Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate medical information transfer between custodial healthcare providers
The earlier warning
Martin Haines · 16 Aug 2019 · Alan Craze, East Sussex
“There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body.”
judiciary.uk/prevention-of-future-death-reports/martin-haines
What was promised
Stated action 1 · response to Martin Haines (16 Aug 2019) · stated timescale: none stated
“The Ministry of Justice will respond directly to the Coroner on this.”
Stated action 2 · response to Martin Haines (16 Aug 2019) · stated timescale: end of 2018
“Partnership NHS Foundation Trust (SPFT) undertook a Root Cause Analysis Investigation following Mr [name redacted] death and three recommendations were made: a. healthcare staff should be trained in how to detect diabetes and hypertension; b. long term conditions such as diabetes and hypertension are managed in line with National Institute for Care Excellence (NICE) guidelines; and c. reviews of repeat medication comply with NICE”
Stated action 3 · response to Martin Haines (16 Aug 2019) · stated timescale: 31 March 2020
“An on-going action plan remains in place and will continue to be monitored closely for the remainder of the trust's contract which ends on 31 March 2020. To support · this, and ensure a reduction in any risk to patients, commissioners have appointed a clinical reviewer (previously Director of Nursing”
2 further stated actions are listed on the full chain page.
What recurred
- 22 Oct 2025 · Amy Cross · Peter Harrowing · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Martin Haines · 16 Aug 2019
“There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body.”
Later · Amy Cross · 22 Oct 2025
“There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare”
What happened next
No web check of the stated actions has been published for this chain.