Recurring concern

Inadequate CCTV coverage and monitoring in custodial settings

First to latest report 6 Jan 2014 — 20 Dec 2019

Reports that mention this concern
9
Times this concern has been raised
11
Stated actions linked to this concern
3

What this concern includes

Includes deficiencies in CCTV facilities, monitored cells, coverage, live monitoring, recording, camera allocation, positioning, instructions or operation in custody suites, prisons and comparable custodial areas, including arrangements for detainees at risk.

What is not included
  • CCTV deficiencies in public, transport, leisure or other non-custodial settings.
  • Broader custody observation, staffing or risk-assessment failures where CCTV is not the deficient control.
  • Investigative or clinical decisions made after adequate CCTV footage was reliably captured and available.

Reports and published responses 9 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester City

    AI-generated summary

    Tomasz Nowosad · 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

    Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by 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

    Insufficient availability of safer cells and CCTV-monitored cells

    Wider context from the report

    “5.14 It is suggested that HMPS should consider increasing the number of Safer cells throughout the whole of the prison and also having more CCTV monitored cells. ”

    Source location

    Tomasz Nowosad · Prevention of Future Deaths report
    Page 7 · 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

    Increase the availability of safer cells for governors wherever possible through the national prison safety programme.

    Verbatim wording from the response

    “Fourth, safer cells (5.13-5.14). You are concerned that more such cells should be available, and that the movement of prisoners who are subject to ACCT from a safer cell to another location should be carefully managed. I understand the importance of reducing access to the means of suicide wherever possible. Physical safety, including increasing the provision of accommodation free of ligature points, is one of the work streams in our national prison safety programme. You will appreciate that large amounts of capital investment are necessary to improve the environment in this way, and we are not able to move as swiftly as we would want to. However, wherever possible we are increasing the numbers of safer”

    Source location

    2019-0445-Response-from-HMPPS
    Page 2 · response
    Published 8 January 2020

    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

    Capital investment requirements prevent safer-cell environmental improvements from progressing as quickly as desired.

    Verbatim wording from the response

    “Fourth, safer cells (5.13-5.14). You are concerned that more such cells should be available, and that the movement of prisoners who are subject to ACCT from a safer cell to another location should be carefully managed. I understand the importance of reducing access to the means of suicide wherever possible. Physical safety, including increasing the provision of accommodation free of ligature points, is one of the work streams in our national prison safety programme. You will appreciate that large amounts of capital investment are necessary to improve the environment in this way, and we are not able to move as swiftly as we would want to. However, wherever possible we are increasing the numbers of safer”

    Source location

    2019-0445-Response-from-HMPPS
    Page 2 · response
    Published 8 January 2020

    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 ACCT support is considered sufficient to manage acute risk in most cases without additional safer-cell provision.

    Verbatim wording from the response

    “cells available to governors. At HMP Manchester there are currently fourteen safer cells. Ten are in the healthcare unit, five of which are equipped with CCTV. Four non-CCTV cells are around the prison healthcare electro-chronic doors. Whilst there are currently no plans to increase the number of safer cells, we will keep this under review.”

    Source location

    2019-0445-Response-from-HMPPS
    Page 3 · response
    Published 8 January 2020

    Open published response

  2. Essex

    AI-generated summary

    Raymond Alan Knight · 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

    Raymond Alan Knight was arrested on suspicion of possessing illicit drugs with intent to supply, taken to Grays Police Station, and collapsed in a holding cell before being pronounced dead at hospital. Toxicological analysis indicated high levels of cocaine in his blood, and the inquest concluded that the death was drug related. The report raised concern that CCTV did not cover the individual holding cells, leaving no photographic record of what happened inside them when officers were not present.

    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 CCTV coverage inside holding cells

    Wider context from the report

    “The CCTV camera positioned in the holding area at Grays Police Station did not include, within its range, sight into the individual holding cells. As a result, there was no photographic record of exactly how Mr Knight was and what he was doing while he was in the holding area. It is essential to be able to see what is happening within the holding cells when a prisoner is detained within one of them. The court was told that a police officer would be required to be at the cell at all times but, if for any reason, there were to be no officer in attendance, a CCTV record of within the cell is essential. The introduction of discrete camera coverage of the holding areas may well prevent future deaths, of whatever cause, in those specific locations. ”

    Source location

    Raymond Alan Knight · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Birmingham and Solihull

    AI-generated summary

    Ricardo Wayne Holgate · 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

    Ricardo Wayne Holgate was found dead in his cell at Birmingham Prison on the morning of 26 March 2018. The post-mortem recorded coronary artery thrombosis and atherosclerosis, with the combined effects of synthetic cannabinoid and codeine. The inquest identified significant concerns about the supply and use of illicit substances, staffing levels, staff training and experience, and inconsistent management and reporting of prisoners affected by such substances.

    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 CCTV coverage on all prison wings

    Wider context from the report

    “1. The new Governing Governor confirmed that further steps are necessary to improve the management of illicit substance misuse. He confirmed the prison requires CCTV on all wings and airport style scanners – one in reception for prisoners and one in the visitor area. ”

    Source location

    Ricardo Wayne Holgate · 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

    Decisions to purchase and install CCTV and airport-style scanners at HMP Birmingham are outside the respondent’s remit while HMPPS manages the prison.

    Verbatim wording from the response

    “HM Senior Coroner will be aware that at present, HMP Birmingham is being managed by HMPPS, Mr Paul Newton being the current Governing Governor. Any decisions in terms of actions to be taken/equipment to be purchased and installed etc. at HMP Birmingham is not therefore currently within the remit of G4S. However, G4S does agree with Mr Newton that HMP Birmingham would benefit from CCTV and airport style scanners.”

    Source location

    2019-0012-Response-by-GS4
    Page 1 · response
    Published 24 May 2019

    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

    HMPPS and the current Governing Governor are responsible for decisions and equipment relating to CCTV and airport-style scanners at HMP Birmingham.

    Verbatim wording from the response

    “HM Senior Coroner will be aware that at present, HMP Birmingham is being managed by HMPPS, Mr Paul Newton being the current Governing Governor. Any decisions in terms of actions to be taken/equipment to be purchased and installed etc. at HMP Birmingham is not therefore currently within the remit of G4S. However, G4S does agree with Mr Newton that HMP Birmingham would benefit from CCTV and airport style scanners.”

    Source location

    2019-0012-Response-by-GS4
    Page 1 · response
    Published 24 May 2019

    Open published response

  4. 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

    Reliance on continuous CCTV monitoring to detect prisoner self-harm

    Wider context from the report

    “(3) Night welfare checks and observations on an ACCT document are at best intermittent and rely on continuous CCTV monitoring could spot a prisoner self-harming. ”

    Source location

    Stephen Mark SHAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner West London

    AI-generated summary

    Ms Michelle Ann 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

    Ms Michelle Ann Lawrence died at home on 2 May 2015 from respiratory failure after taking multiple prescription and illegal sedative drugs, following periods in police and private custody. The principal concerns included failures to identify concealed drugs, limited strip-searching and CCTV facilities, inadequate checking of custody-suite toilets, insufficient detail in risk records, and the lack of independent investigation into deaths following release from private custody providers.

    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

    Insufficient CCTV-monitoring facilities for detainees at risk in custody

    Wider context from the report

    “(5) That all custody suites have sufficient facilities for CCTV monitoring of detainees at risk in custody whether held by the State or private custody providers. ”

    Source location

    Ms Michelle Ann Lawrence · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Manchester City

    AI-generated summary

    Craig Douglas Bell · 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

    Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.

    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 use CCTV monitoring as an adjunct to ACCT observation procedures

    Wider context from the report

    “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures. No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death. One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’s death. ”

    Source location

    Craig Douglas Bell · Prevention of Future Deaths report
    Page 5 · 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

    Unavailability of cells or facilities fitted with CCTV monitoring

    Wider context from the report

    “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures. No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death. One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’s death. ”

    Source location

    Craig Douglas Bell · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  7. Staffordshire South

    AI-generated summary

    Adam Amos 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

    Adam Amos Williams, a serving prisoner aged 29, collapsed at HMP Featherstone on 5 March 2013 and died at New Cross Hospital on 6 March 2013 from a sub-arachnoid haemorrhage. The concerns raised related to communication between prison healthcare staff during emergencies, whether dynamic assessments considered the need for restraint, and the possible benefit of additional CCTV in prison common areas.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient CCTV coverage in prison common areas

    Wider context from the report

    “(3) Although I accept that resource factors must be taken into account in this, I wonder if it may be beneficial for there to be more CCTV in common areas of the prison such as the gym or CV rooms. ”

    Source location

    Adam Amos Williams · 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

    CCTV cannot be installed throughout all prison areas because the required infrastructure and staff monitoring cannot be resourced.

    Verbatim wording from the response

    “The requirement for CCTV in common areas of the prison is risk assessed, and dependant on the need in that area. It is not possible to install CCTV in every area of the prison due to the resource implication; however the location of unsupervised CV rooms enables staff to promptly attend when required. The effectiveness of CCTV is dependant on staff being available to simultaneously watch the CCTV camera, which cannot be resourced. An analysis of reported incidents for the year to date shows that incidents in CV rooms are extremely rare and therefore there are no plans at present to extend the use of CCTV cameras at Featherstone.”

    Source location

    2014-0324-Response-by-NOMS
    Page 2 · response
    Published 14 July 2014

    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

    No further CCTV extension is planned because incidents in cardiovascular rooms are rare and staff can promptly attend those areas when needed.

    Verbatim wording from the response

    “The requirement for CCTV in common areas of the prison is risk assessed, and dependant on the need in that area. It is not possible to install CCTV in every area of the prison due to the resource implication; however the location of unsupervised CV rooms enables staff to promptly attend when required. The effectiveness of CCTV is dependant on staff being available to simultaneously watch the CCTV camera, which cannot be resourced. An analysis of reported incidents for the year to date shows that incidents in CV rooms are extremely rare and therefore there are no plans at present to extend the use of CCTV cameras at Featherstone.”

    Source location

    2014-0324-Response-by-NOMS
    Page 2 · response
    Published 14 July 2014

    Open published response

  8. Teesside

    AI-generated summary

    Andrew Ronald Hall · 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 Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.

    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

    Infrequent observation of CCTV screens

    Wider context from the report

    “12. There was infrequent observation of the CCTV screens on 27 March 2009. (Prison service & Healthcare staff) ”

    Source location

    Andrew Ronald Hall · Prevention of Future Deaths report
    Page 1 · 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

    Inadequate quality of CCTV images within the healthcare unit

    Wider context from the report

    “10. The quality of CCTV images within the healthcare unit was inadequate. ( prison service) ”

    Source location

    Andrew Ronald Hall · 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

    Remove CCTV cameras from healthcare-unit cells and use constant-observation cells with constant supervision for prisoners requiring high observation.

    Verbatim wording from the response

    “You raise a number of concerns about the effectiveness of the arrangements to observe prisoners in cells in the healthcare unit using CCTV (points 9-12, 15 and 16). Cameras have been removed from all cells and any prisoner assessed as requiring high levels of observation is located in a constant observation cell and subject to constant supervision in accordance with the arrangements set out in chapter 6 of PSI 64/2011.”

    Source location

    2014-0122-Response-by-NOMS
    Page 1 · response
    Published 12 March 2014

    Open published response

  9. Manchester South

    AI-generated summary

    Billy Paul Thomas Salton · 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

    Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.

    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 specific instructions and effective positioning for CCTV cell monitoring

    Wider context from the report

    “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy. 2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is. 3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record. 4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted. 5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters. 6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate. 7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen. 1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy). 2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody. 3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked. 4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded. 1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody. 2. Staff should be reminded that all cell checks should be accurately documented. 3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY. ”

    Source location

    Billy Paul Thomas Salton · 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

    Develop a custody-office work system that improves CCTV monitoring coverage and accountability.

    Verbatim wording from the response

    “The programme of work I described earlier in improving communication and management of the office is looking at every aspect of the roles staff undertake in Custody. The monitoring of CCTV is one of those roles and they will be looking for a system that matches or improves the coverage of CCTV we have and also provide greater accountability.”

    Source location

    2014-0002-Response-by-Greater-Manchester-Police
    Page 4 · response
    Published 6 January 2014

    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 CCTV arrangements are considered sufficient; staff will not be specifically instructed to observe the screen for Level 2 observations.

    Verbatim wording from the response

    “At present we remain satisfied with our current arrangements for CCTV usage. We do use CCTV for constant observations in some cases. However, in the case with Mr Salton, the level of observations was at Level 2.”

    Source location

    2014-0002-Response-by-Greater-Manchester-Police
    Page 4 · response
    Published 6 January 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026