Recurring concern

Unreliable Personal Officer scheme for identifying and monitoring prisoner vulnerability

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First reported 30 Jun 2014•Latest report 20 Apr 2020

Definition

What this concern includes

Includes failures of the named Personal Officer scheme and its dedicated controls, including appointment, meaningful engagement, protected time, role understanding, performance monitoring, manager alerts, auditing and fulfilment of Personal Officer obligations where these affect identification or monitoring of prisoner vulnerability and risk.

Not included

  • Excludes generic prison staffing, training, supervision or workload deficiencies unless they directly impair operation of the Personal Officer scheme.
  • Excludes general prisoner welfare, safeguarding or vulnerability-management failures where no Personal Officer scheme control is deficient.
  • Excludes failures concerning other named prison roles or schemes, such as Welfare Officers, equalities officers or ACCT, unless the assertion explicitly identifies the Personal Officer scheme.
  • Excludes ordinary prisoner engagement or social contact where no Personal Officer appointment, obligation or scheme requirement is involved.
Reports
5

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2014–2020

First to latest report issue date

Stated actions
0

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 Service3
Ministry of Justice2
Hindley Prison1
Home Office1
St George's Hospital1
Wandsworth Prison1
Youth Justice Board for England and Wales1

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

    Andrew Patrick Jones · 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

    Andrew Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.

    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 of Personal Officer involvement when prisoners default from the prison regime

    Wider context from the report

    “b. Deselection of prisoners from the Residential Support Unit with no multidisciplinary assessment of past ACCT/self-harm, mental health, psychology input into the decision along with risk factors for an RSU prisoner in the wider jail c. Misapplication by all senior officers and custody managers of wing segregation rules resulting in mass segregation of prisoners with no safety algorithm completion, enhanced checks, involvement of healthcare et cetera; d. No risk assessment by the CM prior to transfer or the transferring wing Senior Officer prior to transfer; e. No prison records of any discussions regarding transfer or the decision to transfer a prisoner between wings or of any checks undertaken prior to transfer f. No risk assessment by the receiving wing senior officer either on reception of the prisoner or at any time in the next 36 hours before his death; g. Inconsistent medication regimes without explanation; h. Closure of ACCT forms when either medical treatments were impossible to deliver or had not been undertaken although the reduction in analgesics had occurred; i. Records of post closure interviews been entered in the records when it was obvious that the risk profile had changed substantially since the post closure interview took place; j. No personal officer involvement to ascertain why a prisoner may be defaulting from the prison regime. ”

    Source location

    Andrew Patrick Jones · Prevention of Future Deaths report
    Page 8 · concerns

    Open source report

  2. Inner West London

    AI-generated summary

    Robert John Richards · 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

    Robert John Richards died by suicide after being found hanging by a sheet in his cell at HMP Wandsworth on 29 July 2014. The report identified concerns about bullying, extortion, inadequate risk management and communication, unsuitable cell allocation, staffing and training, and failings in resuscitation equipment and procedures.

    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

    Absence of a personal officer system providing prisoners with a named officer who knows them well

    Wider context from the report

    “10. That the personal officer system be re-established, so that prisoners have a named officer who knows them well. Risks should then be communicated and managed more appropriately within HMP Wandsworth, such that self-harm and suicide of prisoners is reduced. ”

    Source location

    Robert John Richards · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Cambridgeshire and Peterborough

    AI-generated summary

    Peter Lawrence · 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

    Peter Lawrence was remanded into custody at HMP Peterborough and, on 02.02.15, was found in a prison workshop toilet cubicle having stabbed himself with a chisel; he was taken to hospital where death was confirmed. The concerns related to identifying and recording suicide or self-harm risks during the initial screening of first-time prisoners, and to the absence of meaningful interaction with a custodial officer who could help identify and manage such risks.

    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 meaningful pastoral interaction with a dedicated custodial officer

    Wider context from the report

    “(2) The use of personal (or ‘custodial’) officers was identified as an important aspect of risk management. The jury identified the absence of interaction with a custodial officer in the current case to have been a missed opportunity to further identify and consider the risk of suicide/self harm. Again this has been addressed locally. The lack of meaningful interaction with a dedicated member of staff in a pastoral capacity, particularly for those in prison for the first time, gives rise to a concern that deaths may occur in other cases nationally. ”

    Source location

    Peter Lawrence · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Central Lincolnshire

    AI-generated summary

    Rubel Ahmed · 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

    Rubel Ahmed, who was detained at Morton Hall Immigration Removal Centre, was found hanging in his room on the evening of 5 September 2014 and was pronounced deceased shortly after midnight on 6 September 2014. The concerns included overnight locking of detainees in rooms, the adequacy of detention-awareness training, staff awareness of changes in detainees’ circumstances, insufficient protected time for personal officers, and the use of electrical leads that could be used as ligatures.

    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 protected time for personal officers to carry out assigned duties

    Wider context from the report

    “iv. PERSONAL OFFICER DETAIL: Despite the fact that Mr Ahmed had been allocated a Personal Officer it was abundantly clear that the officer had spent very little time with him, owing to other work pressures. It was also evident that there was no adequate system at Morton Hall for ensuring that staff have protected time to carry out this important work to enable detainees to discuss sensitive or distressing issues with an officer who was familiar to them. I consider that this situation needs to be reviewed to ensure that personal officers at Morton Hall IRC assigned to detainees are given protected time to carry out these duties. ”

    Source location

    Rubel Ahmed · Prevention of Future Deaths report
    Page 1 · 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

    Effective detainee management and care do not require positive engagement to be limited to a single personal officer.

    Verbatim wording from the response

    “At Morton Hall all staff operate on the basis that every contact matters: every interaction between a member of staff and a detainee contributes to their effective management and care, and positive engagement is not limited to a relationship with a single personal officer. Welfare services are provided by specialist staff from Children’s Links, and each detainee has a welfare booklet opened during induction which is regularly reviewed and updated during their stay at Morton Hall. Again, I must stress that in the case of Mr Ahmed there were no indications prior to his death that he was at risk of self-harm or suicide.”

    Source location

    2015-0308-Response-by-Home-Office
    Page 2 · response
    Published 5 August 2015

    Open published response

  5. Manchester West

    AI-generated summary

    Jake Reginald Hardy · 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

    Jake Reginald Hardy, a 17-year-old detained at HM YOI Hindley, died on 20 January 2012 after being found partially suspended by a ligature in his cell. The report describes failures to identify, record and respond to his vulnerabilities, self-harm risk and reports of verbal bullying, including failures in safeguarding, ACCT care planning, supervision and overnight risk assessment. Concerns also included ligature points in cells, inadequate personal officer support, staff training and communication systems, and limited access to family telephone support.

    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 provide detainees with the benefit and protection of a Personal Officer

    Wider context from the report

    “2. The evidence revealed an almost complete failure to provide Jake Hardy with the benefit and protection of a Personal Officer, despite a comprehensive scheme being in place. Currently the scheme is of pivotal importance for the identification and monitoring of vulnerability and risk. There remains a concern about whether all officers at HM YOI Hindley have a sufficient understanding of this role and its importance and about the absence of any system to alert managers to any failure by a Personal Officer to meet his obligations under this scheme or to audit his performance. This concern may be of relevance to other Young Offender Institutes also. ”

    Source location

    Jake Reginald Hardy · 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 understanding and performance oversight of Personal Officer obligations

    Wider context from the report

    “2. The evidence revealed an almost complete failure to provide Jake Hardy with the benefit and protection of a Personal Officer, despite a comprehensive scheme being in place. Currently the scheme is of pivotal importance for the identification and monitoring of vulnerability and risk. There remains a concern about whether all officers at HM YOI Hindley have a sufficient understanding of this role and its importance and about the absence of any system to alert managers to any failure by a Personal Officer to meet his obligations under this scheme or to audit his performance. This concern may be of relevance to other Young Offender Institutes also. ”

    Source location

    Jake Reginald Hardy · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
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Data last updated 7 September 2026