Prison cardiac screening
Omission of questions about family history of sudden cardiac death in prison reception health screens.
Source spread
Where this theme appears
This theme appears across 5 independent accountability sources, so the source mix matters as much as the headline total.
25 PFD reports
3 committee recs
9 PPO recs
1 IOPC rec
3 IMB 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.
Prevention of Future Deaths reports(25)
Redmond Johnson
Concerns: 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.
Overdue
Jason Lawson
Concerns: 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.
Overdue
James Colton
Concerns: 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.
Response (Worcestershire Health Care NHS): • Staff study sessions were held to discuss learning from the case. • Every inpatient now has a named nurse, and two nurses are assigned to each wing to improve … (AI summary)
Overdue
Hayden Norton
Concerns: 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.
Response (Dorset Healthcare University NHS Foundation Trust): • The Trust undertook a baseline review of compliance with national guidelines for blood pressure monitoring and found full compliance. • The Trust now provides an Aortic Aneurysm Screening (AAA) … (AI summary)
Overdue
Greg Revell
Concerns: 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.
Response (Leicestershire Partnership NHS Trust): • A robust system for seeking clinical information has been implemented, including a flowchart detailing team member responsibilities. • The flowchart outlines staff responsibilities for escalating concerns regarding clinical notes … (AI summary)
Response (HM Prison and Probation Service): • Local policies and procedures have been reinforced to ensure an ACCT is opened on reception whenever there is evidence of a recent self-harm attempt. • A new Safer Prisons … (AI summary)
Responded
Luke Myers
Concerns: 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.
Response (Ministry of Justice): • Staff at HMP Liverpool reviewed sentence calculations for the current population. • First aid training is being provided to all Custodial Managers carrying out orderly officer duties. • Operational … (AI summary)
Responded
Carl Smith
Concerns: 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.
Response (Dorset Healthcare University NHS Foundation Trust): • The Trust implemented joint reviews for patients on drug treatment programmes, with shared access to caseload details and clear communication of observation level decisions. • An education package on … (AI summary)
Overdue
Steven May
Concerns: 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.
Response (Steven May): • HMP Ranby staff were reminded of the need for comprehensive record-keeping in ACCT documents, and these documents are now subject to quality monitoring. • The prison and healthcare provider … (AI summary)
Response (Nottingham Healthcare NHS Trust): • The Trust reminded staff of the importance of reviewing patient notes during reception health screens and introduced a keyword search facility for medical records. • Following a Healthcare Needs … (AI summary)
Overdue
Samuel Blair
Concerns: 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.
Response (London Ambulance Service NHS Trust): • The London Ambulance Service (LAS) updated its Computerised Gazetteer to record multiple vehicular entrances for HMP Pentonville and requested prison staff to specify the entrance during 999 calls. • … (AI summary)
Response (Care Uk): • Care UK stated it would collaborate with Barnet, Enfield and Haringey Mental Health Trust (BEH-MHT) to implement their action plan and ensure all healthcare staff are aware of it. … (AI summary)
Response (HM Prison and Probation Service): • HM Prison and Probation Service issued Prison Service Instruction 29/2015, which requires establishments to conduct First Aid risk assessments. HMP Pentonville confirmed its local risk assessment is up to … (AI summary)
Overdue
Alan Stead
Concerns: 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.
Response (Care UK): • A phlebotomy training programme for all nurses and healthcare assistants was introduced at HMP Dovegate in December 2015. • The phlebotomy training programme was completed, and staff were deemed … (AI summary)
Responded
Haydn Burton
Concerns: 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.
Response (HM Prison and Probation Service): • HMP Winchester committed to ensuring all operational staff are trained in ACCT procedures, with refresher training scheduled monthly, and a plan developed for ACCT case managers and assessors. • … (AI summary)
Overdue
Tedros Kahssay
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
Mark Doyle
Response (Care UK): • Care UK confirmed the immediate implementation of a Patient Wing Movement Assessment system. • The new system establishes criteria for prisoner transfers from the Substance Misuse Unit, including a … (AI summary)
Overdue
Robert Richards
Concerns: 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.
Overdue
Martin Haines
Concerns: 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.
Response (Department of Health and Social Care): • DHSC officials brought the coroner's reports to the attention of the Care Quality Commission. • The National Partnership Agreement for Prison Healthcare in England 2018-21 was revised to include … (AI summary)
Response (NHS England): • Sussex Partnership NHS Foundation Trust implemented staff training on detecting and managing diabetes and hypertension in line with National Institute for Care Excellence (NICE) guidelines, which was completed by … (AI summary)
Response (HM Prison and Probation Service): • The Prisons Drug Strategy was published in April 2019, and HMP Lewes updated its local Substance Misuse Strategy in June 2019 to address illicitly brewed alcohol. • HMP Lewes … (AI summary)
Responded
Justin Gallagher
Concerns: 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.
Response (NHS England): • An independent clinical review was commissioned, leading to an action plan completed by April 2017 to address identified issues. • A Prime Provider model for commissioning healthcare services was … (AI summary)
Response (Department of Health and Social Care): • Officials brought the coroner's reports to the attention of the Care Quality Commission. • The National Partnership Agreement for Prison Healthcare in England 2018-21 was published, outlining commitments to … (AI summary)
Response (HM Prison and Probation Service): • The Governor of HMP Lewes ensures sufficient escorting staff are made available for three external hospital escorts each weekday. • A daily meeting between prison and healthcare staff takes … (AI summary)
Responded
David Bird
Concerns: 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.
Overdue
Khairul Rahman
Response (Practice Plus Group): • Practice Plus Group stated it would continue to work with NHSE/I and HMPPS to resolve mobile connectivity challenges for SystmOne. • Practice Plus Group updated a record keeping training … (AI summary)
Overdue
Connor Hoult
Concerns: 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.
Response (HM Prison and Probation Service): • HMP Wakefield issued a Governor’s Order in January 2020 requiring staff to obtain a verbal response from prisoners who are or appear to be awake during roll checks and … (AI summary)
Responded
Joseph Price
Concerns: 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.
Response (NHS England): • The prison healthcare provider for ten prisons in the North East and Yorkshire region added a question about family history of sudden cardiac death to secondary screening templates. • … (AI summary)
Responded
Amarjit Singh
Concerns: 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.
Response (HM Prison and Probation Service): • HMPPS confirmed that new emergency response guides and pocket cards were issued to all prisons in 2021 and 2022, and the HMPPS National Health and Safety Arrangements for First … (AI summary)
Response (Practice Plus Group): • Practice Plus Group stated that nursing staff receive specialised training on reception processes, including risk assessment forms, and the nurse involved in the incident has revisited this training. • … (AI summary)
Responded
Stephen Coster
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
Russell Irvine
Concerns: 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.
Response (HM Prison and Probation Service): • HM Prison and Probation Service stated that existing policy requires staff to monitor meal attendance, record food and fluid refusals, and share information with healthcare staff. • HM Prison … (AI summary)
Pending
Colin Lovett
Concerns: 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.
Response (HM Prison and Probation Service): • The healthcare provider at HMP The Verne provided a diabetes awareness and guidance document. • The diabetes awareness and guidance document has been disseminated to all staff at HMP … (AI summary)
Response (Department of Health and Social Care): • NHS England agreed to share the details of this case and the concerns raised with all regional health and justice commissioning teams. • NHS England agreed to share links … (AI summary)
Responded
Ryan Harding Prevention of future deaths report
Concerns: 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.
Response (HM Prison Parc): • A programme of window replacement works has commenced, with some vulnerable areas already completed, and a timetable agreed for further replacements. • Specialist technological equipment has been purchased and … (AI summary)
Responded
Select committee recommendations(3)
#12 — Review mental health services specification for competent professional screening of prisoners
Recommendation: 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.
Response attribution not verified
#11 — Identify reasons for delayed prisoner health screenings and implement remedial action plans
Recommendation: 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.
Response attribution not verified
#10 — Racial disparity exists in identifying mental health conditions during prisoner health screenings
Recommendation: 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 …
Response attribution not verified
PPO death in custody recommendations(9)
The Head of Healthcare
The Head of Healthcare should ensure that all patients who present with chest pain have an electrocardiogram (ECG) undertaken in accordance with NICE guidelines NG95 Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis.
The Head of Healthcare
The Head of Healthcare should ensure that all new prisoners receive secondary health screens within seven days, in line with NICE guidelines and PSO 3050, Continuity of Healthcare for Prisoners.
The Head of Healthcare
If an initial health screen cannot be carried out on the day of arrival, it is carried out the next day.
The Head of Healthcare
The Head of Healthcare should ensure that staff follow the NICE guidelines [CG181] on cardiovascular disease: risk assessment and reduction, including lipid modification, and that: patients with high cholesterol have annual lipid checks; and patients with cardiovascular disease have a …
Manx Care
Manx Care should ensure there is a long-term conditions monitoring register and clinic.
The Head of Healthcare
The Head of Healthcare should ensure all new arrivals and transfers to prison should receive a second stage health assessment within 7 days of arrival.
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.
The Head of Security, Procedures and Capability in the Security …
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; …
The Head of Healthcare
The Head of Healthcare should ensure that any prisoners with elevated blood pressure readings are monitored in accordance with NICE guidelines.
IMB annual reports(3)
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, and the impact of early release schemes on resettlement and accommodation provision.
PRISON
Key concerns
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, and high levels of assaults on staff, although recent improvements are noted. The Board also raises concerns about the unaddressed needs of its large remand population, the lack of digital infrastructure, and disproportionate adjudications.
PRISON
Key concerns
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 clarity surrounding external service provider contracts, calling for action from the Minister, Prison Service, and Governor.
PRISON
Key concerns