Recurring concern

Unreliable prison cell-hatch observation of prisoners

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First reported 11 Jul 2016•Latest report 29 Jun 2026

Definition

What this concern includes

Includes failures of prison cell-door hatch observation arrangements, including restricted or incomplete views, unsuitable hatch-based observation methods, and related controls where staff rely on the hatch to assess a prisoner’s presence, condition, breathing or immediate safety.

Not included

  • Excludes general prison observation, welfare-check or healthcare-assessment failures where cell-hatch observation is not the deficient control.
  • Excludes failures involving direct in-cell observation or other observation methods that operate reliably without a cell-door hatch.
  • Excludes generic prison staffing, training, communication or documentation deficiencies unless they directly impair the safety of cell-hatch observation.
  • Excludes downstream treatment, resuscitation or escalation failures after a prisoner has been reliably assessed through an appropriate observation method.
Reports
7

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2016–2026

First to latest report issue date

Stated actions
9

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service2
Ministry of Justice2
Care UK1
Central and North West London NHS Foundation Trust1
Dorset Healthcare University NHS Foundation Trust1
HM Inspectorate of Prisons1
HM Prison & Probation Service1
Home Office1
Leicester Prison1
Lowdham Grange Prison1
Nottinghamshire Healthcare NHS Foundation Trust1
Prisons and Probation Ombudsman1
Woodhill 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.

  1. Lancashire and Blackburn with Darwen

    AI-generated summary

    Johnpaul Digweed · 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

    Johnpaul Digweed died by suicide by hanging in his cell at HMP Garth between 17:06 on 12 April 2024 and 11:31 on 13 April 2024. The concerns included failures to open an ACCT process after incidents of self-harm, inadequate assurance about staff training and information-sharing, and welfare observations not being carried out in accordance with prison procedures, including when observation panels were obscured.

    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 ensure removal of coverings from cell-door observation panels

    Wider context from the report

    “2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not aware of the instructions which were issued by email. As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff. In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths ”

    Source location

    Johnpaul Digweed · 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

    Introduce daily mandatory knowledge-check sessions for operational and non-operational staff, recording attendance, completion and understanding to reinforce ACCT and welfare-check practice.

    Verbatim wording from the response

    “The prison have begun introducing daily knowledge check sessions for both operational and non-operational staff, and additional staffing resources are being secured to support the delivery of this initiative. Attendance and completion of the knowledge check sessions will be required and formally recorded, with staff providing written confirmation they have attended a session, and that the content is understood. A training log will be maintained by the prison’s Learning and Capabilities Team to monitor attendance and completion rates.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 3 September 2026

    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

    Reissue the Governor’s Order reminding staff of mandatory instructions for prisoner wellbeing and responding to blocked observation panels.

    Verbatim wording from the response

    “Furthermore, to reinforce local guidance a Governor’s Order has been reissued reminding staff of the mandatory instructions in place in line with PSI 75/2011, and the requirement to ensure the wellbeing of prisoners and action to be taken should a blocked observation panel be discovered.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 3 September 2026

    Open published response

  2. Milton Keynes

    AI-generated summary

    Ronald William MEIKLE · 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

    Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

    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 maintain unobstructed observation panels for effective visual welfare checks

    Wider context from the report

    “Concern 4: Blocked observation panels and inadequate visual welfare checks The evidence raised serious concern that blocked observation panels were not consistently challenged or cleared, and that visual welfare checks were therefore not always effective. The jury heard evidence that officers deliberately avoided opening blocked hatches to escape abuse from the prisoners then or later. In a prison environment where prisoners may be intoxicated, unconscious, self-harming, assaulted, or otherwise incapacitated behind a locked door, failure to maintain an unobstructed observation panel creates an obvious risk of late discovery and preventable death. ”

    Source location

    Ronald William MEIKLE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Healthcare services alone cannot mitigate all risks within custody.

    Verbatim wording from the response

    “Thank you for bringing your concerns to our attention. While healthcare services alone cannot mitigate all risks within custody, the Trust is committed to learning from Mr Meikle’s death and to strengthening how vulnerability is identified and responded to across Health and Justice services. Should you have any questions or comments, please do not hesitate to contact me.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

    Open published response

  3. Nottinghamshire

    AI-generated summary

    Anthony Binfield · 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

    Anthony Binfield died from ligature asphyxiation inside his cell at HMP Lowdham Grange on 6 March 2023. Prison staff delayed entering the cell for 11 minutes after finding the observation panel covered and receiving no response. The principal concerns were unsafe and policy-inconsistent management of covered cell observation panels, an embedded staff practice of delaying entry, and repeated notices failing to address the issue.

    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 keep cell observation panels clear and challenge prisoners who cover them

    Wider context from the report

    “(1) Prison staff failing to manage the covering of cell observation panels in a safe way that is compliant with the policy and guidance issued by the prison over many years. I am taking the exceptional step of writing to you formally before the conclusion of the inquest as I am so concerned by the evidence called to date regarding the custom and practice of officers when discovering obscured cell observation panels at night. There is a dangerous culture of staff assuming the prisoner has obscured the observation panel for privacy purposes or as a form of protest against the regime. This neglects the obvious and very real risk that the prisoner is seeking to harm themselves, without detection. The HMPPS Safety Notice, issued in February 2018, made clear that cell observation panels are a vital tool in keeping prisoners safe and must be kept clear at all times in order to preserve life. The custom and practice of seeking to visualise the prisoner via the inundation unit hole (and other means, such as the side of the door) has developed over time and is now an embedded culture accepted by many officers as a response to this occurrence. This practice leads to delay in entering the cell, risks lives and is contrary to policy. This is not a new issue for the prison and hence my concern that the prison has failed to tackle this issue over many years. In August 2020, a prisoner died at HMP Lowdham Grange as a result of drug use. When officers conducted a welfare check they found his cell observation panel to be obscured. Contrary to policy and guidance, Prison staff delayed entering the cell while they fetched the inundation unit key to attempt to observe inside the cell. The Prison and Probation Ombudsman made a recommendation to the Prison Director that they should ensure that observation panels are kept clear, and that staff actively challenge prisoners who cover them. In response, the Prison Director issued a notice to staff in January 2021 reminding staff of the need to treat any prisoner as unresponsive if they fail to acknowledge the officer, and to call a code blue. A similar notice was issued in April 2021, reminding staff of the need to perform a dynamic risk assessment and enter the cell in a quick and safe manner when there is no response to asking the prisoner to remove the offending item. The notice was re-issued in November 2021, and after the inquest in approximately April 2023. Despite these multiple notices, a number of witnesses who remain members of staff at the prison (now under HMPPS employ) reported being unaware of the expected procedure when faced with an obscured cell observation panel until attending Anthony’s inquest in December 2024. It is clear that the issuing of staff notices has not addressed the problem of prisoner's covering their cell hatches, nor the unsafe custom and practice of staff leaving the cell and thereby delaying safe entry. ”

    Source location

    Anthony Binfield · 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

    Include blocked observation panels in the Incentives Policy Framework, with warnings, loss of privileges and formal sanctions for continued obstruction.

    Verbatim wording from the response

    “I have received assurances from the Governing Governor of HMP Lowdham Grange that since the prison formally became a public sector prison in August 2024, action has been taken to increase staff confidence, skills and understanding of relevant policies and procedures. The prison recognises the inherent risks of blocked observation panels and has taken a number of proactive steps to ensure that staff and prisoners understand the importance of the panels remaining uncovered at all times. There is now a specific”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 13 February 2025

    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

    Communicate required staff actions for blocked observation panels through briefings, notices, governor orders and induction training for new staff and OSGs.

    Verbatim wording from the response

    “It is crucial that staff carry out regular safety checks on prisoners when they are locked in their cells. Every time staff approach a prisoner’s cell they must ensure that the observation panel is clear of obstruction in case of an emergency situation. The obscuring of observation panels is a constant challenge across the prison estate as prisoners continue to cover and block observation panels for a variety of reasons, including for privacy and decency. However, HMPPS has a clear stance on the issue and all prisons must set out to staff what action should be taken if an observation panel is found to be covered or blocked.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 13 February 2025

    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

    Communicate the importance and consequences of keeping observation panels clear to prisoners through video messages.

    Verbatim wording from the response

    “It is vital that prisoners also recognise the importance of observation panels remaining clear and the consequences they could face if they choose to block them. This message has been conveyed to the prisoner population through video messages over the last 12 months, with the most recent video message published in January 2025.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 13 February 2025

    Open published response

  4. Nottinghamshire

    AI-generated summary

    Christopher Howard 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

    Christopher Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.

    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

    Unsafe clinical observations through cell door hatches

    Wider context from the report

    “1. An inability to provide prisoners at HMP Lowdham Grange with safe clinical care I heard evidence, and the jury reached findings, that there was an unsafe practice of staff conducting important healthcare and wellbeing observations via the cell door observation hatch. Observing an unwell prisoner through a hatch slightly larger than a letterbox undermines the safety of the clinical assessment. Healthcare staff did not utilise the NEWS2 system of monitoring the condition of an acutely unwell prisoner, despite the Trust having adopted this recognised healthcare tool many years prior. The Forensic Directorate has continued to lag behind other areas of the Trust where NEWS2 is fully embedded and this has previously been identified as an issue linked to other deaths. There was a lack of robust GP visits, despite such being mandated by the Prison Rules. When visits did take place, they were often via the cell door observation hatch and conducted as “fleeting glances” rather than robust clinical assessments. Again, this is unsafe. There was a lack of effective leadership of the healthcare department to ensure that staff had created a safe plan of care for Christopher. Senior personnel were not aware of Christopher’s week-long deterioration in the segregation unit until very late in the chronology of events, nor were they aware of a dispute between the mental health and physical health teams as to the differential diagnoses that might be causing his concerning symptoms and deterioration. Despite daily lunch time meetings, there was a stark lack of professional curiosity from senior staff as to the plan of care for Christopher and what safety netting, if any, was in place. ”

    Source location

    Christopher Howard SMITH · 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

    Ratify and disseminate an escalation flow chart covering access problems and emergency response.

    Verbatim wording from the response

    “• Escalation flow chart has been developed to assist staff and provide scenarios / context of when this might apply and what to do if unable to access an unwell patient. This has been ratified and disseminated to staff.”

    Source location

    Response from Nottinghamshire Healthcare NHS Foundation Trust
    Page 2 · response
    Published 6 November 2023

    Open published response

  5. Surrey

    AI-generated summary

    Serena Nicolle · 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

    Serena Nicolle died in her cell at HMP Bronzefield on 3 September 2018 from ventricular arrhythmia in the context of hypertensive heart disease, with diabetes, sleep apnoea, obesity and stress also recorded. Two prison staff members incorrectly assessed her as breathing after observing movement through the cell hatch, and the Coroner was concerned that this standard procedure may be an unreliable way to check breathing and could create a risk of future deaths.

    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

    Use of an unreliable chest/abdomen movement observation method for checking breathing through cell door hatches

    Wider context from the report

    “During the course of the inquest the court heard evidence that observing the movement of an individual’s chest and abdomen through a cell hatch is a standard procedure for checking whether they are breathing, in circumstances where they are not otherwise moving or responding to prison staff. The court heard that this is the position across the prison estate and is not limited to HMP Bronzefield. The court also heard evidence from expert witness Dr ████████, a Consultant Cardiologist, who stated that in his opinion it is very difficult to assess whether somebody is breathing or not by looking for movement in the chest/abdomen from a distance. The Coroner is concerned that on 3 September 2018 two members of prison staff assessed that Mrs Nicolle was breathing when she was in fact deceased, and that in doing so they followed standard procedures which are in place across the prison estate. Whilst these errors did not contribute to Mrs Nicolle’s death, the Coroner is concerned that were similar errors to occur in the future, it would present a risk of future deaths, particularly given Dr ████████ evidence that it is difficult to assess whether somebody is breathing or not by looking for movement in the chest/abdomen from a distance. 1. The observation of an individual’s chest/abdomen through a cell door hatch may be an unreliable method of checking whether they are breathing, in circumstances in which they are not otherwise moving or responding to prison staff, and therefore gives rise to the risk of future deaths. ”

    Source location

    Serena Nicolle · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Exeter and Greater Devon

    AI-generated summary

    Stephen Mark SHAYLOR · 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

    Stephen Mark SHAYLOR was found hanging in his cell at HMP Exeter in the early hours of 1 January 2014 and was pronounced dead at 03:35. He was on a drug stabilisation regime and subject to healthcare night welfare checks. Concerns included the inadequacy of checks conducted through cell-door hatches, the absence of continuous CCTV monitoring, and the failure to carry out the 02:00 check.

    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

    Inadequacy of healthcare night welfare checks for determining whether prisoners are breathing or alive

    Wider context from the report

    “(2) Professor Wall, substance misuse expert, said that the system for looking after these inmates was not fit for purpose and that healthcare night welfare checks (looking through a hatch in a cell door) were inadequate because it was not possible to ascertain if a prisoner was breathing/alive by this method. ”

    Source location

    Stephen Mark SHAYLOR · 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

    Conduct overnight welfare checks using daily printed checklists and review completed checks the following day.

    Verbatim wording from the response

    “Night welfare checks are carried out by Health Care Assistants (HCAs). At the start of the night shift, the nurse and HCA will print off the relevant welfare check list which will show all new additions made that day, as well as those prisoners who are already on the list. HCAs will then use that list and the printed template to assist them in conducting checks overnight. A copy of the template used was provided under cover of my first letter.”

    Source location

    2017-0380-Response-by-Care-UK
    Page 1 · response
    Published 12 February 2018

    Open published response

  7. Leicester City and South Leicestershire

    AI-generated summary

    Michael Williams · 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

    Michael Williams died by hanging in his locked prison cell on 15 September 2015 while subject to four observations per hour and after he had threatened to take his life, appeared tearful and anxious, and blocked the observation panel. The concerns included missed and predictable observations, the lack of an explanation for missed checks, and an approximately one-hour delay before the cell was opened after he became unobserved.

    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 maintain visual observation when the observation panel is blocked

    Wider context from the report

    “Mr Williams should have been observed 4x every hour during the evening of 15th September 2015. Several of these checks were missed, and after he blocked the observation panel, he could only be heard, not seen. a) Observations (where they were carried out) were documented at precise 15 minute intervals, commencing on the hour, and were therefore predictable. This is not best practice and should be discouraged. b) There was no explanation for the missed observations. c) Mr Williams was unobserved for approximately 1 hour before the cell door was opened, and he was found deceased. The jury found this was inappropriate delay and I agree with them. Clear guidance and training should be provided, and regularly repeated, to assist the Prison Officers in managing such situations in a timely way. ”

    Source location

    Michael Williams · Prevention of Future Deaths report
    Page 1 · 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

    Revise and disseminate the contingency plan, train staff to intervene quickly when observation panels are blocked, and permit individual staff to open cells during immediate danger.

    Verbatim wording from the response

    “(3) Mr Williams was unobserved for approximately 1 hour before the cell door was opened and he was found deceased. The jury found this was an inappropriate delay and I agree with them. Clear guidance and training should be provided and regularly repeated to assist the prison Officers in managing such situation in a timely way. The contingency plan at HMP Leicester was revised in April 2016, and the amended plan has been brought to the attention of staff through training and briefings. Staff have been made aware that they must intervene quickly if the observation panel has been blocked and a prisoner is refusing to engage. In particular, where there appears to be an immediate danger to life, cells can be opened by an individual member of staff.”

    Source location

    2016-0245-Response-by-NOMS
    Page 1 · response
    Published 11 July 2016

    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

    Introduce the Safer Custody toolkit with guidance on ACCT procedures, emergency response, and communication with hard-to-engage prisoners.

    Verbatim wording from the response

    “(2) There was no explanation for the missed observations. In a notice to staff dated 24 March 2016, all staff were reminded of the importance of ACCT observations. The new Safer Custody toolkit that will be introduced in August 2016 provides clear instructions to staff regarding ACCT procedures and the importance of conducting ACCT observations.”

    Source location

    2016-0245-Response-by-NOMS
    Page 1 · response
    Published 11 July 2016

    Open published response
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Data last updated 7 September 2026