His Majesty's Prison and Probation Service
Coroner Christopher Long · Lancashire and Blackburn with Darwen · in 1 recurrence link
No published response from this organisation found.
Coroner Rachael Griffin · Dorset · in 8 recurrence links
No published response from this organisation found.
Coroner Sean Cummings · Milton Keynes · in 6 recurrence links
No published response from this organisation found.
Coroner Sean Cummings · Milton Keynes · in 4 recurrence links
No published response from this organisation found.
Coroner Mary Hassell · Inner North London
No published response from this organisation found.
Coroner Edwin Buckett · Inner North London
No published response from this organisation found.
Coroner Jonathan Stevens · North London · in 6 recurrence links
No published response from this organisation found.
Coroner David Reid · Worcestershire · in 2 recurrence links
No published response from this organisation found.
Coroner Jonathan Stevens · Surrey · in 5 recurrence links
No published response from this organisation found.
Coroner Sean Horstead · Essex · in 3 recurrence links
Coroner Emma Brown · Birmingham and Solihull · in 1 recurrence link
No published response from this organisation found.
Coroner Sarah Middleton · City of Kingston Upon Hull and the County of the East Riding of Yorkshire · in 1 recurrence link
No published response from this organisation found.
Coroner Fiona Butler · Rutland and North Leicestershire
No published response from this organisation found.
Coroner Paul Marks · City of Kingston Upon Hull and the County of the East Riding of Yorkshire
No published response from this organisation found.
Coroner Ian Brownhill · Kent and Medway · in 6 recurrence links
Response · 1 stated action
2025-0391-Response-from-HM-Prison-and-Probation-Service.pdf ↗“HMPPS are currently undertaking a cell design review which is looking at all aspects of cell design, including furniture and fittings, to ensure it takes account of developments in how prisoners are accommodated and improvements in what is currently available on the market. As part of this review, we will explore the possibility of using different materials which meet the stringent fire safety requirements and can also function as anti-ligature for bedding. The review is expected to conclude at”
Coroner Patricia Harding · Kent and Medway · in 3 recurrence links
No published response from this organisation found.
Coroner Rachael Griffin · Dorset · in 2 recurrence links
Coroner Priya Malhotra · Inner West London · in 4 recurrence links
Response · 1 stated action
2025-0364-Response-from-NHS-England.pdf ↗“Staffing within the Mental Health In-reach team”
Coroner Ian Dreelan · Birmingham and Solihull
No published response from this organisation found.
Coroner Crispin Butler · Buckinghamshire · in 3 recurrence links
Coroner Rachael Griffin · Dorset
No published response from this organisation found.
Coroner Victoria Davies · Cheshire · in 2 recurrence links
No published response from this organisation found.
Coroner Rachael Griffin · Dorset
No published response from this organisation found.
Coroner Susan Ridge · Surrey
No published response from this organisation found.
- Anthony Binfield, David Richards and Rolandas Karbauskas: Prevention of Future Deaths Report7 Feb 2025
Coroner Laurinda Bower · Nottingham City and Nottinghamshire · in 1 recurrence link
Response · 6 stated actions
2025-0079-Response-from-Nottingham-NHS.pdf ↗“The Trust has established enhanced Executive led oversight and assurance reviews for Offender Health. This comprises a weekly meeting where progress against the Transformation Plan is reviewed with individuals held to account.”
“A new national template for prison reception screening for the male prison estate was launched on the 1 April 2025. Staff are in the process of receiving the Nationally delivered Highbury Hospital, Highbury Road, Nottingham, NG6 9DR training for this and the benefits include a standardised and simplified model of screening which enable the understanding and recording of previously documented clinical risk which needs to be further considered as part of the reception and induction process.”
“The Head of Safer Custody has introduced a new Early Days in Custody (EDIC) booklet along with colleagues from Reception and the Induction wing.”
“We have worked with Prison colleagues to ensure that SIMs are attended on a weekly basis by a member of the Mental Health Team. This meeting is to discuss any patients of concern and highlight any specific issues relating to that individual.”
“CSIP: Patients can also be referred to CSIP (Challenge, Support and Intervention Plan). This is a prison risk management system and process that will enable information sharing on risk in the prison estate and also support the development of cross professional relationships. Healthcare staff are currently accessing the training for this, and full compliance is aimed to have been achieved by June 2025.”
“Training - Healthcare staff have arranged to attend the Prison staff induction programme so that they can deliver health training to the Prison Officers. Initially this will be focused on emergency response but will later include Mental Health awareness training. This was agreed at the Local Delivery Board and the first session was provided on 23 January 2025. Feedback from staff was very positive. Healthcare staff will continue to receive clinical risk, self-harm and suicide training, which is”