57match
Jason Lawson
Welfare checks failed to ascertain the prisoner had died. There is no computer system to track non-attendance for prescriptions or lapsed prescriptions, and no policy for 24-hour medical observation in prisons without constant supervision.
Matched on
terms: prison
PFD report
57match
Carl Smith
The quality of custodial and welfare checks for a prisoner on an ACCT and Methadone Stabilisation Programme were insufficient, and information sharing regarding these checks appeared deficient.
Matched on
terms: prison
PFD report
57match
Alan Stead
The coroner identified delays in taking and testing blood samples from prisoners at HMP Dovegate, asking what actions can be taken to improve this situation at the prison and potentially others.
Matched on
terms: prison
PFD report
57match
Haydn Burton
Prison staff at Winchester Prison were not implementing ACCT plans in line with national policy, including inadequate observations. There were also unclear confidentiality rules for Prison Listeners regarding suicide threats and limitations in the NOMIS database for recording closed ACCT plans.
Matched on
terms: prison
PFD report
57match
Justin Gallagher
The coroner noted the absence of a single clinician and proper care plan, with medical history not obtained. Opportunities to diagnose cancer were missed due to cancelled appointments, lack of family involvement, and fragmented healthcare across three organisations with separate databases.
Matched on
classifier match
PFD report
57match
Connor Hoult
Prison officers are not required to obtain a response from all prisoners during welfare checks, including those appearing asleep, which is contrary to PSI 75/2011. This lack of engagement means distressed prisoners may not be identified during checks.
Matched on
terms: prison
PFD report
57match
Amarjit Singh
The coroner noted concerns about the careless completion of a cell sharing risk assessment and the surprisingly low level of first aid understanding among some HMP Pentonville officers. There was also a lack of confirmed guidance for prisoners on how to assist cellmates experiencing a fit.
Matched on
terms: prison
PFD report
57match
Russell Irvine
The coroner noted insufficient escalation of a prisoner's refusal of food and fluids, leading to inadequate monitoring. Concerns were also raised regarding the general lack of a formal policy to monitor meal collection in prisons, identifying a risk in other establishments.
Matched on
terms: prison
PFD report
49match
Redmond Johnson
The coroner identified gaps in gathering medical history, managing complex medications, documenting test results, and assessing detainees' fitness for transfer, including ensuring sufficient notice for these assessments prior to transfer to court.
Matched on
classifier match
PFD report
49match
Greg Revell
The coroner identified a lack of ACCT initiation despite clear self-harm indications, an over-reliance on verbal information rather than documented risks, and an insufficiently robust system for capturing healthcare information, which resulted in a missed opportunity to restart antidepressant medication.
Matched on
classifier match
PFD report
49match
David Bird
The coroner raised concerns about the adequacy of custody officers' training in interpreting detainees' behaviour and formulating suitable care plans, noting the detainee was released without seeing a Health Care Practitioner despite identified vulnerabilities.
Matched on
classifier match
PPO recommendation
47match
The Head of Security, Procedures and Capability in the Security Directorate of HMPPS
The Head of Security, Procedures and Capability in the Security Directorate of HMPPS should amend the guidance on completing the initial segregation health screen to: make assessment of a prisoner’s physical health as important as assessment of their mental health; make it mandatory for the nurse completing the health screen to check the prisoner’s clinical record for the...
Matched on
terms: prison
PFD report
45match
Tedros Kahssay
No specific coroner's concerns were identified within the provided text for this report.
Matched on
classifier match
IMB annual report
43match
Altcourse (2024)
HMP Altcourse experienced a contract transfer to Sodexo in June 2023, leading to initial staffing challenges that have largely been addressed. The Board commends staff for maintaining safety amidst population pressures and notes improvements in mental healthcare and a successful reading strategy. Key concerns include the kitchen's inadequacy, lack of education in CSU, delays in mental health transfers,...
Matched on
terms: prison
IMB annual report
43match
Bedford (2024)
HMP Bedford, a Category B YOI, continues to face significant challenges including persistent overcrowding and an inconsistent induction process, despite some improvements in wing cleanliness and key worker implementation. The report highlights serious concerns regarding healthcare, characterized by poor communication and a decline in drug rehabilitation services. Security remains an issue with illicit items readily entering the prison,...
Matched on
terms: prison
IMB annual report
43match
Holme House (2021)
HMP Holme House experienced a year dominated by Covid-19 restrictions, yet saw notable improvements in overall ambiance, cleanliness, and reduced violence. While healthcare services generally improved and key worker compliance increased, significant concerns persist regarding unacceptable dental waiting times, inadequate education provision, and unscreened toilets in cells. The Board highlights issues with property transport and the lack of...
Matched on
terms: prison
PPO recommendation
32match
Manx Care
Manx Care should ensure there is a long-term conditions monitoring register and clinic.
Matched on
classifier match
IOPC learning recommendation
27match
Recommendations - Humberside Police, January 2022
The IOPC recommends that Humberside Police use this case, within; officer training, force communications and policy/guidance, to highlight the need to maintain effective supervision of a detainee, especially prior to the completion of a search. This follows a Death or Serious Injury (DSI) incident whereby a detainee was able to hide a razor blade within a copy of...
Matched on
classifier match