“No ongoing training had been provided to prison o icers since initial training on basic…”

The coroner’s concerns

1. No ongoing training had been provided to prison o icers since initial training on basic life support or first aid, meaning that o icers confronted with discovery of a ligature situation were unable to provide immediate and basic life support due to a lack of confidence and unfamiliarity of what to do in a situation when every second can count in promoting the chances of an optimal recovery. Training is now to be provided by Sodexo to sta , but it is unclear what the position is within public sector prisons or nationally. 2. Further evidence was provided that a national standard of one trained first aider to 50 prisoners was set by the Health and Safety Executive on a workplace basis. Clarification may be helpful to determine whether this includes life-preserving response in what is an extraordinary type of working environment within a prison. 3. The relevant Prison Service Order (3050) relating to clinical holds and consistency of healthcare for prisoners was noted to be 20 years old. It makes no reference to mental health conditions or neurodiversity issues and how they may a ect the appropriateness or consideration of a prison transfer weighed against clinical judgment to place a clinical hold on transfer. It was apparent that not all witnesses considered these issues, with some displaying a bias to consider only physical health issues as reflected by the wording of the PSO. 4. Evidence was heard that no mental health nurses from primary mental health care charged with completing a segregation algorithm form for segregated prisoners to determine medical suitability had received training on how this should be done, definitions to be applied, or necessary escalation to healthcare for a Multi-Disciplinary Team meeting to occur. On the evidence, a question of whether a prisoner had selfharmed during this period of custody was viewed as meaning since arrival at the establishment, meaning that any acts of self-harm at a former establishment were not included in the risk assessment matrix. Alongside the confusion of when to refer to healthcare for advice (given a view that healthcare were attending to do this assessment), there was an apparent missed opportunity to escalate to secondary mental health care, ongoing bizarre behaviour being witnessed on Jake’s part. 11 COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: 1. HM Inspectorate of Prisons 2. Prison and Probation Ombudsman 3. Inquest Charity I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with the Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12 SIGNATURE Michael James PEMBERTON Area Coroner for Manchester West

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2026-0280

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14 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0