Frazer Williams

Parliamentary Under Secretary of State for  
Patient Safety, Women’s Health and Mental Health. 

39 Victoria Street 
London 
SW1H 0EU 

020 7210 4850 

09 September 2024 

Our Ref: 

Rachael Griffin  
Senior Coroner for Dorset 
Coroner’s Office for the County of Dorset 
BCP Civic Centre 
Bourne Avenue 
Bournemouth 
BH2 6DY 

By Email: 

Dear Ms Griffin, 

Thank you for your Regulation 28 report to prevent future deaths dated 31 May 2024, about 
the  death  of  Frazer  Charlie  Williams.  I  am  replying  as  the  recently  appointed  Minister  with 
responsibility for mental health and offender health.      

Firstly, I would like to say how saddened I was to read of the circumstances of Frazer’s death 
and  I  offer  my  sincere  condolences  to  his  family  and  loved  ones.  The  circumstances  your 
report describes are deeply concerning and I am grateful to you for bringing these matters to 
my attention.  

I  understand  the  concerns  raised  in  your  report  over  a  lack  of  equity  regarding  accessing 
treatment  for  individuals  with  severe  mental  illness  in  prison  settings;  a  lack  of  national 
guidance  relating  to  a  range  of  healthcare  issues  in  prison  settings;  operational  issues 
regarding the assessment, care in custody and teamwork (ACCT) process and engagement 
with prisoners’ family members.  

I am aware that NHS England has now provided its response to your report, which sets out 
the steps it is taking to address inequity in the system for prisoners accessing treatment and 
responds  to  your  concerns  around  the  transfer  of  mentally  unwell  prisoners  and  the 
provision of healthcare in prison settings. 

I share your concerns about the length of time it can take to transfer some mentally unwell 
prisoners to hospital when needed, and we are taking steps to improve that. As highlighted in 
NHS  England’s  response  to  you,  the  Department  is  working  with  NHS  England,  and  His 
Majesty’s Prison and Probation Service to respond to the concerns highlighted in His Majesty’s 
Inspectorate  of  Prisons’  thematic  review  The  Long  Wait,  published  in  February  2024, 
which focuses on delays in the transfer of mentally unwell prisoners. NHS England is leading 
on this response, which I will be reviewing and I will be keeping a close eye on how this work 
progresses.  

In addition to this, the Mental Health Bill will be introduced in this Parliamentary session. The 
Bill sets out vital reforms to support people with severe mental illness in the criminal justice 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 system  with  the  aim  of  speeding  up  access  to  specialist  inpatient  care  and  ensuring  that 
offenders and defendants with severe mental health needs are able to access appropriate and 
timely support in the most appropriate setting.   

The reforms proposed in the Bill will speed up access to specialist inpatient care and treatment 
by introducing a new statutory time limit of 28 days for the transfer of patients from prison and 
other places of detention to hospital. This mirrors the time limit set out in  the NHS England  
good  practice  guide  published  in  2021:  Guidance  for  the  Transfer  and  Remission  of  Adult 
Prisoners and Immigration Removal Centre Detainees under the Mental Health Act 1983.  I 
hope that these reforms will help to reduce the likelihood of the issues outlined in your report 
from being repeated. 

With regard to the other concerns you have raised around a lack of national guidance relating 
to  a  range  of  healthcare  issues  in  prison  settings;  operational  issues  regarding  the  ACCT 
process and engagement with prisoners’ family members, I would expect the other recipients 
of your report to address these in their responses, as they are responsible for matters relating 
to day to day operations within prison settings. I look forward to seeing their responses and 
working with them where appropriate, to avoid a repetition of the horrific events of this case. 

I hope this response is helpful in setting out how we plan to address some of the issues you 
have raised. Thank you for bringing these concerns to my attention.  

Yours sincerely,

ae His Majesty’s Prison and Probation Service
HMP Guys Marsh

HM Prison & Shaftesbury
Probation Service Seana
2ND August 2024

Dear Coroner,

Frazer Williams - ref: 23542028

Please find attached the PFD response reference the death of Frazer Williams.

Yours sincerely,

>

_ Governing Governor

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Mrs Rachael Clare Griffin  
HM Senior Coroner 
Dorset Coroners Service 
Civic Centre 
Bourne Avenue 
Bournemouth  
BH2 6DY 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

24 July 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Frazer Charlie Williams 
who died on 7 March 2022  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 31 May 
2024 concerning the death of Frazer Charlie Williams on 7 March 2022. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Frazer’s family and loved ones. NHS England are keen to assure 
the family and the Coroner that the concerns raised about  Frazer’s care have been 
listened to and reflected upon.   

I  have  responded  to  your  matters  of  concern  which  are  relevant  to  NHS  England 
below.  

1. There is inequity within the system of the treatment of a person with mental 
illness  in  the  prison  setting,  compared  to  an  individual  in  the  community, 
since in the community a person would be placed in a hospital setting on the 
day they were deemed to require hospital admission. In prison however, there 
are delays in transferring a prisoner in the same situation to hospital. 

I would like to reassure you that NHS England consistently strives for equality in mental 
health  healthcare  provision.  To  address  the  specific  concerns  about  Frazer’s  care, 
there are several cross party workstreams underway. 

In February 2024, His Majesty’s Inspectorate of Prisons (HMIP) published “The Long 
Wait”, a thematic review of delays in the transfer of mentally unwell prisoners, which 
identified  several  concerns.  The  concerns  include  areas  such  as  length  of  time  to 
transfer,  hospital  availability,  information  sharing  and  early  identification  of  needs. 
NHS England’s Health and Justice, Specialist Commissioning and Adult Mental Health 
Teams, the Department of Health and Social Care (DHSC) and His Majesty’s Prison 
and  Probation  Service  (HMPPS)  are  in  the  process  of  directly  responding  to  the 
concerns  highlighted  in  this  review.  This  response  is  due  to  be  with  our  National 
Director  of  Health  &  Justice,  Armed  Forces  and  Sexual  Assault  Referral  Centres 
imminently, for approval to meet the timeframe for submission. 

A  new  clinical  template  for  improving  data  collection  and  monitoring  has  been 
developed and is now in place, to record the referral, assessment and transfer process 
for prisoners and detainees, under sections 47 and 48 of the Mental Health Act (MHA) 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 1983. This template is for use within the health and justice information system (HJIS) 
in  prisons  (currently  SystmOne).  NHS  England  is  working  to  use  the  information 
generated to gather data on the timeliness of transfers, whilst also proactively working 
with Health and Justice commissioners to improve data quality and completeness of 
existing manual collection.  

A review of processes, communication and information sharing around mental health 
concerns is also underway and will be completed by February 2025. This review is 
calling  “Health and  Justice  Mental  Health  Pathway”.  Work on  the development  of a 
Mental Health Pathway aims to:  

•  Ensure  from  a  patient  perspective  the  pathway  is  robust,  seamless, 

individualised, and responsive to a person’s needs and requirements. 

•  Provide  people  with  mental  health  concerns  consistent,  high-quality 

advice/treatment/support across all Health and Justice services. 

•  Reduce reoffending and improve health outcomes by addressing the underlying 

mental health and associated vulnerability issues.  

To achieve this, NHS England will: 

•  Clarify  the  current  mental  health  provision  within  each  Health  and  Justice 

• 
• 

service. 
Identify and build on best practice. 
Identify  and  understand  dependencies  between  Health  and  Justice  services 
and other parts of the pathway. 

•  Understand  where  we  are  now  and  develop  a  proposed  pathway  for 

engagement.  

•  Develop  a  pathway  programme  plan  based  on  identified  gaps  and  key 

priorities.   

To  support  this  work,  a  series  of  online  workshops  are  planned  throughout  August 
2024  for  subject  matter  experts  to  come  together  and  share  knowledge  and 
experience  in  areas  such  as  governance,  transfer  and  remission,  and  information 
sharing.  

2. There  is  a  lack  of  NHS  guidance,  and  joint  guidance  with  HMPPS,  on  the 
identification,  management,  and  treatment  of  someone  with  self-neglect  in 
the prison setting. 

It is clear in this case that information sharing, and general communication, could have 
been stronger. NHS England is committed to improving information sharing between 
agencies  and  promoting  better  joint  working,  to  improve  outcomes  for  people  with 
mental health needs, and the Prison Mental Health Service Specification (March 2018) 
covers  these  elements:  service-specification-mental-health-for-prisons-in-england-
2.pdf. 

This service specification links directly the Royal College of Psychiatrists’ (RCPsych) 
guidance  on  Standards  for Prison  Mental Health  Services  (September 2023)  which 
provides clear guidance for mental healthcare provision. The regional  NHS England 
Health and Justice commissioners include these specifications as a link into the Prison 
Mental  Health  Service  Specification.  The  commissioners  monitor  the  providers’ 

 
 
 
 
 progress  against  the agreed  specification.  Regular  NHS  England national meetings 
are held with the regional commissioners, and this will be raised this at the national 
meetings. 

3. There are two parts to this next concern, which I have separated as follows: 

i.  There is a lack of a national directory detailing the facilities and provision 
of  healthcare  at  individual  prisons  across  England  and  Wales,  and 
associated  guidance  on  the  transfer  of  individuals  between  prison 
establishments when they are under the care of the healthcare teams and 
are not placed on medical hold.  

NHS England suggests that this would be for HMPPS to respond to, however we will 
continue to work with HMPPS on any proposed actions requiring healthcare input. 

ii. 

There is a lack of guidance on consultation with prison doctors where a 
prisoner is receiving medical care, whether that be for physical or mental 
health, when there is consideration by the prison to transfer the prisoner 
who is not placed on medical hold. Further there is a lack of consultation 
with the healthcare team at the proposed receiving prison to ensure they 
can provide the appropriate care for the person. 

It  is  clear  that  communication  between  clinicians  in  Frazer’s  case  fell  below  the 
expected standard. It is also a concern whether a receiving prison can manage and 
support significant mental health concerns such as those experienced by Frazer.   

As explained above, the pathway work currently underway will review issues around 
consistency of clinical care, information sharing and communication, not only within 
NHS  England but  across  the  dependent  and  aligned  services.  The  output  from this 
work should address the concerns highlighted.  

4. There is a lack of national guidance for healthcare teams working in prisons  
around the handover of healthcare of a prisoner to the receiving prison when 
they are transferred to another prison. 

NHS  England  is  continually  striving  to  improve  communication,  information  sharing 
and handover of information between the custodial services. In addition to the Mental 
Health  Pathway  work,  each  Health  &  Justice  regional  commissioner  manages  the 
contract and monitors the services against the agreed specification. 

There is a National Partnership Agreement (NPA) in place which sets the agreement 
between DHSC, HMPPS, the Ministry of Justice (MOJ), NHS England and the United 
Kingdom  Health  Security  Agency  (UKHSA),  which  supports  and  strengthens 
partnership working across agencies.  

The NPA sets out the basis of shared understanding of, and commitment to, the way 
in which partners will work together across prison and people - National Partnership 
Agreement for Health and Social Care (publishing.service.gov.uk). This is a regional 

 
 
 
 
 
 
 
 
 
 
 
 commissioner responsibility, to ensure from a health perspective that the providers are 
fully engaged with the partnership agreement.  

HMPPS  can  provide  a  response  regarding  the  NPA  from  their  perspective  to  also 
commit to this.  

5. There is a lack of national specification in respect of prison healthcare units. 

The  Prison  Mental  Health  Service  Specification  (March  2018),  referred  to  above, 
provides  clear  guidance  for  mental  healthcare  provision  within  prisons.  This  will  be 
updated  and  reviewed  by  quarter  one  of  2025.  In  the  meantime,  following  the  sad 
death of Frazer, NHS England will work with our commissioning teams to ensure the 
specifications  are  being  followed  and  measures  are  put  in  place  to  monitor  their 
progress. 

In addition to the concerns highlighted above, I note that there are also concerns at 
paragraphs 7 (vii), 8 (viii) and 9 (ix) of your Report around: 

7.  The  lack  of  Assessment  Care  in  Custody  and  Teamwork  (ACCT)  quality 
assurance or audit between day 7 of the ACCT and post closure review. 
8.  The lack of automatic flagging of a missed ACCT review at HMP Guys Marsh, 

which may be a national issue.  

9.  Relevant individuals such as key workers not being invited to attend ACCT 

reviews at HMP Guys Marsh, in line with ACCT 6 guidance.  

The  points  above  relating  to  the  ACCT  process  (annex-to-psi-64-2011-acct_.docx 
(live.com)  will  be  shared  with  NHS  England’s  regional  Health  and  Justice  
commissioners, with a request that they monitor this in contract review meetings and 
feedback via the Health and Justice Oversight Delivery Group (HJDOG).  

The HJDOG is the senior leadership forum, which holds responsibility for the oversight 
of delivery and continuous improvement in Health and Justice commissioned services, 
through  both  the  national  and  regional  teams,  with  a  focus  on  improving  health 
outcomes and reducing variation across England.  

Overall,  HMPPS  is  responsible  for,  and  oversees,  the  ACCT  process,  including 
delivery  of  effective  training  that  is  carried  out  at  establishment  level  for  all  staff, 
including  healthcare,  and  I  note  that  HMPPS  is  responding  independently  to  the 
concerns about ACCT in Frazer’s case.  

I  understand  that  in  September  2022,  the  Safer  Custody  Team  provided  refresher 
training  to  healthcare  staff  at  HMP  Guys  Marsh,  to  ensure  they  understand  their 
responsibilities to identify prisoners at risk of suicide and self-harm. Further guidance 
supporting  this was  issued  to  ensure  staff awareness  of  the need to notify  relevant 
departments  where  concerns  about  a  prisoner’s  risk  of  self-harm  or  suicide  are 
identified.  Relevant  training  highlighting  the  importance  of  sharing,  recording,  and 
considering  all  relevant  risk  information  has  also  been  provided  to  induction  and 

 
 
 
 
 
 
 
 reception staff who conduct first night interviews. HMP Guys Marsh confirms this will 
continue at regular intervals throughout the year. 

NHS  England  will  continue  to  work  in  partnership  with  HMPPS  nationally  and 
regionally to support the ACCT process.  

Additionally,  HMP  Guys  Marsh  sit  as  a  member  on  the  Dorset  Local  Safeguarding 
Board and are therefore subject to Bournemouth and Poole and Dorset Safeguarding 
Boards’ guidance on self-neglect. NHS England’s South West region also supported 
the  development  of  the  e-learning  training  for  healthcare  staff  on  safeguarding  in 
secure and detained settings: Adult Safeguarding in a Secure and Detained Setting - 
elearning for healthcare (e-lfh.org.uk). 

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around preventable events are shared across 
the NHS at both a national and regional level and helps us to pay close attention to 
any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director

Unilink Software Ltd                                                    
Europoint              
5 – 11 Lavington Street 
London SE1 0NZ 

31st July 2024 

Coroner’s Support Officer 
The Coroner’s Office for the County of Dorset 
Civic Centre, Bourne Avenue 
Bournemouth BH2 6DY 

Dear

, 

Re: Frazer Charlie Williams – HMP Guys March.  Your reference 

I am writing to express our profound sadness at the tragic death of Frazer Charlie Williams while in 
custody at HMP Guys March. We also apologize for the delay in our response to your correspondence. 
This was due to our company’s year-end work around the 30th of June, which regrettably impacted 
our ability to reply promptly. 

Following the receipt of your letter, we have conducted a thorough internal investigation regarding 
the email a prisoner service provided to Frazer. Our records indicate that four messages were sent to 
Frazer, one to HMP Lewes and three to HMP Winchester, with the last one being sent on Friday, 14th 
January, at HMP Winchester. It is most likely that this message was printed at HMP Winchester on 
15th January or on Monday, 17th January. 

However, we now understand that Frazer was moved to HMP Guys March on 14th January, and it is 
therefore unlikely that he received this last message. As you may know, Unilink does not have access 
to prison rolls or prisoner movement information for security reasons.  This is expected to be known 
by  the  person  contacting  them.  In  this  case  neither  the  sender  nor  Unilink  was  aware  of  Frazer’s 
transfer and hence were unable to take any action to redirect the message or notify the sender of the 
situation. 

We  fully  recognize  the  importance  of  ensuring  that  such  communications  reach  their  intended 
recipients, particularly in situations like this, and we deeply regret any distress this may have caused. 
To prevent similar occurrences in the future, we will raise this issue with the Ministry of Justice and 
explore whether  there is  a possibility of confidentially  sharing relevant information about prisoner 
movements, which could help to better manage and redirect communications in a timely manner. 

We are committed to doing everything within our power to improve our processes and ensure that 
our services function effectively and compassionately. 

We remain at your disposal should you require any further information or assistance. 

Yours sincerely, 

CEO - Unilink Software Ltd 

Unilink Software Ltd established 1994 

Registered address: 5-11 Lavington Street, London SE1 0NZ.  Co Registration: 2924046.   
Web: www.unilink.com  Tel: +44 20 7036 3810  

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