Recurring concern

Unreliable constant-observation arrangements for detained persons

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First reported 16 Sep 2013•Latest report 7 Apr 2026

Definition

What this concern includes

Includes failures in the dedicated constant-observation process for detained persons, including setting or maintaining the required observation status, transferring that status between staff or custody settings, completing and handing over observation forms, providing required briefings, and auditing compliance with those controls.

Not included

Excludes generic audit, documentation or handover failures where no constant-observation or constant-watch requirement is involved.
Excludes ordinary intermittent observation, welfare checks or general custody monitoring when constant observation is not the identified control.
Excludes clinical treatment, staffing or accommodation deficiencies that do not directly impair constant-observation arrangements.
Excludes failures occurring after constant observation has been reliably provided where the remaining issue is unrelated to the observation process.

Reports: 4
Individual concerns: 6
Date range: 2013–2026
Stated actions: 11

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service2

Bristol Prison1

Care UK1

Herefordshire and Worcestershire Health and Care NHS Trust1

Hewell Prison1

Lewisham and Greenwich NHS Trust1

Practice Plus Group1

South Yorkshire Police1

Thameside Prison1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

7 Apr2026
Inner South London
Concerns raised1
1. Unavailability of larger disabled cells adapted for constant watch
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mark Robert Smith · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mark Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of larger disabled cells adapted for constant watch
Wider context from the report
“(4) There are no larger disabled cells (which can accommodate hospital beds and wheelchairs) adapted to also facilitate a constant watch. Security concerns, in this might not be possible, and a similar situation might occur to that in Mark’s case. (HMPPS) ”
Source location
Mark Robert Smith · Prevention of Future Deaths report
Page 4 · concerns
Open source report
27 Mar2024
South Yorkshire (Western)
Concerns raised3
1. Inconsistent or omitted custody sergeant briefings for constant observations
2. Lack of audit trail for signed constant observation forms and sergeant briefings
3. Lack of timely controlled handover of constant observation forms
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Provide Custody Sergeants with training and continuing professional development on constant-observation standards and responsibilities following the document review.
  Stated by South Yorkshire PoliceStated planned
2. Action
  Conduct compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.
  Stated by South Yorkshire PoliceStated planned
3. Action
  Consult the Performance and Governance team about activating body-worn video during constant observations.
  Stated by South Yorkshire PoliceStated planned
AI-generated summary

Matthew Terrill · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Matthew Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inconsistent or omitted custody sergeant briefings for constant observations
Wider context from the report
“4. Lack of refresher or mandatory annual training for police officers in relation to constant observations. I am told that there is no specific mandatory training for police officers on constant observations, but that trainee police officers are now given training on constant supervision as part of their introduction to the custody suite. I have been told that there is an optional CPD module available to officers on constant observation training. I am concerned that police officers are being regularly asked to perform constant observations on detainees of the highest risk levels without any mandatory training or refresher training on the subject. Whilst the Custody Sergeant is tasked with providing a briefing to officers who are tasked with constant observations, I am concerned that there is no evidence of consistency in this task being completed to an appropriate standard or at all. There is a risk that in a busy custody suite, this briefing will be overlooked or omitted (and in fact that was the evidence in this case). There is no evidence to reassure me that this was a one-off incident, rather the evidence before me suggested that it was not. This gives rise to a risk of future death for detained persons on level 4 constant observation. ”
Source location
Matthew Terrill · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of audit trail for signed constant observation forms and sergeant briefings
Wider context from the report
“6. Lack of safety net for custody suit documentation, specifically the constant supervision forms. I am told that whilst there has been a welcomed change to the format of the constant observation forms, there is no safety net for ensuring that these forms are handed over in a timely manner or by the custody sergeant. I am also told that there is no audit trail in place for checking that these forms are being signed by police or custody officers to ensure that the envisaged sergeant briefing is being given. I am concerned that there is a risk of future death to detained persons on level 4 constant supervision in circumstances where the sitting officers may not be experienced in the task, have not been trained, and are not consistently being briefed by the custody officers. ”
Source location
Matthew Terrill · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of timely controlled handover of constant observation forms
Wider context from the report
“6. Lack of safety net for custody suit documentation, specifically the constant supervision forms. I am told that whilst there has been a welcomed change to the format of the constant observation forms, there is no safety net for ensuring that these forms are handed over in a timely manner or by the custody sergeant. I am also told that there is no audit trail in place for checking that these forms are being signed by police or custody officers to ensure that the envisaged sergeant briefing is being given. I am concerned that there is a risk of future death to detained persons on level 4 constant supervision in circumstances where the sitting officers may not be experienced in the task, have not been trained, and are not consistently being briefed by the custody officers. ”
Source location
Matthew Terrill · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide Custody Sergeants with training and continuing professional development on constant-observation standards and responsibilities following the document review.

Verbatim wording from the response
“Training/ CPD will be given to all Custody Sergeants following this review setting out clear standards and expectations around their role and responsibilities of this document. Dip samples will be carried out by the Custody Inspectors to ensure compliance, this will include reviewing of CCTV to ensure that this document is briefed, relevant checks by the Sergeant are carried out for anyone under constant observations.”

Source location
Response from South Yorkshire Police and Humberside Police
Page 7 · response
Published 4 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.

Verbatim wording from the response
“Training/ CPD will be given to all Custody Sergeants following this review setting out clear standards and expectations around their role and responsibilities of this document. Dip samples will be carried out by the Custody Inspectors to ensure compliance, this will include reviewing of CCTV to ensure that this document is briefed, relevant checks by the Sergeant are carried out for anyone under constant observations.”

Source location
Response from South Yorkshire Police and Humberside Police
Page 7 · response
Published 4 April 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Consult the Performance and Governance team about activating body-worn video during constant observations.

Verbatim wording from the response
“The Custody lead for South Yorkshire Police is to have further consultation with the Performance and Governance team to look at whether BWV should be activated when observing a prisoner, this could then capture the briefing, roles and responsibilities, action of the officers and any behaviour of the detainee.”

Source location
Response from South Yorkshire Police and Humberside Police
Page 7 · response
Published 4 April 2024
Open published response
21 Mar2019
Oxfordshire
Concerns raised1
1. Lack of guidance for reducing observations of newly arrived prisoners from constant watch
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.
  Stated by Care UKStated completed
2. Action
  Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.
  Stated by Care UKStated completed
3. Action
  Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.
  Stated by Care UKStated in progress
1. Action
  Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.
  Stated by HM Prison and Probation ServiceStated completed
2. Action
  Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.
  Stated by HM Prison and Probation ServiceStated completed
3. Action
  Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.
  Stated by HM Prison and Probation ServiceStated completed
4. Action
  Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.
  Stated by HM Prison and Probation ServiceStated completed
AI-generated summary

John Wright · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

John Wright, aged 32, died at Bullingdon Prison on 15 December 2017 after being found partially suspended by an electrical cable in his cell. He had expressed suicidal thoughts and had previously been kept on constant watch, but observations were reduced to twice hourly during reception. The concerns relate to the receipt and sharing of information about heightened suicide risk and the guidance and decision-making processes for reducing observation levels.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of guidance for reducing observations of newly arrived prisoners from constant watch
Wider context from the report
“The second matter I wish to raise, also to the prison and healthcare, is in relation to the level of observations. I heard evidence that this is often a joint responsibility held by the prison and healthcare. In this case, Mr Wright had been on constant watch, but a decision was taken during the reception process to step down to twice hourly observations. Given that staff may not have access to all available information in those first few hours, and the fact that there will not have been an opportunity for a prisoner to be observed over a significant period of time, and the fact that a more detailed assessment will not have taken place yet, there should in my view be some guidance to staff when reducing observations from constant watch. I note that the Prison and Probation Ombudsman stated at the beginning of her report that ……. ‘Mr Wright had been under constant watch by police and court staff because he said he wanted to take his life at the earliest opportunity. Although prison staff started suicide and self-harm prevention procedures when Mr Wright arrived at Bullingdon, they reduced the level of observations from constant to twice an hour. In my view, this decision was misjudged and taken far too quickly, without a proper assessment of Mr Wright’s risk.’ I appreciate there is a great deal of responsibility on prison and healthcare staff when making assessments. Much depends on how they assess the prisoner in front of them. It may be appropriate to reduce a newly arrived prisoner from constant cell watch to less frequent observations on occasions. The concern which I raise relates to such decisions being made in reception and I enquire if there should be some guidance available to assist staff in their decision-making process? For example, should such a decision be postponed until a further assessment has been carried out the following day? I realise that this issue is not straightforward and there are significant resource implications in keeping a prisoner under constant watch. ”
Source location
John Wright · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Train staff to comply with PSI 64/2011 requirements for managing prisoners at risk of harm.

Verbatim wording from the response
“All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached.”

Source location
2019-0175-Response-by-CARE-UK
Page 3 · response
Published 15 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Consolidate self-harm and suicide-risk training through the PROTECT initiative, including comprehensive patient assessment and proactive ACCT involvement.

Verbatim wording from the response
“All staff are trained to adhere to the requirements of PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from others. The PSI specifies that staff should be trained at least every three years. In addition, Care UK have substantially consolidated this training with it’s PROTECT initiative which upholds standards to protect patients and maintain safety, including thoroughly assessing all patients and proactive involvement with the ACCT process. A copy of the PROTECT initiative is attached.”

Source location
2019-0175-Response-by-CARE-UK
Page 3 · response
Published 15 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide internationally accredited ASIST training to all patient-facing staff to improve identification and management of suicide risk.

Verbatim wording from the response
“Staff meetings are held every two weeks to continue to improve and share knowledge and lessons learned regarding the management of prisoners in custody. Currently HMPPS are providing specialist HMPPS training for both healthcare and discipline staff; “Understanding Risk: Why is Risk Risky?” and “Defensible Decision Making”, both of which seek to reinforce rational and appropriate decisions when applying the ACCT process and understanding suicide risk. Care UK are providing ASIST - Applied Suicide Intervention Skills Training, which is an internationally accredited and licensed 2-day course to all patient-facing staff to increase their confidence in identifying suicide risk. This improved learning, supported by SASH training will better inform decision making in all cases, including those cases where removal from constant watch is being considered.”

Source location
2019-0175-Response-by-CARE-UK
Page 3 · response
Published 15 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Issue a national learning bulletin guiding prisons on setting observation levels for prisoners at risk.

Verbatim wording from the response
“With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.”

Source location
2019-0175-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 15 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require duty governors to establish prior observation levels from documentation when constant supervision preceded arrival.

Verbatim wording from the response
“With regard to your second concern, setting the appropriate level of observations for a prisoner who has been identified as being at risk is a difficult decision, and we have recently issued a learning bulletin to all prisons providing guidance about the issues to consider when making it. At HMP Bullingdon, the Governor has reminded the escort contractors of the importance of alerting reception staff in all cases in which constant supervision has been in place prior to a prisoner’s arrival. In all such cases the process is that the duty governor is informed and all documentation is studied to establish definitively the level of observations to which the prisoner has been subject, in order to avoid confusion over different organisational terminology.”

Source location
2019-0175-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 15 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Open an ACCT and require multidisciplinary review before reducing observations, recording decisions in the ACCT document.

Verbatim wording from the response
“In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.”

Source location
2019-0175-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 15 August 2019
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Brief duty governors that observation decisions must be risk-based and unaffected by resource constraints, with continuing reminders.

Verbatim wording from the response
“In all cases in which constant supervision has been in place, an Assessment, Care in Custody and Teamwork (ACCT) is opened and any decision to reduce the level of observations will be taken at a multidisciplinary case review (including the Duty Governor, a nurse and a member of prison staff, as well as the prisoner) and recorded in the ACCT document. All duty governors have been briefed and will frequently be reminded that decisions about the use of constant supervision should be based on the level of risk and must not be affected by resource constraints.”

Source location
2019-0175-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 15 August 2019
Open published response
16 Sep2013
Worcestershire
Concerns raised1
1. Failure to communicate constant watch status to relevant prison staff
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Ensure appropriate information is communicated to receiving prisons when prisoners transfer from Trust-supported prisons.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated planned
Respondent positions 1
1. Position
  Existing healthcare, discipline-team and prison-transfer communication arrangements are considered sufficient to address information-sharing concerns.
  Stated by Herefordshire and Worcestershire Health and Care NHS TrustExisting arrangements considered sufficient
AI-generated summary

Reggie Johns · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Reggie Johns, a prisoner on constant watch after two attempts to hang himself, was transferred to HMP Hewell on 19 October 2010. His constant watch status was discontinued after a review by two prison officers, and he was found hanging from a bed-sheet ligature about six hours later; he died in hospital the next day. Concerns included inadequate communication between prisons and healthcare staff, insufficiently robust review of his ACCT status, and failure to involve appropriate qualified personnel.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate constant watch status to relevant prison staff
Wider context from the report
“(1) The extent of communication between HMP Hewell and HMP Bristol was unclear because no written record was kept of discussions held between the respective governors or their staff. Whilst it seems clear that some individuals at Hewell were aware that Mr Johns was on an open ACCT they were not made aware of his constant watch status. (2) Whilst the prison staff were aware of the "then" Prison Service Order 2700 and the requirement to hold a multi disciplinary meeting the reasons which they gave for not doing so were inadequate. It was also of concern that one of the officers left the review after some 10 minutes and there was a significant doubt as to whether in fact either or both of the officers spoke to any member of Healthcare. This when coupled with a lack of formal record keeping as between HMP Hewell and HMP Bristol seems significant concern about the quality of communication between individuals, the robustness of the review process for a prisoner deemed to be a high risk and the involvement of appropriately qualified individuals in the conduct of the review. Although the Treasury Solicitors on behalf of HMP Hewell provided me with confirmation that the present Safer Custody Policy has "effected change" in these matters it remains of concern that the policies at the time (the Prison Service Order in particular) appeared not to be followed. (3) Further concerns involved the failure of the nurse to be provided with the ACCT document when Mr Johns was interviewed by her and her further failure to make any entry within that document detailing her professional view. Put simply there was a concern in the matter that despite the known and understood protocols at the time there was a lack of communication and a lack of sufficiently robust and detailed review of Mr Johns involving all appropriate personnel. Whilst the Safer Custody process has, I am assured, been strengthened those involved should take steps to ensure that all members of staff are fully familiar and trained in the requirements of the policy documents. ”
Source location
Reggie Johns · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Ensure appropriate information is communicated to receiving prisons when prisoners transfer from Trust-supported prisons.

Verbatim wording from the response
“Messrs ████████ and ████████ will ensure that appropriate information is communicated to receiving prisons”

Source location
2013-0202-Response-by-Worcestershire-Health-Care-NHS
Page 1 · response
Published 16 September 2013
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing healthcare, discipline-team and prison-transfer communication arrangements are considered sufficient to address information-sharing concerns.

Verbatim wording from the response
“Whilst this concern largely focuses on the issue of communication between HMP Bristol and HMP Hewell I think it is appropriate to seek to reassure you about communication between the healthcare team at HMP Hewell and other HM Prisons. There is continuous dialogue within HMP Hewell between the healthcare and the discipline teams. Some of this is formalised through various meetings and forums and some is informal and reflects a relatively constant ebb and flow of communication on patient specific issues, task related discussion, operational issues and joint working. If prisoners are transferring to other prisons the prisoner’s healthcare record is transferred to the receiving prison. In some cases the Nurse in Reception at HMP Hewell will contact the receiving prison to raise specific issues or concerns.”

Source location
2013-0202-Response-by-Worcestershire-Health-Care-NHS
Page 1 · response
Published 16 September 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Unavailability of larger disabled cells adapted for constant watch

Concerns raised3

Inconsistent or omitted custody sergeant briefings for constant observations

Lack of audit trail for signed constant observation forms and sergeant briefings

Lack of timely controlled handover of constant observation forms

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Lack of guidance for reducing observations of newly arrived prisoners from constant watch

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7

Concerns raised1

Failure to communicate constant watch status to relevant prison staff

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 3

Actions described in response 7

Actions described in response 1

Respondent positions 1