Carol Taylor

Rachael Clare Griffin
Senior Coroner for the Area of
Dorset
HM Coroner’s Office
Town Hall
Bournemouth
BH1 6DY

Dear Ms Griffin,

Director General of Operations
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London
SW1H 9AJ

28 October 2025

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – FRAZER WILLIAMS

Thank you for your Regulation 28 report addressed to the Minister of State for Prisons,
Parole and Probation, the Director General of His Majesty’s Prison and Probation Service
(HMPPS), and the Governor of HMP Guys Marsh as well as to other agencies. I am
responding as Interim Director General of Operations for HMPPS and my response
addresses all concerns relating to HMPPS on behalf of the above named recipients. I am
grateful to you for allowing us additional time to respond and apologise for the delay in
providing our response.

I know that you will share a copy of this response with Mr Williams’ family, and I would first
like to express my condolences for their loss. Every death in custody is a tragedy and the
safety of those in our care is my absolute priority.

Following evidence heard at the inquest, you have raised a number of concerns. I will
address those for which HMPPS has responsibility in the order of which you have raised
them.

Your report identifies a lack of guidance on the management of self-neglect in the prison
setting.  Informed by the learning from the investigations into Mr Williams’ death, guidance for
prison and probation staff on ‘Managing Self-Neglect in Prisons and Approved Premises’ was
published on the HMPPS intranet in July 2024.  This is designed to raise awareness of the
issue amongst staff and to equip them to work in partnership with healthcare staff to
safeguard people who self-neglect in a prison or an approved premise.

 Your report describes a lack of quality assurance of the operation of the Assessment, Care in
Custody and Teamwork (ACCT) process.  The Prison Safety Policy Framework that was
implemented on 1 January 2025 mandates the use of a quality assurance tool which involves
a three-stage check of ACCT documents, including a weekly check of all open ACCT
document.  At Guys Marsh this local assurance process is supplemented by the regional
Safety Team which attends the prison twice monthly to undertake ACCT assurance and
provide feedback to the establishment.

Your report draws attention to the absence of a system for flagging missed ACCT reviews at
Guys Marsh, and to the fact that relevant individuals were not being invited to reviews.  A
new booking tool was introduced in August 2024 to schedule reviews, and this also supports
consistent attendance from relevant individuals.  The safety team now highlights any reviews
that have been missed to the Orderly Officer so that they can be rescheduled promptly.

Your report notes that key work at Guys Marsh was not operating in accordance with key
work national guidance.  This has not been possible because of staffing issues, but the
prison has been operating a priority key work scheme, designed to ensure that the most
vulnerable men are seen regularly.  A new shift pattern was introduced in September 2024
detailing officers to carry out key work to increase the delivery of key work sessions beyond
the priority group as well as providing consistency with sessions being delivered by the same
key worker where possible.

I have noted your concern regarding the similarity in colour of cell doors and bedsheets, but I
am not aware of any problems having arisen previous to this.  I have passed your
observations on to the national Safety Team to consider as part of their ongoing work on
ensuring a safe physical environment for prisoners.

Your report draws attention to local procedures at Guys Marsh that did not comply with
national policy on when to call an ambulance.  The Governor has issued a Notice to Staff that
explains that it is mandatory to call an ambulance when an emergency code is called, and
compliance with this expectation is regularly reviewed.

Your report notes problems with the process for recording information about a prisoner’s next
of kin at Guys Marsh.  This has been reviewed, and the Offender Management Unit is now
involved to ensure that the process is managed effectively.

Thank you again for bringing your concerns to my attention.  I trust that this response
provides assurance that action is being taken to address each of these issues.

Yours sincerely,

 Interim Director General of Operations

OFFICIAL

Minister of State for Justice

Rachael Clare Griffin
Senior Coroner for the Area of Dorset
HM Coroner’s Office
Town Hall
Bournemouth
BH1 6DY

Dear Senior Coroner,

28 October 2025

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS – FRAZER WILLIAMS

Thank you for your Regulation 28 Report to Prevent Future Deaths following the inquest into the
death of Frazer Williams, who died on 7 March 2022 at HMP Guys Marsh.

I have read your report with care as a death in custody is a tragic event for families and friends,
as well as other prisoners and staff, and learning lessons to improve the safety of those in prison
custody is essential. I understand that you will share this letter with Mr Williams’ family and I
would like to offer them my sincere condolences for their loss.

The concerns you have raised within your report are operational issues and it is therefore
appropriate that 
 who is the Interim Director General of Operations, HM
Prison and Probation Service (HMPPS), has responded to them. I have seen the response from

 and I endorse the content of it, which sets out the action being taken by

HMPPS to address your concerns.

Minister for Prisons, Probation and Reducing Reoffending

E https://contact-moj.service.justice.gov.uk/
www.gov.uk/moj

102 Petty France
London
SW1H 9AJ

23 July 2025 

Private and Confidential 
Mr Stephen Simblet KC  
HM Assistant for Essex 
Coroner’s Office 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Mr Simblet 

Carol Taylor (RIP)  

Chief Executive Office 
The Lodge 
Lodge Approach 
Wickford  
Essex 
SS11 7XX 

Tel: 0300 123 0808 

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, 
of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) 
Regulations 2013, dated 12th June 2025 in respect of the above, which was issued following the 
inquest into the death of Carol Taylor (RIP) . 

I would like to begin by extending my deepest condolences to  Mrs Taylor’s family. The Trust 
sympathises with their very sad loss.   

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed 
and noted.  I will now respond in full to the concern raised in the hope that this provides both 
yourself  and  Mrs  Taylor’s  family  with  comprehensive  assurance  of  changes  that  have  been 
made at the Trust to address the concern you have raised.  

Concern 1)  
There  was  no  system  that  prevents  staff  that  are  non-compliant  with  mandatory  training, 
including basic life support training from being able to work on EPUT in-patient wards 

Response:  
Ward managers are able to access and review the skills of staff on the ward, which includes 
bank worker training compliance, via a training tracker. If there is a staff shortage then 
requests may be made for bank and agency staff, identifying the skill set required to ensure 
those booked onto shift hold the necessary skills / training to deliver the required care 
competently.  

A ‘bar’ on temporary staff / substantive working on the ward unless they are compliant with all 
mandatory training, including basic life support training brings the significant risk in relation to 
having the necessary number of staff on shift however compliance with mandatory training is 
vital.  To address this Ward Managers actively manage compliance with mandatory training.   

Ward managers have access to training trackers which are checked on a monthly basis during 
substantive staff member’s 1:1 support meeting. As soon as a training is showing as Amber 
which shows that training will be non-complaint within three months, staff are supported by the 
Ward Manager/Supervisor to book into that training before it expires. Bank staff training 
compliance is checked by the ward manager/charge nurses when they are booked. If they are 
non-complaint for training, this is escalated to the temporary staff manager. Staff who are 
found not to be compliant are supported during their 1:1 support meeting with their supervisor 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 to book onto trainings by their supervisor or ward manager. Mandatory training is reviewed by 
the Clinical Manager/Matron on a monthly basis with Ward Managers in their management 
meeting. We hold a locality performance and accountability meeting with Ward Managers and 
Clinical Leads chaired by Associate Director with a focus on Mandatory Training compliance 
and performance.  

Mandatory training is monitored through the Quality of Care and Accountability Framework 
meetings on a monthly basis. The Accountability Framework meetings are chaired by an 
Executive Director and attended by supporting executives and directors and the Care group 
leadership team who present their performance for the month, mandatory training is a key 
focus.  

Concern 2)  
This is a particular concern generally, but especially in hospitals such as St. Margaret’s where 
at least some of the wards specialise in treating elderly patients who are likely to be at greater 
risk of medical collapse than the general population. 

Response:  
Following on from our reply under concern 1 above, all staff working on EPUT wards and clinical 
areas, are inducted on the process for summoning help in a medical emergency. This is covered 
in the Basic Life Support (BLS) and Immediate Life Support (ILS) training and is also highlighted 
on the attached two documents.  

The Royal College of Physicians NEWS2 training has been undertaken by staff working at these 
sites  and  staff  are  signposted  to  the  additional  ‘364  Recognising  &  Managing  Deterioration’ 
training which is available for all staff to access via the online learning portal. The Assessing a 
Critically  Unwell  Patient  and  ‘Non-Contact  Physical  Observations’  aide  memoirs  have  been 
implemented Trust wide, in order to support staff members to carry  out a robust ‘Head to toe’ 
physical  health  assessment  of  a  patient.  The  situation,  background,  assessment  and 
recommendation (SBAR) tool is utilised to provide a structured handover upon escalation, whilst 
the  ‘Calling  (9)999  in  a  Medical  Emergency’  document  assists  with  communication  when 
contacting the Ambulance Service. Each Ward has a nominated Resus Link Practitioner to aid 
in sharing lessons identified and safety alerts and helping to facilitate regular medical emergency 
simulations within the clinical areas. These important resources and previous lessons identified 
were presented to EPUT staff via an online ‘Learning Matters’ event which was delivered on 25th 
June 2025 and the event was recorded for future access. 

In addition, there is a Physical Health Task and Finish Group which has been formed to review 
the existing physical health provision on the Inpatient Wards. The Physical Health Competency 
Framework and Bite Sized Training support packages are amongst a number of resources which 
are currently being explored for implementation across the Trust. There are 84 Physical Health 
Link  Practitioners  in  place  across  the  inpatient  Wards  and  the  volunteers  join  the  bi-monthly 
Resus Link Practitioner meetings where learning is shared. A ‘Physical Health Secondary Care 
planning Cycle’ has been piloted on a number of in-patient wards, with a view to implementing 
this Trust wide. 

I hope that I have provided some reassurances around the steps that we have taken to address 
the issues of concern contained within your report.  We know there is an acute need to embed 
and effect change, hence we will monitor the above provisions to ensure these are contributing 
to our overall aim of keeping patents safe.  

Please do let me know if you require any further information at this stage, including copies of 
any of the documents referred to above.   

 
 
 
 
 
 
 
 
    
 
 
 We understand that a copy of this reply will be shared with the family.   

Yours sincerely, 

Chief Executive