Recurance · prevention of future deaths reports
Pre-inquest brief
Absence of fitness to transfer assessment
The earlier warning
Redmond Johnson · 20 Jun 2014 · Peter Dean, Suffolk
“There must be a robust and clearly documented process in place when assessing a detainee's fitness to transfer, together with clear arrangements made in respect of any medication that the detainee needs to take while out of the prison's care.”
judiciary.uk/prevention-of-future-death-reports/redmond-johnson
What was promised
No published response from NHS England was found for the earlier reports.
What recurred
- 24 Oct 2023 · Jonathan McCarthy · Hassan Shah · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Redmond Johnson · 20 Jun 2014
“There must be a robust and clearly documented process in place when assessing a detainee's fitness to transfer, together with clear arrangements made in respect of any medication that the detainee needs to take while out of the prison's care.”
Later · Jonathan McCarthy · 24 Oct 2023
“There was also no evidence that Mr [name redacted] had a fitness to transfer assessment at either HMP Altcourse or HMP Thameside.”
What happened next
No web check of the stated actions has been published for this chain.