Prison healthcare best practice
Absence of clear national replication or sharing of critical learning and improved practices in prison healthcare.
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.
11 inquiry recs
114 PFD reports
22 committee recs
20 HSSIB recs
27 PPO recs
1 IOPC rec
380 IMB recs
17 IMB reports
8 Scottish FAIs
90 Article 2 learning points
2 detention investigation recs
13 DHR recs
4 PHSO decisions
15 LGO/SPSO decisions
19 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.
Inquiry recommendations(11)
78 — Guide on disclosure by healthcare staff
Recommendation: The Prison Service should prepare a readable guide, which explains the circumstances in which personal information about a prisoner should be disclosed by healthcare staff to officers on the wing. The guide should contain practical examples of situations where disclosure …
Unknown
77 — Measures for mentally disordered prisoners on wings
Recommendation: The measures which should be taken to minimise the risk which a mentally disordered prisoner on ordinary location poses to staff and other inmates includes: • not placing such a prisoner in a shared cell • if such a prisoner …
Unknown
74 — Mental health assessments to address risk
Recommendation: When prisoners are referred for a mental health assessment, the assessment should address the risk which they pose to staff and other inmates.
Unknown
73 — Reception health screen referral to mental health
Recommendation: The first reception health screen questionnaire should be revised so as to trigger a referral to a mental health professional on the healthcare team even if the prisoner has only self-harmed in prison. A referral should also be triggered where …
Unknown
72 — Review of mental health care in prisons
Recommendation: A comprehensive review of the quality of care provided to prisoners with mental health problems and its effectiveness should be conducted once the changes introduced since Zahid’s murder have had a chance to work.
Unknown
61 — Risk management model for highest-risk prisoners
Recommendation: The risk management model for the management of prisoners to whom MAPPA applies and who have been identified as posing the greatest risk to the public should be adopted by all establishments. Prisoners who have been identified as being a …
Unknown
60 — OASys for short-sentence prisoners at induction
Recommendation: All adult prisoners serving sentences of less than 12 months’ imprisonment who had an OASys assessment before being sentenced should have that assessment reviewed during the induction process. The review need only address the risk of harm which the prisoner …
Unknown
53 — Timing of first review of assessment
Recommendation: The first review of the initial assessment should take place within one week of the initial assessment, and should take place in every case. It should be a multi-disciplinary review, with representatives from the prisoner’s wing, healthcare and the team …
Unknown
7 — Consent exception limited to named prisoner
Recommendation: The sole exception to that rule – namely when the unconvicted prisoner consents to share a cell with a convicted prisoner – should be regarded as applying only when the unconvicted prisoner consents to share a cell with a particular …
Unknown
6 — Unconvicted and convicted prisoners not sharing
Recommendation: Subject to recommendation 7, the rule that an unconvicted prisoner should not be required to share a cell with a convicted prisoner should always be complied with.
Unknown
5 — Not asking new prisoners about sharing preference
Recommendation: The Prison Service should retain the present practice of not asking new prisoners at reception or in the first night centre or during induction whether they would prefer to be in a cell on their own or to share a …
Unknown
Prevention of Future Deaths reports(114)— showing 50 strongest matches
Reggie John
Concerns: Concerns included insufficient communication between prisons regarding the prisoner's constant watch status, a lack of robust multi-disciplinary ACCT review processes, and instances where the Prison Service Order 2700 policy was not followed, impacting healthcare documentation.
Response (Worcestershire Health Care NHS): • The Trust stated it would ensure appropriate information is communicated to receiving prisons upon prisoner transfer. • The Trust confirmed that expectations for nurses reviewing and documenting Assessment, Care … (AI summary)
Response (HM Prison and Probation Service): • HMP Bristol implemented a system for its safer custody team to contact receiving establishments and escort contractors regarding prisoners on open ACCTs, with these communications recorded on Prison-NOMIS. • … (AI summary)
Overdue
Leo Deady
Concerns: The coroner notes a significant rate of undiagnosed breech presentations and the absence of national guidelines for routine late-stage pregnancy scans to detect them, with no national consideration of the risks, benefits, and funding implications.
Response (Department of Health): • The Department of Health stated it considered there was no benefit to developing a national system of routine scanning in late pregnancy. • Officials consulted with the Royal College … (AI summary)
Overdue
Zeeyad Hamadi
Concerns: The coroner noted a lack of routine patient weighing, poor medical record keeping, and confusion regarding the funding and logistical arrangements for a prisoner seeking private healthcare outside the prison, further complicated by a lack of formal policy.
Response (Department of Health): • The Department of Health stated that several concerns, including record-keeping, liaison between prison and hospital staff, security issues, and ownership of the situation at the prison, were not for … (AI summary)
Overdue
Lee Curran
Concerns: PPO recommendations for high cholesterol and NICE-compliant investigations for loss of consciousness were not fully implemented. The coroner also noted inaccurate medical record entries by prison staff and doctors' lack of awareness regarding NICE guidelines for transient loss of consciousness.
Overdue
Andrew Hall
Concerns: Inadequate documentation and communication among mental health, healthcare, and prison staff regarding the deceased's condition and self-harm risk were identified. Also noted were insufficient observation, unadministered medication, and deficiencies in CCTV systems and staff training.
Response (HM Prison and Probation Service): • The prison stated that ACCT reviews include recorded information from the mental health team, and mental health staff receive ACCT training, with further courses arranged for visiting psychiatrists. • … (AI summary)
Overdue
Matthew Simmonds
Concerns: The coroner noted that a local action plan for complex care pathways, particularly for ventilated patients discharged to the community, has not been shared with other Clinical Commissioning Groups, limiting its potential to prevent similar deaths nationally.
Overdue
Kevin Scarlett
Concerns: The coroner noted that the prison service and healthcare did not assess Mr. Scarlett's risk of taking his own life, as staff lacked access to a risk assessment tool or protocol.
Response (HM Prison and Probation Service): • HMP Woodhill reviewed and revised its local ACCT process, issuing new guidance to staff. • Notices were issued to staff to remind them of known triggers and risk factors, … (AI summary)
Responded
Wilfred Aspinwall
Concerns: PPO and Clinical Review reports were not shared with the healthcare provider at HMP Liverpool, potentially reducing the optimal effect of recommendations.
Overdue
Satheeskumar Mahatheaven
Response (HM Prison and Probation Service): • HMP Pentonville and HMP Thameside have implemented local policies and new procedures to improve information sharing between prison staff, healthcare providers, and external agencies. • Staff at both prisons … (AI summary)
Responded
John Stabler
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
Darren Wright
Concerns: The staff nurse did not know the location for a Code Blue emergency, and prison officers who responded lacked recent CPR training due to resource limitations which created gaps in trained personnel.
Response (Serco): • Serco stated it no longer provides services to HMP Norwich and therefore has no power to implement the recommendations at that location. • Serco stated it would use the … (AI summary)
Response (Virgin Care Services Limited): • The induction process for new and agency staff has been reviewed and revised to include shadowing time, with a checklist template to be introduced by 31 March 2015 and … (AI summary)
Response (Ministry of Justice): • The Ministry of Justice stated that HMP Norwich operates within existing first aid regulations, with a risk assessment in place and appropriate staff trained. • It confirmed that a … (AI summary)
Responded
Paul Hardy
Concerns: Healthcare staff did not follow instructions to obtain blood and urine samples for a possible cancer investigation, nor did they act on recommendations for INR monitoring samples. There was also a failure to conduct a Significant Event Analysis regarding the death, as recommended by the Clinical Reviewer.
Overdue
Laurence Boyens
Concerns: Coroner noted insufficient compliance with drug dependence guidelines, specifically regarding blood pressure monitoring before Methadone/Buprenorphine administration and escalation of low readings. Gaps in record-keeping and recognition of patient drowsiness were also identified.
Response: • The organisation commenced a review of its decision to close a case regarding Dr Amayo's care. • The organisation obtained the doctor's comments as part of this review. • … (AI summary)
Response: • The Nursing and Midwifery Council (NMC) stated it would conduct an initial assessment of the referral. • The NMC indicated it would determine how to proceed following the assessment. … (AI summary)
Overdue
Anthony Dwyer
Concerns: Insufficient guidance for trusts was identified regarding the general management of long-term tracheostomy patients with complex medical needs.
Response (Department of Health): • The Department of Health stated that adequate guidance for staff caring for tracheostomy patients is available, citing resources from the UK National Tracheostomy Safety Project, NCEPOD, and the Intensive … (AI summary)
Responded
Ian Emsley
Concerns: The coroner noted a lack of formal guidance and training for prison healthcare staff regarding decisions on restraints and compassionate release for terminally ill prisoners, which could delay transfers and compassionate release.
Overdue
Daniel Byrne
Concerns: The coroner noted repeated issues identified by the PPO regarding the failure to assess risk of self-harm in new prisoners at Woodhill. A specific concern was that nursing staff did not participate in Mr Byrne's health screen or first review.
Response (Daniel Byrne): • The reception screening tool was strengthened to include more detailed questions on mental health and self-harm risk, and staff were trained in its use. • The number of experienced … (AI summary)
Response (Daniel Byrne Response2): • Reviews of all aspects of safer custody and healthcare services at HMP Woodhill have been commissioned. • The Entry to Custody Risk Assessment (ECRA) record is being introduced in … (AI summary)
Responded
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
Helen Patton
Concerns: Concerns were raised regarding the mortality risk associated with Mini Tracheostomy Procedures performed outside theatre or without ultrasound guidance, and the lack of national guidance for these procedures.
Response (Department of Health): • The Department of Health referenced existing national guidelines and reports concerning safe tracheostomy procedures, including publications from NICE, NCEPOD, NTSP, and RCOA. • The Royal College of Anaesthetists and … (AI summary)
Response (The Royal College of Anaesthetists): • The Faculty and College supported the NCEPOD recommendation that insertion of any device for front of neck airway access is classed as a surgical procedure. • The Faculty and … (AI summary)
Responded
Shalane Blackwood
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
Steven Trudgill
Concerns: The coroner noted the absence of standardised treatment programmes for fire setters within HM Prison Service and that a suggested therapeutic community option for Steven's care was not pursued before his death.
Overdue
Peter Seale
Concerns: The coroner identified a lack of national guidance for monitoring patients with pleural plaques, leading to inconsistent medical approaches and a risk of patients being lost to follow-up, potentially delaying early diagnosis and treatment.
Overdue
Terence Adams
Response (Care UK): • Care UK allocated an additional healthcare assistant to the reception process to review prisoner information, including risk assessments. • Care UK committed to rolling out refresher training to all … (AI summary)
Overdue
Thomas Jordan
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 Jordan
Concerns: Prison healthcare staff continued administering Digoxin despite hospital instructions to discontinue, a drug error arising from a breakdown in communication and failure to review discharge correspondence at the prison.
Overdue
Dildar Shariff
Concerns: The coroner notes insufficient awareness among medical professionals and in NICE guidelines regarding the elevated haemorrhage risk for haemodialysis or uremic patients after a head injury. This gap in guidance could pose a risk to future patients.
Response (Response Dept of Health): • The Department of Health noted NICE's decision not to update its guidelines immediately in relation to the assessment and early management of head injury. • The Department of Health … (AI summary)
Response (N.I.C.E): • N.I.C.E. stated its existing head injury guideline does not require amendment. • The organisation logged the coroner's concerns with its guideline surveillance team for information during the next guidance … (AI summary)
Overdue
Karnel Haughton
Concerns: Concerns were raised about the open accessibility of uncensored online videos depicting dangerous 'choking game' activities without warnings. The coroner also identified a lack of national guidance for schools and youth groups, and no dedicated support for parents regarding these online challenges.
Overdue
Dean Saunders
Concerns: The coroner identified lacunas in the admissions protocol for transferring mentally disordered individuals from police custody and a lack of clarity in hospital transfer processes. Concerns were also raised regarding ACCT process training, family involvement, and the resilience of psychiatric cover at Chelmsford prison.
Response (NHS England): • Care UK circulated a document to staff providing contact details for medical staff authorised to sign Mental Health Assessment documents. • A new provider will deliver healthcare at HMP … (AI summary)
Response (Essex Partnership NHS Trust): • The Trust submitted its admissions protocol for regional review and referred the issue of best practice for the forensic pathway for regional discussion. • The Trust engaged with NHS … (AI summary)
Response (Care UK): • Care UK revamped its national Mental Health Pathway and adapted it to incorporate best practice. • The new Mental Health Pathway was formally signed off on 28 March 2017. … (AI summary)
Overdue
Daniel Dunkley
Concerns: The coroner noted that three referrals for mental health assessments for Mr Dunkley were not carried out before his death, and a scheduled assessment was not communicated to him or his unit.
Overdue
Terrence George
Concerns: The coroner noted a lack of local guidance in most South West NHS Trusts for gallstone pancreatitis surgery. Urgent cholecystectomy was not prioritised due to competing demands, despite doctors being aware of international recommendations.
Overdue
Pamela Keech
Concerns: The coroner noted a lack of national guidance for predicting and managing fatal graft/fistula haemorrhage. Concerns were raised that A&E doctors and paramedics do not receive specific training on this risk, potentially delaying specialist review for patients presenting with such bleeds.
Response (Association of Ambulance): • The Association will request JRCALC to review UK ambulance service clinical practice guidelines for the management of renal patients, specifically concerning fistula bleeds. • It will ensure that any … (AI summary)
Response (the JRCALC): • JRCALC stated it is not responsible for setting health education requirements for paramedics. • JRCALC clarified its role as providing clinical specialty advice under the instruction of the Association … (AI summary)
Overdue
Richard Davies
Concerns: The coroner raises concerns about Bedfordshire, Cambridgeshire and Hertfordshire Police's use of unbonded 5.56mm ammunition, which was not the type recommended by ACPO since 2005 due to identified fragmentation risks.
Response (Bedfordshire Police): • The BCH APU has moved to using 55 grain tactical bonded 5.56 ammunition, as recommended in the May 2012 ACPO circular, for all operational purposes. • The BCH APU … (AI summary)
Overdue
Timothy Shaw
Concerns: The coroner noted a lack of clarity among healthcare staff regarding Intelligence Reports, requiring improved communication, criteria, and audit. Further improvements are needed in reducing access to illegal substances, psychosocial service referrals, and record keeping.
Overdue
Anthony Paine
Concerns: The coroner noted the circumstances where an individual on hourly mental health checks was found deceased shortly after a check, having used a bedsheet and a light fitting as a ligature point.
Response (NHS England): • A new healthcare provider, Spectrum Community Health CiC, commenced its contract for HMP Liverpool in April 2018, with mental health provision subcontracted to Mersey Care NHS Foundation Trust. • … (AI summary)
Response (HM Prison Probation Service): • Responsibility for healthcare provision at HMP Liverpool transferred to Spectrum Community Health CiC, in partnership with Mersey Care NHS Foundation Trust, from 1 April 2018. • Learning from the … (AI summary)
Overdue
Dean Barrell
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
Jerome Jones
Concerns: The coroner identified a lack of policy for additional checks on prisoners with repeat NPS use, especially when combined with existing medical conditions. There was also no method for drug workers to communicate these risk factors to healthcare or prison officers, and drug workers lacked access to medical records to inform their advice.
Response (Shropshire Community Health NHS Trust): • The Trust described its current practice for additional observations following prisoner substance use and referral to Forward Trust staff. • The Trust stated that the Forward Trust is in … (AI summary)
Response (HM Prison Probation Service): • An updated drug strategy was launched at the establishment, and staff were notified of it, including reminders about healthcare staff's responsibility for determining and communicating additional checks for prisoners … (AI summary)
Overdue
Ryan Trimmer
Concerns: The coroner noted inadequate ACCT reviews at HMP Lewes and identified that not all prison staff, who act as first responders, had received first aid training, with one staff member lacking training for 16 years.
Response (HM Prison and Probabtion Service): • A revised version of the ACCT process is undergoing evaluation following a pilot, with national implementation intended for early 2020. • HMP Lewes will introduce monthly first aid training … (AI summary)
Responded
Xander Curran-Pass
Concerns: The coroner identified issues in the management of reduced fetal movement, including unclear guidance for prolonged episodes and inadequate monitoring and review. Concerns were also raised regarding documentation and CTG observation during Induction of Labour.
Overdue
James Frankish
Concerns: Professionals lacked understanding of Pica's significant health risks, including bezoar development, and there is no national or professional guidance for Pica identification, management, or monitoring for bezoars.
Response (The British Psychological Society): • The British Psychological Society wrote to programme directors of UK Clinical Psychology training programmes to seek confirmation that Pica and its associated health risks are explicitly addressed in teaching. … (AI summary)
Overdue
Daniel Davey
Concerns: The coroner noted it was not routine for healthcare staff to attend ACCT reviews, which was a concern relating to both prison and healthcare operations despite improvements introduced after the death.
Response (Care UK): • Care UK updated its Local Operating Procedure for healthcare attendance at ACCT reviews in February 2019. • A new electronic quality assurance process has been introduced to ensure continued … (AI summary)
Response (HM Prison Probation Service): • New electronic quality assurance checks, including healthcare attendance at reviews, are to be introduced by August 2019. • A new version of the ACCT form and guidance, piloted in … (AI summary)
Response (Midlands NHS Trust): • The Trust stated it continues to work with partners to support attendance at ACCT reviews, maintain improved processes, and will contribute to quality assurance checks. • The Trust indicated … (AI summary)
Overdue
Joseph Charles
Concerns: The coroner noted the absence of national guidelines or recommendations for preventing deep vein thrombosis and pulmonary embolism in patients undergoing upper limb surgery, despite clear guidelines existing for other contexts.
Response (North Middlesex Hospital): • The Trust implemented a further VTE risk assessment for surgical patients prior to discharge. • An extra domain has been added to the pre-operative checklist to ensure anaesthetists prescribe … (AI summary)
Overdue
Trevor Oakley
Concerns: Communication of prisoners required for court the next day was not immediately apparent to night staff, preventing the identification of increased self-harm risk for those prisoners.
Response (Wye Valley NHS Trust): • The Trust relaunched and clarified the use of thromboprophylaxis to surgery for pertinent staff, specifically regarding the time period before which it should be withheld. • The Trust is … (AI summary)
Responded
James Wheeler
Concerns: The coroner identified an absence of national guidance on monitoring people with refractory epilepsy, particularly concerning assistive technology. Concerns were also raised that Stockport Council did not consistently undertake annual Care Act Reviews for eligible individuals, citing insufficient resources provided to local authorities.
Response (National Institute for Health and Care Excellence): • NICE stated it has published guidance (CG137) on the diagnosis and management of epilepsies, including recommendations on sudden unexpected death in epilepsy (SUDEP) and risks for people with learning … (AI summary)
Response (the Department of Health and Social Care): • The Care Quality Commission (CQC) conducted a comprehensive inspection of Cheddle Lodge in March 2018, identifying four breaches of regulations, and a re-inspection in October 2019 found the facility … (AI summary)
Response (Stockport Metropolitan Borough Council): • Stockport Council agreed a business case to fund and create a dedicated review team, comprising six social workers and a team manager. • The dedicated review team will address … (AI summary)
Responded
Marlon Watson
Concerns: The coroner noted concerns that healthcare staff at HMP Dovegate do not have a full and proper understanding of the ACCT process, requesting details on appropriate training and auditing.
Response (Care UK): • Care UK offered additional refresher ACCT training to all staff. • Care UK requested the prison to provide this training, which is scheduled to take place within 12 weeks. … (AI summary)
Response (HMP Dovegate): • Care UK confirmed that initial ACCT and SASH training is provided during staff induction, with refresher training completed annually or every three years. • Care UK stated that additional … (AI summary)
Responded
Andrew Goldstraw
Concerns: The SystmOne computer system hinders prison healthcare staff from effectively accessing prisoners' mental health histories for risk assessments due to poor search functionality and unreliable 'Summary' and 'Active Problems' sections. This limits the identification of suicide risk, relying instead on a prisoner's immediate presentation.
Response (Central and North West London Foundation Trust): • The Trust modified staff training and developed a reception guide for nursing staff on accessing previous medical records. • Guidance was issued to staff on using SystmOne search functions … (AI summary)
Overdue
Ian Allen
Concerns: The coroner identified that a high clozapine level in Mr Allen's blood was not acted upon, with no system in place to escalate such results to a consultant. Concerns were also raised about a general lack of understanding among mental health practitioners regarding clozapine monitoring and the need for national guidance and education on its importance.
Response (Birmingham and Solihull Mental Health Trust): • The Trust commenced an audit of patients prescribed Clozapine and is issuing a practice alert to doctors regarding anomalous results. • An additional control has been implemented for the … (AI summary)
Response (Dept Health and Social Care): • The UK product information for clozapine was updated to include advice on monitoring blood clozapine levels for toxicity. • The Medicines and Healthcare products Regulatory Agency (MHRA) communicated advice … (AI summary)
Responded
Alvin Black
Overdue
Richard Ormond
Concerns: The prison control room delayed providing critical information, including the need for CPR, to the ambulance service, resulting in a lower emergency response category. The coroner notes concerns that staff may not recognise the importance of promptly updating the ambulance service with critical patient information.
Response (Practice Plus Group): • Practice Plus Group disseminated a Purple Alert across all sites in April 2021 to ensure systems are in place to escalate deteriorating patients. • Immediate life support trainers were … (AI summary)
Response (HM Prison and Probation Service): • Local policies, instructions, and protocols relating to emergency incidents were reviewed, updated, and republished. • A checklist was created for staff in the Emergency Control Room to ensure vital … (AI summary)
Responded
Corin Bonaparte
Concerns: An ACCT was not opened despite the patient seeking help from the mental health department at HMP Dartmoor and revealing recent self-harm, suggesting inadequate training; the ambulance was kept waiting 8 minutes at the main gate, suggesting inadequate arrangements for swift ambulance departure in emergencies.
Response (HM Prison and Probation Service): • A new version of the Assessment Care in Custody and Teamwork (ACCT) system was rolled out, and associated training is being delivered to all staff, including healthcare colleagues. • … (AI summary)
Responded
Lola Sheldrake
Concerns: The coroner identified an absence of national guidelines for monitoring and treating infants at risk of haemolytic disease of the newborn/DCT positive infants, especially regarding care after acute treatment and following discharge.
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
Select committee recommendations(22)
#32 —
Recommendation: The UK Government must revise its funding formula for the recurrent transfer it has sent to the Welsh Government to support prisoner healthcare services at HMPs Cardiff, Swansea and Usk & Prescoed. The transfer amount should be uplifted in line …
Response status not verified
#31 —
Recommendation: Prisoner populations in Wales have higher, more complex and more concentrated healthcare needs than those seen in the community. In this context, it is concerning that the UK Government’s recurrent transfer to the Welsh Government to support healthcare provision in …
Response status not verified
#30 —
Recommendation: We recommend that the Ministry of Justice and the Welsh Government co- commission an independent review of the provision of healthcare services in prisons in Wales. This review should specifically investigate the effectiveness of the current health board model and …
Response status not verified
#29 —
Recommendation: Prisoners in Wales should not be disadvantaged when it comes to healthcare provision just because they are in prison, nor should they expect better or worse service depending on the prison they are held in. As it stands, the current …
Response status not verified
#21 —
Recommendation: An ageing prison population creates specific pressures on the prison system. Currently, the response to these and the treatment of older prisoners is highly inconsistent across the prison estate. Though the Model for Operational Delivery: Older Prisoners contains useful operational …
Response attribution not verified
#20 —
Recommendation: We disagree with the argument that older prisoners’ needs are too wide-ranging to generalise. Though it is important to treat each prisoner as an individual, there is a commonality among older prisoners which warrants a specific approach to their management. …
Response attribution not verified
#14 —
Recommendation: The ageing prison population has and will continue to increase the need for end-of- life and palliative care in prisons. We welcome the publication of the Dying Well in Custody Charter and the good practice at some establishments. But standards …
Response attribution not verified
#13 —
Recommendation: Peer support or ‘buddy’ schemes can be an effective way to help meet the care needs of older prisoners. We commend the good work done by some prisons in partnership with third sector organisations to develop such initiatives. Prisons must …
Response attribution not verified
#12 —
Recommendation: An ageing prison population will increase demand for social care services in prisons. While the Care Act 2014 has brought some improvements, standards of provision are highly variable across the estate. A more strategic and coordinated approach is needed to …
Response attribution not verified
#11 —
Recommendation: Continuing to incarcerate prisoners with severe dementia, who may no longer remember or understand why they are imprisoned, raises practical and ethical 46 Ageing prison population considerations, especially as their condition is very difficult to manage on the prison estate. …
Response attribution not verified
#10 —
Recommendation: The prevalence of dementia in prisons is poorly understood and prison staff can lack awareness of the condition. All older prisoners should have access to screening services for dementia, and prison officers who work with older prisoners should receive training …
Response attribution not verified
#8 — Charging bodies would benefit from improved sharing of best practice and expert advice.
Recommendation: We heard charging bodies would value more signposting of where to go for expert advice and support and to learn from others’ experience. DVLA told us that more can be done to share good practice and that it is important …
Response attribution not verified
#43 — Prisoners are not receiving equivalent healthcare services compared to the wider population
Recommendation: Given the acute needs of those in prison, particularly regarding mental health, it is imperative that prisoners have access to good health and wellbeing services to assist them in properly engaging with rehabilitative programmes. However, despite the principle of equivalence, …
Response attribution not verified
#25 — Support neighbourhood pilot sites to address digital interoperability challenges and share best practice.
Recommendation: In order for the neighbourhood pilots to realise the potential of the innovative model of care they are trialling, the Government should support the pilot sites to address challenges with digital interoperability, for example through sharing of learning and best …
Response attribution not verified
#19 —
Recommendation: We are concerned about reports of older prisoners being released without prescription medication or without being registered with a GP. We recommend all older prisoners are supported to register with a GP prior to release; where a prisoner is unable …
Response attribution not verified
#18 —
Recommendation: Prisons, local authorities, and health and care providers do not always work together effectively to ensure continuity of older prisoners’ health and social care. This can have a detrimental impact on an individual’s health and their efforts to re-integrate into …
Response attribution not verified
#15 —
Recommendation: Prisoners applying for early release on compassionate grounds should have their applications processed in an efficient and timely manner. This is especially important for terminally ill prisoners near the end of their lives. We recommend prisons identify a single member …
Response attribution not verified
#1 —
Recommendation: A clear definition of the older prisoner is necessary for establishing a more strategic approach to the cohort and the ageing prison population. We do not take a view on what that definition should be, but whatever age threshold is …
Response attribution not verified
#9 —
Recommendation: Older prisoners are disproportionately affected by cancellations to external medical appointments, and their health can be seriously impacted by non-attendance. While increasing the number and availability of prison staff to escort prisoners to appointments is important, we also recommend that …
Response attribution not verified
#1 — Unmet need for mental illness treatment in prisons remains surprisingly high
Recommendation: While there have been improvements in prison mental healthcare, provision is still not adequate. The high unmet need for treatment for mental illness in prisons is surprising and disappointing. Around 10% of prisoners were recorded as receiving treatment for mental …
Response attribution not verified
#35 — Direct College of Policing to collate and share best practices in modern slavery investigations.
Recommendation: In collaboration with the National Police Chiefs’ Council, the Home Office should direct the College of Policing to collate learning from forces that are effective in pursuing and investigating modern slavery and human trafficking and work with the Crown Prosecution …
Response attribution not verified
#15 — HMPPS prioritises staff investment through pay and development to improve probation officer retention.
Recommendation: HMPPS told us it is seeking to improve the conditions of service for existing staff to assist with staff retention. It has implemented a new three-year pay deal and increased its focus on staff development and wellbeing. We asked whether …
Response attribution not verified
HSSIB safety recommendations(20)
Healthcare provision in prisons
HSSIB recommends that NHS England/Department of Health and Social Care, working with healthcare service providers and their healthcare teams at prisons which hold remand prisoners, reviews and amends the process for GMS registration of patients on remand. This is to …
Safety Recommendation
Healthcare provision in prisons
HSSIB recommends that NHS England/Department of Health and Social Care ensures that the General Medical Services registration process, for patients in prison, is designed using informed consent principles, providing patients sufficient time, advice and support to understand what registration means …
Safety Recommendation
Healthcare provision in prisons
HSSIB recommends that HM Prison and Probation Service standardises the approach to the provision of prison officer escorts for outpatient appointments to protect the dignity of patients and reduce variability of escort slots. This will assist in reducing the likelihood …
Safety Recommendation
Healthcare provision in prisons: needs assessments and disability access
HSSIB recommends that the Department of Health and Social Care works with local authorities to redesign how the health and social care needs of prisons’ populations are assessed. This is to ensure that appropriate services are commissioned to meet the …
Safety Recommendation
Healthcare provision in prisons: needs assessments and disability access
HSSIB recommends that HM Prison and Probation Service, in collaboration with the Department of Health and Social Care, formalises arrangements for alerting healthcare commissioners and providers to changes in prison populations likely to impact on healthcare provision requirements. This is …
Safety Recommendation
Healthcare provision in prisons: data sharing and IT
HSSIB recommends that NHS England/Department of Health and Social Care includes within its healthcare IT procurement system specification the need to support interoperability between the operational prison IT systems and any future prison healthcare IT system. This will ensure that …
Safety Recommendation
Healthcare provision in prisons: data sharing and IT
HSSIB recommends that NHS England/Department of Health and Social Care, working with healthcare service providers and their healthcare teams at prisons which hold remand prisoners, reviews and amends the process for GMS registration of patients on remand. This is to …
Safety Recommendation
Healthcare provision in prisons: data sharing and IT
HSSIB recommends that NHS England/Department of Health and Social Care ensures that the General Medical Services registration process, for patients in prison, is designed using informed consent principles, providing patients sufficient time, advice and support to understand what registration means …
Safety Recommendation
Healthcare provision in prisons: continuity of care
Prisons and NHS trusts can improve patient safety by working together to ensure outpatient escort availability and the timing of hospital appointments is aligned to fit with the prisons’ and the trusts’ regimes. This will reduce the administrative burden and …
Safety Observation
Healthcare provision in prisons: continuity of care
Prison officers can improve patient safety by encouraging patients to engage with the healthcare team to discuss the reasons why they do not want to attend appointments. This will help to increase the appointment attendance rate.
Safety Observation
Healthcare provision in prisons: continuity of care
Prison healthcare departments can improve patient safety by increasing awareness and education for prisoners in terms of health, hygiene and the importance of engaging in their own healthcare. This will help patients to make informed decisions about whether to attend …
Safety Observation
Healthcare provision in prisons: continuity of care
Prison healthcare departments and operational staff in prisons can improve patient safety by working together to develop internal policies in relation to clinical holds, to include a requirement for communication with any receiving healthcare team about a patient’s health needs. …
Safety Observation
Healthcare provision in prisons: continuity of care
HSSIB recommends that NHS England, via regional commissioning teams, works with HM Prison and Probation Service to identify barriers to using telemedicine for outpatient appointments, and then implements local solutions to promote and enhance the capability and usability of telemedicine. …
Safety Recommendation
Healthcare provision in prisons: continuity of care
HSSIB recommends that HM Prison and Probation Service standardises the approach to the provision of prison officer escorts for outpatient appointments to protect the dignity of patients and reduce variability of escort slots. This will assist in reducing the likelihood …
Safety Recommendation
Healthcare provision in prisons: continuity of care
HSSIB recommends that HM Prison and Probation Service updates Prison Service Order 3050, ‘Continuity of healthcare for prisoners’, including guidance on communication of information about prison patients when transferring between prisons, and on the process when prison patients are released …
Safety Recommendation
Management of chronic health conditions in prisons
It is recommended that NHS England/Improvement (NHS E/I) health and justice national commissioning team review how they monitor and assure the provision of healthcare in prisons to reduce variability in standards, particularly in the areas of incident reporting and investigations.
Safety Recommendation
Management of chronic health conditions in prisons
It is recommended that the National Prison Healthcare Board for England oversees work to implement interoperability between SystmOne and the Prison-National Offender Management Information System, enabling sharing of essential information across the prison service which does not impinge on the …
Safety Recommendation
Management of chronic health conditions in prisons
It is recommended that the Care Quality Commission amends its inspection criteria to ensure that interprison transfer processes are fully encapsulated within the inspection schedule to assure the provision of care throughout.
Safety Recommendation
Local integrated investigation pilot 1: Incorrect patient identification
‘Management of chronic health conditions in prisons’ (Healthcare Safety Investigation Branch, 2019b).
Learning Prompt
Healthcare provision in prisons: data sharing and IT
HSSIB recommends that HM Prison and Probation Service ensures that the development of the Digital Prison Services system includes interoperability with healthcare IT systems. This will ensure that information which does not impinge on the confidentiality requirements of either system, …
Safety Recommendation
PPO death in custody recommendations(27)
The Head of Healthcare
The Head of Healthcare should ensure that clinical checks on prisoners who are refusing food and/or fluids are carried out and recorded appropriately to ensure risks are managed.
The Governor
The Governor should implement a process for monitoring food collection, to ensure follow up action can be taken where necessary.
The Head of Healthcare
The Head of Healthcare should ensure that staff are aware of their responsibilities under the food refusal policy, including sharing information with prison staff and completing an incident report.
The Director and Head of Healthcare
The Director and Head of Healthcare should remind staff that compassionate release applications on medical grounds may be made for prisoners who are incapacitated, and not only for those who are terminally ill.
The GP provider
The GP provider should review the prison GP wait times to ensure all is being done to bring it in line with community access to GPs.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff complete the medical risk assessment in full, including signing and dating the form.
The Governor
carry out fresh risk assessments for each escort when/if the prisoner’s condition changes to establish the appropriate level of restraints when travelling to and from hospital; and
The Head of Healthcare at Lewes
The Head of Healthcare at Lewes should ensure that a formal clinical handover is arranged for all complex mental health prisoners before transfer to a new prison.
Manx Care
Manx Care should ensure there is a dedicated lead pharmacy provision at Isle of Man Prison and there is a prescriber available every day, even if that is for remote prescribing.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are aware of the circumstances in which resuscitation is inappropriate.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners are kept informed of the status of their referrals to healthcare services, particularly when referrals are rejected. Information about repeated referrals should be clearly recorded and identify follow-up action.
The Governor
The Governor should ensure that there is an effective key worker scheme which provides meaningful and ongoing support to prisoners.
The Head of Healthcare
The Head of Healthcare should ensure that staff carry out a proper assessment of a prisoner after a use of force incident.
The Head of Healthcare
The Head of Healthcare should ensure that staff understand when they should make referrals under the suspected cancer pathway.
The Head of Healthcare
The Head of Healthcare should ensure that there is a robust blood test monitoring system in place so that samples that are lost, insufficient or mislabelled are reviewed and, if necessary, repeated.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff adhere to NICE Guidance [NG28] for patients presenting with raised blood glucose levels.
The Head of Healthcare of HMP Holme House
The Head of Healthcare should ensure that prisoners have access to appropriate therapy services, such as physiotherapy and occupational therapy, following major surgery.
The NHS Commissioner for Northeast and Yorkshire Region
The NHS Commissioner for Northeast and Yorkshire Region should write to the Ombudsman, setting out how they intend to improve mental health care at Wakefield, within twelve weeks of receiving our initial report.
The Head of Healthcare
The Head of Healthcare should ensure that there is an effective recall system for patients receiving regular injections such as Prostap.
The Head of Healthcare of HMP Holme House
The Head of Healthcare should ensure that prisoners with complex pain management needs have access to a local specialist pain service.
The Governor and Head of Healthcare
The Governor and Head of Healthcare will wish to consider this.
The Head of Healthcare
The Head of Healthcare will wish to consider this.
The Ministry of Justice’s Release Policy Team
The Ministry of Justice’s Release Policy Team should amend the ROTL Policy Framework to include that healthcare staff are consulted when there is information available to indicate concerns about a prisoners ability to comply with ROTL.
The Governor of HMP Manchester
It is important that Manchester continues to strive to meet its obligations in the matter.
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should review the disclosure of DNACPR instructions to custodial staff. Custodial staff should be aware of those who wish not to be resuscitated and have access to a DNACPR instruction form (which can …
The Governor
Ensure there is a robust quality assurance process in place to check that escort risk assessments properly consider the appropriateness of restraints based on the prisoner’s age, health and mobility.
The Director General of HMPPS and Prison Group Directors
The Director General of HMPPS should issue guidance to ensure that prisons are clear about their responsibilities to ensure that prisoners who attend court by video link are assessed for their risk of suicide and self-harm and seen by healthcare …
IOPC learning recommendations(1)
IMB annual reports(17)
Altcourse (2020)
HMP Altcourse maintained safety and humane treatment during the COVID-19 pandemic, with low levels of self-harm and violence. Staff and prisoner morale remained high due to positive staff attitudes and good communication, despite severe regime restrictions. Key concerns include the challenges of housing an aging prison population, delays in mental health transfers, and persistent issues with prisoner property and food quality.
PRISON
Key concerns
Bronzefield (2024)
Bronzefield faced significant challenges in the reporting year, primarily due to severe staff shortages impacting all aspects of the regime, leading to prisoners being locked up for extended periods and missing activities. Healthcare delivery was suboptimal due to lack of staff and poor coordination, resulting in medication delays and cancelled appointments. The prison also grappled with a high incidence of self-harm and challenges in managing complex, mentally unwell prisoners, compounded by external bed shortages.
PRISON
Key concerns
Youth estate (2020)
Pre-COVID, Boards raised concerns about high levels of violence, gang activity, and inadequate mental health resources, calling for cross-governmental action. During the first national lockdown, young people endured exceptionally restrictive regimes, locked in rooms for over 22 hours daily with minimal activity, severely impacting their mental and physical health and education. The pandemic exposed and exacerbated existing systemic problems, particularly in mental health, education, and progression, with an increased remand population further compounding issues.
PRISON
Key concerns
Highpoint (2021)
HMP Highpoint is a male Category C training and resettlement prison. The reporting year saw a positive reduction in self-harm and violence, with staff commended for humane Covid management. Key concerns include persistent issues with property transfers, under-resourcing in contracted services like mental health and education, poor maintenance by GFSL, and the ongoing security vulnerability from unrepaired netting.
PRISON
Key concerns
Aylesbury (2023)
HMP Aylesbury underwent a challenging transition from a Young Offender Institution to a Category C prison, which significantly impacted the regime, staffing, and healthcare provision. Staffing levels remained critically low, leading to limited purposeful activity and complaints about time spent in cells. Healthcare services experienced a chaotic start with a new, unprepared provider, though improvements were initiated by year-end. Despite a reduction in violence, concerns persisted regarding prisoner safety, drug use, and the prison's capacity to support resettlement for the 65 prisoners released directly from Aylesbury.
PRISON
Key concerns
Durham (2023)
HMP Durham, a Reception and Resettlement Prison for adult and young adult men, holds a significant population of unsentenced prisoners (75.6%). The past year has seen a notable increase in self-harm incidents (596) and total assaults (340), including those on staff (77), alongside 8 deaths in custody. Despite these challenges, 92% of prisoners report feeling safe, and the Board commends staff de-escalation techniques and efforts to reduce illicit item supply.
PRISON
Key concerns
Drake Hall (2023)
Drake Hall continues to provide a largely safe and humane environment, with commendable support for vulnerable women and effective management of challenging behaviours, although self-harm and violence have increased. Key concerns persist regarding the poor condition of Richmond and Plymouth houses, systemic issues with property, and healthcare resources being outstripped by the increasing complexity of the population's needs. The Board also highlights issues around staffing, regime restrictions, and the halting of planned capacity improvements.
PRISON
Key concerns
The Verne (2024)
HMP The Verne is a Category C training prison for sex offenders, holding 605 prisoners with an operational capacity of 608. The IMB noted generally good staff-prisoner relationships and effective healthcare, but raised significant concerns about the deplorable state of the healthcare building and kitchen roof. Key issues also include the barely functioning key worker scheme, a backlog in OASys assessments, and increased bullying linked to the prison's more moderate regime.
PRISON
Key concerns
Dovegate (2024)
HMP Dovegate, a privately run Category B training prison for men aged 21 and over, operated at or near its 1160 operational capacity during the reporting year. The Board observed generally calm wings with good staff-prisoner relationships and commended improvements in education. Key concerns include three deaths in custody, long healthcare and mental health transfer waiting times, persistent issues with lost property during transfers, and regime restrictions due to tight staffing levels exacerbated by a more complex prisoner population.
PRISON
Key concerns
Risley (2024)
HMP Risley, a large Category C training and resettlement prison with a complex population including PCoSOs and foreign nationals, faced significant challenges during the 2022-2024 reporting period. The Board noted extremely high and increasing self-harm rates, poor estate maintenance exacerbated by contractor issues, and insufficient purposeful activity spaces. Positive observations included well-managed mental health provision, improved resettlement planning for some groups, and a well-regarded chaplaincy team, but critical concerns remain regarding safety, infrastructure, and regime provision for the diverse prisoner population.
PRISON
Key concerns
Berwyn (2023)
HMP Berwyn faced staffing shortages and a more challenging prisoner cohort, impacting regimes and increasing violence in early 2023, despite overall reductions in self-harm and staff assaults. The Board noted positive staff-prisoner relationships, comprehensive resettlement services, and strong education/work provisions. However, significant concerns remain regarding healthcare (medication restrictions, mental health transfers, appointment attendance), estate maintenance, and the need for improved staff training and activity for vulnerable groups.
PRISON
Key concerns
Coldingley (2023)
HMP Coldingley, a Category C training prison, maintains a relatively open regime and positive staff-prisoner relationships, contributing to low self-harm levels. However, the Board notes a concerning rise in violence, use of force, and illicit substances, often linked to population pressures and insufficient new arrival checks. Significant challenges remain, including dilapidated older wings lacking in-cell sanitation, a struggling kitchen, and persistent issues with lost property and perceived disproportionality in treatment for some ethnic minority groups.
PRISON
Key concerns
Belmarsh (2023)
HMP Belmarsh operates as a Category A men's prison, holding approximately 650 prisoners with an operational capacity of 814. The report highlights both positive developments, such as improved induction processes, a new employment hub, and dedicated staff supporting vulnerable prisoners, alongside significant concerns. Key issues include persistent property loss, prolonged waits for mental health transfers, a restricted regime limiting purposeful activity for many, and staffing challenges impacting key worker provision and educational opportunities. The IMB urges HMPPS and the Governor to address these long-standing issues and improve the daily life and progression pathways for prisoners.
PRISON
Key concerns
Bristol (2023)
HMP Bristol faced significant challenges in the reporting year, marked by an increase in deaths in custody (9), self-harm, and violence, alongside persistent overcrowding at over 50% capacity in single cells. Staffing shortages severely impacted regime delivery, leading to increased time in cell and reduced access to purposeful activity. The Board expressed concern that the HMIP Urgent Notification Action Plan did not adequately address systemic issues such as occupancy levels or substantive staff numbers, hindering effective prisoner care and safety improvements.
PRISON
Key concerns
Bure (2023)
HMP Bure, a Category C prison primarily for older prisoners, maintains a calm and safe environment with good staff-prisoner relationships and effective healthcare, including a fully staffed mental health team. Key concerns include insufficient purposeful activity, inconsistent key worker engagement, and the significant impact of not having formal medical care on-site at night. Persistent estate maintenance issues and a call for the re-sentencing of IPP prisoners highlight areas requiring urgent attention from both the prison and the Ministry of Justice.
PRISON
Key concerns
Exeter (2023)
HMP Exeter faced another challenging year, operating under an Urgent Notification due to high levels of violence and self-harm, alongside significant staffing instability, particularly in healthcare. Major refurbishment projects continued, impacting operational capacity and regimes, compounded by persistent overcrowding and unsuitable conditions in the temporary Care and Separation Unit. While improvements were noted in induction processes and use of force governance, critical issues like security vulnerabilities, challenges in purposeful activity due to high turnover, and deficiencies in property management remained key concerns.
PRISON
Key concerns
Bronzefield (2023)
HMP/YOI Bronzefield is a privately run local prison for female remand and sentenced prisoners, with an average population of 471 and Certified Normal Accommodation of 542. The reporting year saw concerns over staffing shortages impacting regime, increased healthcare complaints following a contract change, and a significant number of prisoners released without safe accommodation. Positive developments included the implementation of PPO recommendations, a new Employment Hub, and re-established gardening team.
PRISON
Key concerns
IMB individual recommendations(380)— showing 50 strongest matches
Drake Hall (2021)
Additionally, during the year the prison had to deal with a prisoner experiencing difficulties associated with an eating disorder. However, no facility existed that could provide specialist services for this individual. As a result, the prison was forced to manage the situation without specialist support. This constitutes a service deficit (see section 6.3).
HMPPS
Noted
Whatton (2022)
Will the Prison Service, once again, consider substantial refurbishment or replacement of the healthcare facilities so that they match those expected in the community?
HMPPS
In Progress
Long Lartin (2023)
Healthcare Centre (HCC). What full programme of measures is planned to provide an acceptable level of care for inpatients?
HMPPS
In Progress
Lincoln (2025)
The Board recommends that provision is put in hand to deal with the problems arising from the Victorian infrastructure for the increasing numbers of frail older people, particularly those with dementia, end of life care and disabled prisoners.
HMPPS
In Progress
Portland (2020)
The provision of healthcare services has suffered for lack of a psychologist and psychiatrist at times during the reporting period. The appointment and retention of psychologists and psychiatrists to posts in Portland have been problematic since the contract transferred from the local health authority. It would be helpful if the reasons for this could be explored and, where possible, addressed.
Governor / Director
Featherstone (2020)
While the performance of healthcare staff appears adequate, there are a number of concerns: attendance at segregation reviews and use of force incidents; the monitoring of self-dispensing of medication held by prisoners; the operation of the healthcare complaints procedure; the thoroughness of mental health reviews and the reporting relationship with general healthcare. Can the Governor discuss these shortcomings with the …
Governor / Director
Drake Hall (2020)
The Board is interested in how the prison will mitigate the long-term impact of the pandemic on some prisoners’ mental health.
Governor / Director
Dovegate (2021)
Accelerate plans for the conversion of the in-patient unit in healthcare to provide consultation and treatment rooms adequate for the number of residents in the prison. Should it be decided not to proceed with the above, then urgently upgrade the inpatient bath/shower room.
Governor / Director
In Progress
Altcourse (2021)
The transfer of seriously mentally ill prisoners to appropriate healthcare facilities continues to be a problem, with one particular prisoner spending over 300 days in segregation this year. This case was escalated to a national level. In addition we are concerned about the long-term legacy of the pandemic on prisoners’ mental health. Altcourse is already seeing more seriously ill men …
Ministry of Justice
In Progress
Whitemoor (2022)
Will the minister please secure the cooperation of the Department of Health and other interested parties to conduct a wide-ranging review of the role and capacity of the secure hospitals and their relationship with the prison service?
Ministry of Justice
Peterborough (Men) (2022)
Because of the widespread perception among prisoners that all Healthcare services (Clinical, Mental, and substance misuse) are not up to the standard expected, going forward the prison should prioritise the review and monitoring of Complaints to Healthcare e.g. in the Monthly Clinical Governance Meeting, to ensure that standards are maintained and improved.
Governor / Director
Gartree (2022)
Therefore, can the Prison Service confirm to the Board that the integrated health services at Gartree are achieving the outcomes expressed in various commissioning documents, and that the healthcare is equivalent to the local wider community (i.e. the Market Harborough district)?
NHS / Healthcare Provider
Durham (2022)
How will you ensure that all prisoners in reception receive healthcare screening before moving to first night centres (4.1.6)?
Governor / Director
Buckley Hall (2022)
Ensure an effective and valued healthcare provision.
Governor / Director
Thameside (2023)
We urge the Minister to look at the problem of transferring mentally ill prisoners to a secure hospital setting again, as the establishment of the Transfer Time Limit Working Group (TTLWG) has not improved the situation for mentally ill prisoners at HMP Thameside.
Other
In Progress
Swinfen Hall (2023)
Can the Minister liaise with other departments to create a detailed and funded plan for sufficient spaces in secure mental health units to reduce the number of seriously mentally ill being held in prison, especially in segregation units?
Ministry of Justice
Liverpool (2023)
The Board has repeatedly raised concerns around the inhumane length of time prisoners experiencing mental health illness are kept segregated whilst waiting for transfer to an appropriate mental health establishment. A recent example is a prisoner who spent 377 days in the CSU waiting for a transfer, which the Board view as completely inhumane. What immediate action will the Minister …
Other
Implemented
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
Gartree (2023)
We ask the Minister to explain how the Ministry of Justice perceives the performance of prisoner healthcare at HMP Gartree when compared against the performance specification in the contract.
Ministry of Justice
Eastwood Park (2023)
Women with mental health issues and complex needs would be better treated in the health system rather than the criminal justice system. Women with complex needs continue to have delays in transferring to a secure hospital. Are there plans to address this concern?
Ministry of Justice
In Progress
Downview (2023)
As commented on last year, the considerable rise in the number of prisoners being transferred to the prison, often from HMP Bronzefield, who exhibit more challenging mental health symptoms and consequent behavioural issues is causing safety concerns. Prison is not an appropriate environment for these women and staff do not have the appropriate training to manage them. The Board is …
Other
Dovegate (2023)
Ensure there is enough staff to make sure all health care appointments are attended.
Governor / Director
Dartmoor (2023)
The commitment by the new healthcare provider, Oxleas NHS Foundation Trust, to provide overnight care at a category C prison in Devon - which will be a pathway available to prisoners at HMP Dartmoor - has not yet materialised. What is the progress on this initiative and when will it be introduced?
NHS / Healthcare Provider
Ashfield (2023)
With the large number of elderly prisoners in the custodial estate (particularly in prisons such as Ashfield), cases of dementia and terminal illness requiring 24-hour care are increasing. The specific needs of these prisoners cannot be adequately met in normal prison conditions. What plans does the Prison Service have for addressing this issue through the creation of specialist custodial centres?
HMPPS
In Progress
Wealstun (2024)
As referenced in our previous report, what steps will the Minister take to ensure that prison is not used to house severely mentally ill people whilst they await a place in a suitable institution?
Ministry of Justice
In Progress
The Verne (2024)
HMPPS to ensure funding for an alternative accommodation for the healthcare unit.
HMPPS
Rejected
The Mount (2024)
The Prison Service should consider what can be done with existing resources to better support IPP prisoners (see §7.3.1).
HMPPS
The Mount (2024)
The continued detention of prisoners long after they have served the punitive part of their sentence can only be morally justified if they are given all the support they need to become ready for release and if the conditions for such release are clear and objective. This should not be conditional on their being able to demonstrate that they are …
Ministry of Justice
Thameside (2024)
The Board would like the new Minister to look at the continued lengthy delays in transferring mentally ill patients from a custodial setting to a secure hospital setting, an issue highlighted by this Board and the majority of other IMBs across the country for several years. In the Board’s view, these delays are not only inhumane for the patients involved …
Ministry of Justice
In Progress
Nottingham (2024)
Again, the Board raises its continuing concern about prisoners who are seriously mentally unwell being held in prison and frequently having to be detained in the Care and Separation Unit. Prison is not the appropriate environment for prisoners who are severely mentally unwell. We again ask for greater provision to be made available for such prisoners so they can be …
HMPPS
In Progress
Northumberland (2024)
What measures can be implemented to ensure mental health support is available within a reasonable timeframe to prisoners who require it?
Ministry of Justice
In Progress
New Hall (2024)
What will the Minister do to help accelerate the process of transferring prisoners with mental health issues to secure units?
Other
In Progress
Long Lartin (2024)
Healthcare centre (HCC): what full programme of measures is planned to provide all necessary facilities (including end of life) for in-patients?
HMPPS
In Progress
Leicester (2024)
What actions will the Minister take, together with colleagues in health commissioning, to ensure there are sufficient secure hospital places to cope promptly with the demand?
Ministry of Justice
In Progress
Leeds (2024)
The IMB has seen no improvement in the extent to which prisoners who have been assessed as requiring treatment in secure mental health facilities are quickly removed to those facilities. Does the Prison Service agree that, whilst the prison may be a safe place to hold those prisoners, it is not an appropriate place to do so and what is …
HMPPS
In Progress
Lancaster Farms (2024)
When will the Minister increase the number of specialist secure prison settings for prisoners with complex and/or enduring mental health conditions?
Ministry of Justice
In Progress
High Down (2024)
The Government should address the physical needs of the ageing prison population, including social care provision, accessibility, purposeful activity for retired prisoners and end of life care.
Ministry of Justice
In Progress
Featherstone (2024)
Issues with low numbers of healthcare staff have, on occasion, meant that the regime has been disrupted because of delays dispensing medication. This has been an ongoing issue and consideration should be given as to whether the system can be changed to increase its reliability and consistency.
Governor / Director
Featherstone (2024)
Mental illness is a serious issue within prisons. The compassionate answer appears to be to locate some of these prisoners in isolation in the CSU, where largely untrained staff attempt to deal with them in a humane way. This is not acceptable and there needs to be a way of speedily transferring these prisoners to more appropriate accommodation that can …
HMPPS
Implemented
Exeter (2024)
Given the high proportion of prisoners with mental ill health, will the Prison Service ensure the delivery of standalone mental health training for all officers?
HMPPS
Implemented
Exeter (2024)
When will the non-statutory independent role, referred to in the Minister’s response last year, improve the timely transfer of prisoners with serious mental health conditions?
Ministry of Justice
In Progress
Altcourse (2024)
Can an assurance be given that the provision of hospital escorts will be prioritised?
Governor / Director
Usk and Prescoed (2025)
The ageing population at HMP Usk presents several challenges. The increased demand for both general and palliative healthcare will necessitate additional resources and funding, such as expanded weekend services and more staff allocated to hospital escorts. Furthermore, the current infrastructure at HMP Usk is not well suited to the needs of older individuals. What specific measures are being considered to …
HMPPS
In Progress
Nottingham (2025)
As referenced in our previous report, we again raise with the Minister the issue of the wellbeing of prisoners who are severely mentally ill. The Board remains concerned at the length of time it takes for suitable places in secure mental health hospitals to become available. This means that severely unwell prisoners are having to be detained in the care …
Other
In Progress
Moorland (2025)
What more will the Governor do to improve the quality of health care provided?
Governor / Director
Leicester (2025)
What pathways can be developed for prisoners with severe dementia to meet their needs in specialist facilities in prison or community facilities?
Other
Implemented
Bure (2025)
Are there plans to provide specialised units for dementia and geriatric healthcare, given the increasing age profile and fragility of many prisoners? This is especially required in those prisons like HMP Bure that do not have 24/7 healthcare on site.
NHS / Healthcare Provider
In Progress
Ashfield (2025)
Inadequate social care, including end-of-life and dementia care, for people convicted of sexual offences. With an increasing older population, what additional measures will be taken to assist prisons such as HMP Ashfield?
Other
In Progress
Lancaster Farms (2022)
Given concerns expressed above to invite Department of Health colleagues to work with the Minister to review the capacity associated with the provision of mental health services across the prison estate for those prisoners with severe and enduring mental illness.
Other
In Progress
Whatton (2020)
The standard of the accommodation in the healthcare centre remains a significant concern, as indicated in our letter to the minister in April 2020 (see paragraphs 6.1.8 to 6.1.11). Will the Prison Service consider substantial refurbishment or replacement of the healthcare facilities, now that more capital funding has been made available?
HMPPS
In Progress
Health investigations(52)
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
The head of prison healthcare must ensure that the current approach to the monitoring and audit of documentation is reviewed. The Investigation Team suggests that a peer-review approach is considered to enable health staff to reflect on the quality of their documentation and whether or it accurately portrays: care and …
north_east_yorkshire
Independent investigation: Paul Royston Herbert, Brent (2010) — Rec Eight
It is recommended that the Inreach team at HMP Pentonville should ensure that systems are in place for the early referral of all remand prisoners who have a serious mental illness to their relevant CMHT in a timely fashion.
london
Independent investigation: Michael Martin, Almondsbury, (1999) — Rec 12
The Prison Health Policy Unit and/or Task Force should recommend that prisons review the training of those prison medical staff who conduct reception screening. Training should focus particularly on the detection of severe mental illness and the actions to be triggered by recognition of such illness. In-reach services and prisons …
south_west
Independent investigation: Hugh McCaffrey, Willesden — Rec 4.83
The prison medical services should maintain close links with the rest of the NHS. Appropriate protocols should be negotiated.
london
Independent investigation: Gillian PhilippsDavid Oakes, Stansted Mountfitchet (2015) — Rec 5
Commissioners of prison health services in the East, North Midlands and the South must ensure that robust procedures are in place to maintain continuity of mental healthcare in prison, on reception and on inter-prison transfer when a prisoner has received secondary mental health care in the community.
east_of_england
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.11
The Caswell Clinic should formalise the weekly meetings held to discuss patients, including those currently in the community or in prison, for whom the Caswell Clinic still formally retains section 117 after-care responsibility, on behalf of mental health services. Actions should be appropriately recorded and communicated to the relevant prison. …
wales
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.10
Arrangements should be put in place37 to ensure more robust and formalised communication arrangements between the Caswell Clinic and HMP Parc. Prison healthcare staff should advise the Caswell Clinic of any new prisoner that is under the care of a Responsible Clinician based at the Caswell Clinic.
wales
Independent investigation: Anthony Harrison, Andover (1998) — Rec 3
The Health Authority should support the development of a prison CMHT.
south_east
Independent investigation: Anthony Harrison, Andover (1998) — Rec 2
The Health Authority, in conjunction with Mid Hampshire PCG and the Prison Medical Service should jointly develop a Health Improvement Programme for Winchester Prison, with mental health as a priority.
south_east
Independent investigation: Anastasia Voykina, Streatham (2012) — Rec 10
Commissioners of prison health services must ensure that providers take appropriate and timely action to obtain relevant details about detained prisoners’ care plans and risk assessments when they are made aware that the prisoner is known to a community mental health team.
london
*Independent investigation into the care of Mr A: March 2013 — Rec 3
CPFT should undertake a review of the clinical governance policies and procedures operated by the MHIRT in order to ensure that all CPFT policies have been appropriately tailored to take account of the specific challenges posed by a custodial environment.
Cambridge and Peterborough NHS Foundation Trust
east_of_england
*Independent investigation into the care of Mr A: March 2013 — Rec 1
CPFT to prepare a detailed action plan, incorporating a timetable and measurable deliverables, in relation to the Bradley Report to ensure that the recommendations of the Bradley Report have been incorporated into MHIRT practices and procedures with a view to improving the provision of services to offenders with dual mental …
Cambridge and Peterborough NHS Foundation Trust
east_of_england
An independent inquiry into the care and treatment of Mr … — Rec 5
Health and justice specialist commissioners and commissioners of local services should promote opportunities to enable prison officers and prison healthcare workers, (including mental and physical health care) to undertake mental health screening aimed at making appropriate referrals prior to impending discharge. A progress report reflecting current best practice should be …
Southern Health NHS Foundation Trust
south_east
An independent inquiry into the care and treatment of Mr … — Rec 4
Health and Justice specialist commissioners (NHS England and the Ministry of Justice) and commissioners of local services should promote greater collaboration between prison-based mental health and substance misuse services on the one hand and NHS mental health and local substance misuse services on the other. A progress report should be …
Southern Health NHS Foundation Trust
south_east
Independent investigation into the care and treatment of Mr F: … — Rec 8
NHS England’s Regional Homicide Leads need to address the lack of information sharing by prisons’ medical services.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the multi-agency care and supervision of … — Rec 5
There needs to be effective oversight of, and clear provision of escalation routes for concerns about, health and social care provision to HMP Parc. HMP Parc Prison Health, Wellbeing & Social Care Partnership Board should routinely seek assurance that health and social care services are meeting the requirements of the …
midlands
An independent investigation into the care and treatment of a … — Rec 5
Commissioners of prison health services in the East, North Midlands and the South must ensure that robust procedures are in place to maintain continuity of mental healthcare in prison, on reception and on inter-prison transfer when a prisoner has received secondary mental health care in the community.
east_of_england
An independent investigation into the care and treatment of a … — Rec 4
Trust CPA and discharge policies should provide clear guidance on how liaison with prison services mental health teams will occur at entry and exit, to maintain continuity of care.
east_of_england
Independent investigation: Julie McKinley, Finsbury Park (2009) — Rec 3
NHS London should share with other mental health and learning disability Trusts the risk that Consultant Forensic Psychiatrists visiting prisons may not input and update electronic patient record systems meaning that critical information is not shared with community mental health teams when patients are discharged from prison.
london
Independent investigation: Julie McKinley, Finsbury Park (2009) — Rec 6
Interface between NLFS and the Trust – It is recommended that that the NLFS review the way in which information about known service users is recorded onto RiO when they are assessed and seen in prison. The outcome of all reviews and assessments must be recorded on RiO.
london
Independent investigation: Hugh McCaffrey, Willesden — Rec 4.86
Service Agreements should be developed for the role of Consultant Psychiatrists visiting prisons for the purposes of assessment of inmates in order to make reports to courts.
london
Independent investigation: Hugh McCaffrey, Willesden — Rec 4.85
The therapeutic role of Consultant Psychiatrists visiting prisons for the purposes of assessment of prisoners for forensic purposes should be developed further.
london
Independent investigation: Gillian PhilippsDavid Oakes, Stansted Mountfitchet (2015) — Rec 4
Trust CPA and discharge policies should provide clear guidance on how liaison with prison services mental health teams will occur at entry and exit, to maintain continuity of care.
east_of_england
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015) — Rec 7
The National Probation Service, in conjunction with HMP Manchester and other prison establishments, should review the practice of frequently moving prisoners with complex mental health needs between different prison facilities. This review should consider the impact of such moves on the continuity of mental health care, assessment, and treatment, and …
north_west
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.9
The protocols in place should be reviewed to ensure appropriate referrals are made to the in-reach team. We note this may be strengthened by the in-reach team now being located at HMP Parc.
wales
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.8
In line with the Prison Mental Health Pathway36, HMP Parc healthcare services and the Abertawe Bro Morgannwg University Health Board in-reach service should ensure that relevant prison nurses attend clinical and MDT meetings in order to strengthen relationships.
wales
*Independent investigation into the care of Mr A: March 2013 — Rec 6
A dedicated meeting should be established for senior managers from the Prison service and CPFT to review on an on-going basis, policy documentation in areas of joint practice, on a regular basis. In addition, there would be considerable merit in those individuals identifying and reducing their respective operational components to …
Cambridge and Peterborough NHS Foundation Trust
east_of_england
*Independent investigation into the care and treatment of Patient C: … — Rec 19
The panel also recommends to the SHA that it liaises with the North East Offender Health Commissioning Unit regarding the establishment of a system that ensures that if a prisoner requires examination by a psychiatrist and it has not occurred by the due date, prompt remedial action is taken.
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of patient M … — Rec 97
Various methods of information sharing have been adopted, such as prison radio, poster campaigns and distributing leaflets and promotional materials. This should be a priority because prisoners report only patchy access to information, with particularly low levels of information on harm reduction such as keeping safe if using, and keeping …
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 94
Once the person is accepting of the need for change, evidence-based interventions include an individual assessment of treatment need, and both educational and therapeutic groups. This can include group work led by prisoners. Other self-help initiatives are the establishment of users’ forums, and the use of peer mentors to offer …
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 92
Prison services have considerable expertise in delivering clinical and psychosocial treatments to substance misusers. Users of NPS can be offered the same range of interventions.
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 91
If the person fails to respond, or their condition is deteriorating, they will need to be in an environment where their safety can be maintained. On assessment, this may be a place with heightened levels of observation within the prison, or transfer to hospital may be necessary.
east_of_england
Independent external quality assurance review following the independent investigation into … — Rec 18
To consider what protocols if any, within the current legislative framework can be developed and implemented to share relevant healthcare information about prisoners at risk of mental health problems who refuse consent to share information with GPs.
midlands
Accepted
Independent external quality assurance review following the independent investigation into … — Rec 17
to consider what action can be taken to allow healthcare teams in prisons to have access to the prison records P-NOMIS.
midlands
Partially Accepted
Independent external quality assurance review following the independent investigation into … — Rec 16
HMP Birmingham (Healthcare) should provide assurance to the Trust and their commissioners that the issues with SystmOne (accessing prisoner’s full medical notes from the point of admission) have been resolved.
midlands
Accepted
Independent external quality assurance review following the independent investigation into … — Rec 14
The Trust should discuss their PICU guidance with all the prison health care services who refer to their PICU units.
midlands
Accepted
Independent external quality assurance review following the independent investigation into … — Rec 12
NHS England’s Health and Justice Commissioning Team (North Midlands) should discuss the findings of the original Trust report with the new provider of healthcare at HMP Hewell to ensure that implementation is still progressing and that lessons learnt are continuing to inform practices and policies.
midlands
Accepted
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The question of confidentiality of prison medical records should be fully reviewed. As a first step towards such review, the General Medical Council and other professional bodies should be asked for their views.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The Prison Service should ensure, by the end of 1996, that it has in place a database and a fully effective system whereby prisoners' IMRs, including those of remand prisoners, follow them wherever they may be in the system. The provision should encompass access to the system for all those …
east_of_england
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: Paul Royston Herbert, Brent (2010) — Rec Ten
It is recommended that Camden and Islington NHS Foundation Trust are sent a copy of this report as the responsible organisation for the Inreach mental health service at Pentonville Prison.
london
Independent investigation: Gilbert McCallum, Dover (2001) — Rec 18.5
In the light of the shortcomings identified in Mr Regan’s case, the arrangements by PCTs to commission secondary prison medical health care should be reviewed. This is to ensure that adequate mechanisms are maintained to ensure the continuing medical and psychiatric care of prisoners following their release.
south_east
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.7
As per the Prison Mental Health Pathway34 guidance and PSO 350035, HMP Parc should ensure that robust and effective multi-disciplinary discharge planning processes are in place. Consideration given to the CPA status of the prisoner. A copy of the CPA plan should be given to the prisoner upon release and …
wales
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.4
HMP Parc should review its compliment of Registered Mental Health Nurses (RMNs) and ensure that levels are appropriate to enable timely and appropriate screening assessments to taking place at the prison mental health clinics.
wales
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.3
With regards to HMP Parc and consent issues being a potential barrier to making a referral to health and social care agencies, HIW believes that a clear protocol should be put in place whereby consent can be overridden when appropriate. This should also be made clear on the consent forms …
wales
*Independent investigation into the care of Mr A: March 2013 — Rec 4
CPFT and the MHIRT should undertake a review of the pathways through which information concerning offenders is received, requested and recorded in order to ensure that information concerning the needs of individual offenders and the risk that they pose is available to all members of the MHIRT.
Cambridge and Peterborough NHS Foundation Trust
east_of_england
An independent review of the independent investigations for mental health … — Rec 5
It is recommended that the IIGC identifies the strategic co-dependencies with agencies such as police, probation, prison engaged with mental health services to optimize the learning and improvement and to provide a platform for joint working at the strategic level.
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 96
Education is the main preventative health intervention, especially in preventing the proportion of users who use NPS for the first time in prison. Topics include drug refusal skills, risks to physical and mental health, and the unpredictable effects of NPS compounds as they are composed of different types of substances …
east_of_england
Independent external quality assurance review following the independent investigation into … — Rec 7
Healthcare staff at both HMP Hewell and HMP Birmingham who are undertaking CPA and risk assessments should familiarise themselves with the Home Office ‘Adolescent to Parent Violence and Abuse Guidance for Practitioners’ (2015) and be categorising incidents of violence by children on a parent and/or carer as incidents of domestic …
midlands
Accepted
Scottish Fatal Accident Inquiries(8)
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
Raymond Gavin
It is recommended that NHS Ayrshire and Arran should give careful consideration to the requirements for the delivery of General Medical Practitioner services to the prisoners detained within HMP Kilmarnock and to the specification of the required services in the successor to the existing contract.
Mar 2018
Angus Sinclair
Mar 2020
Alexander Douglas Bradie
Mar 2020
Andrew McBride
Mar 2021
Robert William Marshall
It seems to me that if inmates are discharged from hospital when they are stabilised, as happened to Mr Marshall on numerous occasions, then greater provision for care of a nursing nature may require to be looked at by the relevant authority.
Nov 2011
Steven Taylor
3. In terms of Section 6(1)(e) of the said Act, that the vulnerability assessment form completed by police custody security officers in respect of persons held in police custody should accompany such persons in addition to the Personal Escort Record. 4. In terms of Section 6(1)(e) of the said Act, that investigation should be carried out by the Scottish Prison …
Feb 2015
Jordan Barron
Given that HMYOI, Polmont has a high intake of disturbed young men from socially and economically deprived backgrounds, perhaps further thought should be given by NHS and SPS to their future aims towards mental health and behavioural issues of such inmates whilst within the prison setting and to supported care from other agencies on their release.
Jun 2016
Article 2 learning points(90)
— LP 1
I recommend that, those responsible for healthcare governance at HMP Lincoln and HMP Ranby: identify the requirements of good practice in the specific areas identified below, in the light of the problems that occurred in this case and taking account of NHS and NOMS policies; review their current arrangements and …
HMP Lincoln, HMP Ranby
— LP 2
I recommend that NHS England and NOMS: take note of the findings in Chapter 11, and consider jointly in the light of this investigation whether the lessons of this investigation have a wider application; in particular, that they consider whether they are satisfied that adequate arrangements are now in place …
NHS England, NOMS
— LP 4
We recommend that people presenting with multiple complex symptoms, in particular in the context of a serious episode of self-harm, should have a full diagnostic psychiatric and suicide/self-harm risk assessment, highlighting triggers for self-harm and likely high risk times, with contingency planning.
HMPPS
Accepted
— LP 2
We recommend that across the Prison Service Estate nationally there is enhanced provision for the assessment and treatment of alcohol misuse and dependence disorders.
HMPPS
Accepted
— LP 17
To make better use of pre‐existing information, we recommend that psychiatric assessment guidelines used on HMP Pentonville’s Healthcare unit reference the need to source and consider the results of medical and psychiatric assessments that may have been conducted by other institutions.
PPG
Accepted
— LP 15
We recommend the ongoing use of the record‐keeping audit tool being used on HMP Pentonville’s Healthcare unit, whilst ensuring that it continues to make a tangible difference and informs decision‐making, rather than being seen as a paper‐filling exercise. Showing staff exactly how it is making a difference should further encourage …
PPG
Accepted
— LP 12
We recommend that HMP Pentonville’s Healthcare unit reviews its use of ‘Special Observation forms’ and clarifies what value, if any, they are adding to the care and management of a prisoner who is on an observation regime.
PPG
Accepted
— LP J
When a prisoner is identified as requiring assessment by a psychiatrist, he should be escorted to that appointment where necessary. If, for whatever reason, such an appointment is missed, medical staff should ascertain the reasons for the missed appointment on the same day.
HMPPS and PPG
— LP H
A much more robust system should be in place to account for missed medical appointments. This system should explore reasons for non-attendance, emerging patterns of non-attendance and identify vulnerable prisoners. As happened with the Substance Misuse Team, two consecutive failures to attend GP appointments should trigger a visit to the …
HMPPS and PPG
— LP F
Drug Dependence Reviews of dual diagnosis patients should consider the range of medication prescribed to a patient.
PPG
— LP E
In a case where a prisoner has both substance misuse and mental health problems – so-called dual diagnosis – a joint assessment by a mental health and a substance misuse specialist should be carried out.
PPG
— LP C
In the period between an assessment by the Mental Health Outreach Team and a decision about whether to accept a prisoner on to the caseload, a pending case should be subject to a provisional zoning priority. A system of monitoring and auditing compliance with the zoning protocol should be in …
PPG
— LP B
The Medical Record should be properly updated within 24 hours of any action taken or decisions made.
PPG
— LP 5
We recommend that policy on the sharing of medical information in the prison setting is clarified and a training programme established to ensure staff understand its implications.
HMPPS
Accepted
— LP 8
I recommend to NOMS that: An inquiry into an incident of life-threatening self-harm should always include an examination of healthcare as well as the actions of the discipline staff. Findings and conclusions should take account of both aspects considered jointly.
NOMS
— LP 8
HMPPS should ensure that liaison between Article 2 investigators and prisons is improved by ensuring that the member of staff in an establishment appointed to liaise: a) understands the nature of the Article 2 process, and b) is of sufficient seniority to direct staff and resources to facilitate the investigation.
HMPPS
Accepted
— LP 7
HMPPS takes steps to reduce the time between incidents and the commission of Article 2 Investigations.
HMPPS
Accepted
— LP 6
As the impact on staff well-being of traumatic incidents may not be immediately apparent, all staff should be actively encouraged by their managers to access staff care services following such incidents.
HMPPS
Accepted
— LP 5
As a considerable time may pass before an Article 2 investigation is commissioned, HMPPS should clarify whether the prison is responsible for completing a full investigation where serious harm to an individual has been sustained.
HMPPS
Accepted
— LP 4
HMP Durham should review the minimum staffing level needed to safely oversee prisoners taking part in association.
HMP Durham
Rejected
— LP 3
In order to reduce congestion in and around showers and make observation easier HMP Durham should introduce a prisoner reservation booking system for the use of showers.
HMP Durham
Partially Accepted
— LP 2
In order to reduce the risk of violence to prisoners the Violence Reduction Strategy should be monitored by managers to ensure that all prisoners to whom it applies are included and steps taken to reduce their likelihood of potential violence.
HMP Durham
Accepted
— LP 1
In order to reduce the risk of harm posed by prisoners to other prisoners’ Cell Sharing Risk Assessments should be better recorded and steps to mitigate risk of harm clearly stated. In addition, there should be a system for retrieval of the document upon request.
HMP Durham
— LP 5
We invite the Governor to examine whether the 12 minutes from arrival at the prison to attending a patient on K wing is unavoidable or whether the process of accessing the wings in emergencies can be made more efficient.
HMPPS
Accepted
— LP 4
We recommend that the Governor of Stocken (locally) and HMPPS (nationally) review the present arrangements for communications with the ambulance services to examine whether current policy and practice appropriately reflects the ambulance services’ system of allocating priorities.
HMPPS
Accepted
— LP 3
We recommend that PPG review their protocols for supplying data for the investigation of a suspected crime where the alleged victim has no capacity to give or withhold consent. Any request to disclose information to the police should be recorded, with a note of the reasons for the decision to …
PPG
— LP 2
We recommend that the prison takes note of the problems that occurred in this case and ensures that where the police are investigating an incident in the prison, clear arrangements are made for a single point of contact in the prison and for another staff member to deputise if they …
HMPPS
— LP 11
We recommend that in the Prison Service nationally, for prisoners with complex and serious medical conditions, the need for ongoing use of handcuffs should be regularly reviewed, with a full assessment of risk to the public and of absconding, and that this should be clearly documented in the case notes.
HMPPS
Accepted
— LP 9
We recommend that Doncaster Prison develops a robust system for testing and ensuring that all medical devices, including defibrillators, are in full working order.
The Governor
Accepted
— LP 3
We recommend that across the Prison Service Estate there is more focus on conducting full psychiatric and psychological assessments of prisoners, particularly those with complex needs. This should include the gathering and assimilation of all relevant previous records. This process should be followed by a full psychological formulation with longitudinal, …
HMPPS
Accepted
— LP 1
We recommend that across the Prison Service Estate nationally there is a review of psychological therapy provision and an audit of the use of antipsychotic medication for agitation, in the absence of a diagnosis of psychosis. There should be enhanced provision of psychological therapies nationally and cessation of inappropriate use …
HMPPS
Accepted
— LP 3
HMP Featherstone should comply with the mandatory action contained in Prison Service Order 1300 – ‘Investigations’ that a formal investigation is completed when there is serious harm to any person.
HMP Featherstone
Accepted
— LP 2
HMP Featherstone should review its procedures so that families are informed of a prisoner’s illness with a minimum of delay.
HMP Featherstone
Accepted
— LP 1
HMP Featherstone and the health care providers in the prison should explore how to maximize information-sharing between Health Care and Security so that both of these components of care can work together to reduce the ingress and use of illicit substances in the prison. This includes the completion of agreed …
HMP Featherstone, Midlands Partnership NHS …
Accepted
— LP 3
I recommend that all prisoners should have a mental health assessment within 72 hours of entering custody, for case-finding. Prison Service Instruction (PSI) 74/2011 Early Days in Custody – Reception In, First Night in Custody, and Induction to Custody indicates that all prisoners should have a health review within a …
HMP Altcourse and HMPPS
Partially Accepted
— LP 19
We recommend that officers’ attendance at ward rounds is embedded as a norm on HMP Pentonville’s Healthcare unit, if this is not already the case. This should help further improve understanding and promote a sense of collegiate working among discipline and clinical staff.
PPG
Accepted
— LP 3
We recommend that HMP Pentonville’s Healthcare unit keeps a log of temporary staff who have received a prison induction, whether they be booked through NHS Professionals or otherwise. We think it’s important that this log is easily accessible and made visible to help promote ownership for the provision of these …
PPG
Accepted
— LP 1
At an organisational and cultural level, we recommend that further measures are taken to close the perceived gap between the main prison and the Healthcare unit at HMP Pentonville. This should help create a greater sense that HMP Pentonville is functioning as one organisation, comprised of staff and managers working …
HMPPS
Accepted
— LP 13
Prisoners on Level A of the Safe Supervision of Prisoners (in-patients) policy should be reviewed on a daily basis in accordance with that policy and these reviews should be documented.
The Governor
Accepted
— LP 3
As a considerable time may pass before an Article 2 investigation is commissioned, HMPPS should clarify whether the prison is responsible for completing a full investigation where serious harm to an individual has been sustained.
HMPPS
Accepted
— LP 2
The in-reach team should consider whether an algorithm based on risk presentation that is high, medium or low, would help to dictate time-frames for specific actions to be taken.
Central and North-West London NHS …
Accepted
— LP 1
The psychiatric in-reach service at HMP High Down should consider the delay in completing the actions arising from the assessment on GN in October 2015 and describe the current arrangements for avoiding such delays.
Central and North-West London NHS …
— LP 12
We recommend that GEOAmey review the staff training modules on mental health awareness and interpersonal skills in the light of Dr Craissati’s advice in paragraphs 5.42 to 5.46, noting in particular her focus on behaviours likely to be encountered in a prisoner population, and in developing skills in listening, exploring, …
GEOAmey
Accepted
— LP 11
We recommend that GEOAmey puts in place express policy for aftercare for staff involved in a serious incident through immediate informal support from managers, and further recognition over a longer period, as well as access to independent counselling for staff who wish to use it.
GEOAmey
Accepted
— LP 10
We recommend that GEOAmey and HMPPS consider how friends and families of prisoners at risk can be encouraged and enabled to pass on any concerns about risk of self-harm. Protocols may be required as to how to reconcile requirements of privacy and requirements of safe custody that may be in …
GEOAmey and HMPPS
Accepted
— LP 1
We recommend that PECS and GEOAmey review the number of custody officers required in the Southampton Magistrates’ Court custody suite and how they are deployed.
PECS and GEOAmey
Accepted
— LP Healthcare 7
An auditable system should be implemented to monitor completion of annual resuscitation training updates for staff within the healthcare team.
Healthcare Provider
— LP Healthcare 6
Individual staff log-in details should not be shared or used by other members of the healthcare team to make entries to the electronic Patient Record.
Healthcare Provider
— LP Healthcare 5
Paper documentation which is generated and subsequently scanned to the electronic Patient Record should clearly identify the location, date, time and author along with their designation.
Healthcare Provider
— LP Healthcare 4
The date and time of an individual’s transfer to secondary care and discharge back to prison should be documented in the clinical record. This should include any required actions which are identified on discharge from secondary care.
Healthcare Provider
Detention investigations(2)
Assessment of government progress in implementing the report on the … — Rec 4
I remain concerned about the position of detainees held in the prison estate and recommend that a policy be developed to equate to Detention Centre Rule 35.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 3
The Home Offce should establish a joint policy with HMPPS on provision for those held in prison under immigration powers.
Immigration Detention
Independent reviews(8)
Harris Review: Deaths in Custody — Rec 71
All commissioning, contract and performance management policies and documents for health and mental health provision in custody should include responsibilities for SAVRAS and will include the following: 71.1 Health teams must be actively involved in the operation of the SAVRAS process, although the delivery of services through the ICP to …
Justice & Legal
Harris Review: Deaths in Custody — Rec 67
Further to the statement of the purpose of prison, the European Prison Rules (5) state the principle of approximation as closely as possible the positive aspects of life in the community; therefore healthcare must take a central responsibility in this area.
Justice & Legal
Harris Review: Deaths in Custody — Rec 65
NHS England should commission prison mental health services in line with the recommendations of this report.
Justice & Legal
Harris Review: Deaths in Custody — Rec 64
There must be parity of health care services in prisons and YOIs with those in the community and NHS England and Local Health Boards in Wales should commission the services necessary to do this and deliver what is set out in this chapter.
Justice & Legal
Shaw Detention Review — Rec 24
Recommendation 24: I note that DSO 03/2013 on food and fluid refusal is currently the subject of internal review within the Home Office. I recommend that the review consider alternatives to treatment within a prison or IRC in light of my discussion of this issue.
Immigration
Gauke Review — Rec 6.7
Agree a strategy to manage older offenders’ complex health needs
Justice & Legal
Lammy Review — Rec 21
The prison system, working with the Department of Health (DH), should learn from the youth justice system and adopt a similar model to the CHAT for both men and women prisoners with built in evaluation.
Justice & Legal
Accepted
Harris Review: Deaths in Custody — Rec 84
Each prison and YOI should have an emergency medical response plan that contains the following elements: 84.1 A mandatory Medical Emergency Response exercise each year, including emergency medical codes, in conjunction with local health care providers and emergency services. 84.2 NHS needs to consider developing an appropriate health “NEVER” event …
Justice & Legal
PHSO casework decisions(4)
P-003496 — An independent provider in the Isle of Wight …
Mr K complained about missed medical appointments, lack of dental treatment, and being denied possession of his sleep medication in his cell, causing delays, stress, and anxiety.
NHS in England
Apr 2025
P-003565 — Oxleas NHS Foundation Trust
Mr R complained about inappropriate stopping of medications without detox in prison, delays in new prescriptions, and inadequate management of his physical pain and mental health.
NHS in England
Not Upheld
Dec 2024
P-003123 — Oxleas NHS Foundation Trust
Mr A complained the Trust transferred him back to prison without properly considering his mental health, alleging misdiagnosis, lack of assessment, and inappropriate medication changes.
NHS in England
Nov 2024
P-004363 — An independent provider in the Wychavon area
Mr F complained he was denied A&E access for a hand injury, refused pain medication, and received inadequate aftercare, leading to severe pain, depression, and self-harm.
NHS in England
Nov 2025
LGO / SPSO decisions(15)
201304654 — Scottish Prison Service
Mr C complained that a prison manager had refused to contact the on-call doctor after Mr C was sick and got something stuck in his throat, causing him chest pain. Mr C said that the prison did not act in accordance with the prison rules because a healthcare professional must …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Feb 2015
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
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
NIPSO-202004929 — South Eastern Health and Social Care Trust
A man claimed that prison authorities unfairly denied him treatment for his opioid addiction. We did not uphold the complaint but made observations on the case for the Trust to consider going forward.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Dec 2024
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
201102802 — Scottish Prison Service
Mr C, who is a prisoner, complained because he was unhappy with the delay in him being able to access the smoking cessation programme. Our enquiries with the prison confirmed that prisoners are selected onto the programme in line with their liberation date and because of that, we were satisfied …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Feb 2012
201101364 — Scottish Prison Service
Mr C, who is a prisoner, complained because he felt the prison were failing to issue privileged mail to prisoners with a reasonable time in accordance with published standards. Privileged mail is mail sent to a prisoner from their legal representative, the courts and other organisations, such as SPSO. Our …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Dec 2011
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
201709050 — Scottish Prison Service
Mr C complained that the Scottish Prison Service (SPS) stopped his Special Escorted Leave (SEL). He also complained about the handling of his complaint. We found that the prison did not stop Mr C's access to SELs but, within their authority under the relevant legislation, they questioned Mr C's need …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Jan 2019
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
201303091 — Scottish Prison Service
Mr C, who is a prisoner, complained because he said the prison failed to take reasonable steps to improve television reception. He said his in-cell signal was poor and although repair work had been carried out, the problem was not fixed. The prison told us that the repair work indicated …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Mar 2014
201304894 — Scottish Prison Service
Mr C complained that the prison he was in failed to make adequate arrangements for the provision of halal food. He said that he wanted the imam for the prison to taste random halal meals, as he considered that the halal goods brought into the prison were not halal by …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jan 2015
201407669 — Scottish Prison Service
Mr C alerted staff in the prison that he was experiencing chest pain, and it was agreed that he should attend hospital. However, Mr C decided not to attend and staff agreed to carry out regular observation checks on him throughout the night. Mr C complained because he said staff …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jul 2015
201504160 — Scottish Prison Service
Mr C complained that there was inadequate choice to meet his food preferences in prison. For example, he liked plain food, rather than curried or spicy food. We considered the relevant prison rule about the provision of food in prison and looked at sample menus. The prison also explained how …
SPSO (Scottish Public Se…
Prisons
Not Upheld
May 2016
Domestic Homicide Reviews(13)
Gloucester — recommendation 4
NHS England to develop capability for prison healthcare to access Summary Care Records for prisoners so that prisoners’ healthcare needs are addressed immediately.
NHS England
NHS England
Gloucester — recommendation 3
NHS England to ensure that community GPs promptly provide comprehensive details of a patient’s health records when asked by a prison healthcare team for this information. This should include details of the prisoner’s history of both physical and mental health problems.
NHS England
NHS England
Buckinghamshire — recommendation 5
That the Department of Health continues to remind primary care, particularly in this case, with the prison establishment of the requirement to co-operate with Domestic Homicide Reviews.
Department of Health
Department of Health and …
Tendring — recommendation 2
That the specification for the provision of prison healthcare services includes the requirement for the service provider to have in place a clear care pathway for service users who are to be released from prison with a diagnosis of a mental health condition which ensures referral to Community Mental Health …
NHS England Midlands & East (East)
NHS England Midlands and …
Cumbria — recommendation 3
Prison health care providers must ensure that systems are in place to share secondary prison health care consultations and information with GPs on discharge or release.
Prison health care providers
North East Lincolnshire — recommendation 2
The Home Office consider whether further national policy and practice guidance is indicated on prison reception processes in checking probation and community health systems.
Home Office
Home Office
North East Lincolnshire — recommendation 4
The prison should provide a summary of learning for the reception and health care team and review operational guidance on checking for risk flags on community-based data systems.
The prison
North East Lincolnshire — recommendation 3
The prison should review and ensure that domestic abuse training is provided to staff working in prisons and ensure that staff completing reception and health screening processes with prisoners have enhanced levels of training and awareness about checking for evidence of domestic abuse whether or not it is associated with …
The prison
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
Gloucester — recommendation 2
NHS England to ensure that, at regional and national level, patients with severe mental health issues (such as schizophrenia) requiring regular antipsychotic medication have clear and specific care plans that identify their regular medication needs. This information must be contemporaneous and should be visible across all healthcare systems, including prison, …
NHS England
NHS England
St Helens — recommendation 1
The existing practice of prohibiting domestic abuse interventions from being offered to victims and perpetrators of domestic abuse whilst on remand in H. M. Prison be changed and such interventions be encouraged.
Ministry of Justice
Ministry of Justice
Tendring — recommendation 4
A review should take place into the system of releasing an offender from prison custody from court without accommodation and/or a prescription for existing medication being arranged, especially where the person being released has been in receipt of prison health services and prescribed medication for mental illness or disorder.
Essex Criminal Justice Board
Tendring — recommendation 20
That the Trust develop a care pathway for patients who are released from prison with a diagnosis of a mental health condition to ensure there is no delay in receiving care and treatment, and that there is a fast track system for those with a diagnosis or a Mental Health …
North Essex Partnership Foundation NHS Trust …
CJINI inspection reports(19)
Ash House (Hydebank Wood Women’s Prison) (14-17 March 2005)
Hydebank Wood Women’s Prison, Prisons
Nov 2004
Report on an announced inspection of Magilligan Prison (20-24 September 2004)
Prisons, Magilligan Prison
Mar 2005
Inspection of the Juvenile Justice Centre (Northern Ireland)
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
Apr 2005
Hydebank Wood Young Offender’s Centre (Secure College) (14-17 March 2005)
Prisons, Hydebank Wood Secure College
Oct 2005
Report of an announced inspection of Maghaberry Prison (10-14 October 2005)
Maghaberry Prison, Prisons
May 2006
An unannounced inspection of Magilligan Prison (10-19 May 2006)
Prisons, Magilligan Prison
Dec 2006
Roe House -Maghaberry Prison Unannounced inspection of infection prevention and hygiene
Maghaberry Prison, Prisons
Mar 2012
Report on an unannounced inspection of Maghaberry Prison (20 September – 6 October 2022)
Maghaberry Prison, Prisons
Jun 2023
Report of an Independent Review of Progress (IRP) at Maghaberry Prison (31 October – 2 November 2023)
Maghaberry Prison, Prisons
Feb 2024
Report of an Independent Review of Progress (IRP) at Magilligan Prison (31 October – 2 November 2023)
Prisons, Magilligan Prison
Feb 2024
Report on an unannounced Inspection of Hydebank Wood Women’s Prison (21 May – 6 June 2024)
Hydebank Wood Women’s Prison, Prisons
Nov 2024
Report on an unannounced Inspection of Hydebank Wood Secure College (21 May – 6 June 2024)
Prisons, Hydebank Wood Secure College
Nov 2024
Report of an Unannounced Inspection of Magilligan Prison (9-26 September 2025)
Prisons, Magilligan Prison
Mar 2026
Report on an announced inspection of Magilligan Prison (29 March – 2 April 2010)
Prisons, Magilligan Prison
Sep 2010
Hydebank Wood Women’s Prison (Ash House) (21-25 March 2011)
Hydebank Wood Women’s Prison, Prisons
Oct 2011
Report on an unannounced short Follow-Up Inspection of Hydebank Wood Young Offenders Centre (21-25 March 2011)
Prisons, Hydebank Wood Secure College
Oct 2011
Report on an announced inspection of Maghaberry Prison (19 – 23 March 2012)
Maghaberry Prison, Prisons
Dec 2012
Ash House Hydebank Wood Women’s Prison (18-22 February 2013)
Hydebank Wood Women’s Prison, Prisons
Oct 2013
Hydebank Wood Young Offenders Centre (18–22 February 2013)
Prisons, Hydebank Wood Secure College
Oct 2013