Anthony Binfield, David Richards and Rolandas Karbauskas
7 Feb 2025 · Coroner Laurinda Bower · Nottingham City and Nottinghamshire
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. risk identification and information sharing
“complete failure to identify and share risk pertinent information between prison and healthcare staff”
2. failure to review core files
“failure by prison and healthcare staff to read the incoming prisoner's core file”
3. missed trigger communication
“Healthcare staff concluding on Friday 3 March 2023 that [the deceased]'s inability to attend a candle lighting service might be a trigger for self-harm, but such was not communicated to prison staff or safer custody or recorded on any prison systems”
4. lack of awareness of risk factors
“[the deceased]'s PNOMIS file clearly indicated his fear of joining the general prison population led to him requiring VP status in his previous establishment”
5. lack of understanding of previous self-harm
“without any understanding of their previous self-harm and suicidality”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“It is suggested that receiving HMPS staff should ensure that they read and consider the ACCT file with particular emphasis on the assessment of risk of self-harm and suicide”
This report
“a failure by prison and healthcare staff to read the incoming prisoner's core file. This hard copy file contains valuable information such as previous ACCT documents and SASH warning forms”
Responses
2025-0079-Response-from-HMPPS.pdf ↗· His Majesty's Prison and Probation Service
2025-0079-Response-from-NHS-England.pdf ↗· NHS England
2025-0079-Response-from-Nottingham-NHS.pdf ↗· Serco
Stated action
“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.”
Stated action · 1 April 2025
“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.”
Stated action
“The Head of Safer Custody has introduced a new Early Days in Custody (EDIC) booklet along with colleagues from Reception and the Induction wing.”
Stated action
“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.”
Stated action · June 2025
“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.”
Stated action · July 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”
2025-0079-Response-from-Serco.pdf ↗· Serco
Stated action
“Failure to identify and share risk pertinent information between prison and healthcare staff.”