Declan Carr

Miss Sarah Middleton 
Assistant Coroner  
East Riding & Hull Coroner’s Service 
The Guildhall 
Alfred Gelder Street  
Hull 
HU1 2AA 

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

2nd January 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Declan Lewis Carr who 
died on 28 August 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  20 
October  2025  concerning  the  death  of  Declan  Lewis  Carr  on  28  August  2023.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express  my  deep  condolences  to  Declan’s  family  and  loved  ones.  NHS  England  is 
keen to assure the family and yourself that the concerns raised about Declan’s care 
have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to  Declan’s family or friends. I realise that 
responses to Coroners’ Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them. 

Your Report raised concerns around psycho-social support and the handover of care 
to the support services in prison. Your Report also raised concerns around the lack of 
a national policy allowing prisons to share information about those receiving psycho-
social  support  when  transferring  prisoners,  and  the  lack  of  continuity  of  care  for 
prisoners receiving psycho-social support for drug misuse. Prison continuity of care 
refers to a structured process that ensures individuals maintain access to healthcare 
services,  such  as  physical  health,  mental  health,  substance  misuse  treatment,  and 
social  care  as  they  move  between  prison  settings  or  transition  back  into  the 
community.  

To  provide  assurance  in  relation  to  the  sharing  of  all  healthcare  appointments, 
including psycho-social related support, NHS England can confirm that when a patient 
transfers  between  prisons  their  clinical  record  will  transfer  with  them,  meaning  that 
healthcare workers at the receiving prison will be able to access details including the 
prisoner’s medical history, prescribed medication, services currently being accessed 
and any appointments. 

If  the  psycho-social  service  provider  had  been  inputting  information  into  the  main 
clinical system at HMP Hull, then HMP Humber would have had access to the records 

                                                                                                                       
 
 
 
 
 
  
 
 
  
 
 
 
 
 
  
 when Declan was registered onto their clinical system, which should have happened 
when he was received into HMP Humber. Once registered onto the clinical system, 
full record sharing takes place. Unfortunately, this did not happen in Declan’s case.  

A  review  of  the  NHS  England  Health  and  Justice  service  specifications  is  being 
undertaken by NHS England through 2025 to 2026, and any learning from this case 
will be used to inform this review.  

The  findings,  information  and  any  learning  from  this  case  will  also  be  listed  for 
discussion  at  a  future  NHS  England  Health  and  Justice  Delivery  Oversight  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  national  and  regional  teams.  All  health  and 
justice  related  Reports  to  Prevent  Future  Deaths  are  shared  and  discussed  at  the 
HJDOG, and assurance is sought from regions where learning and action is identified.  

Prison continuity of care refers to maintaining a prisoner’s health services throughout 
their  time  in  the  system,  including  during  transfers  and  after  release.  Key  aspects 
include  coordinating  with  healthcare  providers,  improving  internal  prison  policies, 
preparing  patients  for  release  and  linking  them  to  community  services  including 
substance misuse treatment. Efforts are made to address barriers to care and ensure 
seamless transitions, although challenges remain.  

Key elements of prison continuity of care 

Key aspects of Continuity of Care include:  

1.  Seamless  Healthcare  Transition  -  ensuring  that  upon  release,  individuals  have 
access to timely, appropriate follow up care, such as substance misuse treatment 
or  mental  health  services  which  are  typically  arranged  within  a  designated 
timeframe. (Continuity of care between prison and the community: self-assessment 
tool guidance - GOV.UK) 

2.  Care  coordination  pre  and  post  release  -  programs  like  NHS  England’s 
RECONNECT arrange pre-release engagement (up to 12 weeks) and post-release 
support  (up  to  6  months)  offering  liaison,  referral,  advocacy,  and  a  named  staff 
(NHS 
member 
commissioning » RECONNECT) 

into  community  healthcare. 

to  ensure  a  safe 

transition 

3.  Maintaining treatment during custody transfers - within prison, continuity refers to 
maintaining ongoing healthcare; primary, secondary, mental health, dental, despite 
internal  transfers,  court  appearances,  or  remote  health  appointments.  This 
includes  sharing  health  records  and  managing  logistical  barriers  like  escorts  or 
security protocols. Prison Health providers and Prison services need to coordinate 
secondary care appointments with Hospital Trusts to ensure timely coordination of 
hospital  appointments  based  on  the  individual’s  clinical  needs  and  reason  for 
referral to specialist services. This is to ensure that the prison service can enable 
patients  to  their  appointment  whilst  maintaining  public  protection  and  security 
arrangements, considering the different security parameters that each prison may 
pose – i.e. Category A High Security prisons, Category C Resettlement Prisons. 

 
 
 
 
 
 
 
 
 Prison  officers  will  still  be  paid  as  the  escorting  of  an  external  appointment  will 
usually be part of their rostered shift. (Continuity of care between prison and the 
community:  self-assessment  tool  guidance  -  GOV.UK;  Healthcare  provision  in 
prisons: continuity of care) 

4.  Holistic health management - recognising the high prevalence of complex health 
and social care needs such as substance dependency, mental illness, infectious 
diseases,  and  unstable  housing.  Continuity  of  care  extends  beyond  clinical 
treatment  to  include  support  for  social  determinants  of  health.  (Healthcare 
provision in prisons: continuity of care; Continuity of care between prison and the 
community:  self-assessment  tool  guidance  -  GOV.UK;  NHS  commissioning  » 
RECONNECT)  

Continuity of care is improved in a number of different ways, including the following:  

• 

Inter-agency collaboration: Prisons, the NHS and  the Probation service must 
work together to align healthcare needs with available resources. Please refer 
to  the  National  Partnership  Agreement  for  Health  and  Social  Care  for 
information relating to Inter-Agency Collaboration, which is a signed agreement 
between a number of agencies outlined on Page 25.  

•  Policy  and  process  updates:  Embedding  guidance  into  practice,  such  as  the 
Prison Service Order 3050 and Physical Health of People in Prison guidance 
to include clear communication protocols for transfers and release is crucial. 
Improved  communication:  Healthcare  and  prison  staff  need 
to  share 
information  effectively  to  ensure  a  patient’s  needs  are  met  without  delay,  as 
highlighted by the Health Services Safety Investigations Body (HSSIB).  

• 

•  Prisoner  engagement:  Educating  prisoners  about  their  health  needs  and 
encouraging them to attend appointments can increase engagement and lead 
to better outcomes.  

•  Dedicated support services: Programs like RECONNECT provide non-clinical 
support  including  advocacy  and  signposting  to  help  individuals  connect  with 
community health services after release.  

• 

North East and Yorkshire regional colleagues have advised that HMP Hull and HMP 
Humber have introduced a local policy to share information about prisoners receiving 
psycho-social  support  during  transfers  between  these  two  establishments,  and  this 
pathway was developed and embedded following learning from Declan’s death.  

There are nationally agreed clinical templates embedded on SystemOne, which is an 
electronic patient medical record system. One of these templates is specific to Court, 
Release and Transfer Out screening. A copy of the template has been attached with 
this response.  The  purpose  of  national agreed  templates  is  to  ensure  standardised 
healthcare  delivery  aligned  with  National  Institute  for  Health  and  Care  Excellence 
(NICE) guidance and key performance indicators.  

 
 
 
 
 Whilst it is recognised that, in this case, the prison healthcare providers developed a 
local  policy  to  support  with  continuity  of  care;  national  templates  are  mandated  to 
support  with  information  sharing  and  this  is  monitored  through  key  performance 
indicators in regional contract management. In Declan’s case, the national template 
was  completed,  however  he  had  denied  any  substance  or  alcohol  misuse  upon 
reception  screening  in  HMP  Humber  following  transfer.  Declan,  as  with  all  new 
prisoners into HMP Humber, had an induction to the prison where he was made aware 
of Change Grow Live (CGL) and their service offer, including information on how to 
self-refer should he require support.   

For assurance, an audit on the continuity of care between HMP Hull to HMP Humber 
for those in service with CGL not prescribed opioid substitution therapy was conducted 
for transfers in June 2025. This audit confirmed that: 

•  There were 11 non-prescribed service users transferred from HMP Hull to HMP 

Humber 

•  100% of those had a referral opened as per the Non-Clinical Prison to Prison 

Transfer (H&H) Pathway upon arrival at HMP Humber.  

•  45.5% declined entry into the service and their referrals were closed.  
•  9% signed into the service and completed an initial assessment, however they 

dropped out at the next intervention.  

•  45.5% signed into the service and for continued care.  

A second audit will be completed against the same parameters in January 2026. There 
was no action plan attached to the audit, as the findings showed that the pathway was 
being followed correctly and 100% of those transferred from HMP Hull were picked up 
and a referral opened in HMP Humber.  

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  events,  such  as  the  sad  death  of 
Declan, 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 
NHS England