Recurring concern
Unreliable emergency cell-entry arrangements in prisons
First reported 28 Dec 2014•Latest report 7 Apr 2026
What this concern includes
Includes failures in prison arrangements for deciding, authorising, escalating, coordinating and carrying out emergency or urgent cell entry, including entry criteria, dynamic risk assessment, night or patrol-state procedures, staffing requirements, communication between prison and healthcare staff, and escalation when responsible staff disagree or cannot enter.
Not included
- Excludes general prison healthcare, emergency-response or cell-security deficiencies where the failure does not concern entering a cell to provide urgent care or assistance.
- Excludes generic staff training or policy deficiencies unless they directly impair the emergency cell-entry process.
- Excludes ordinary access-control, sanitation-room or prison-door maintenance failures unless they specifically prevent or delay emergency entry into a prisoner's cell.
- Excludes failures occurring after staff have safely entered the cell, including subsequent clinical assessment or treatment.
- Excludes broader emergency forced-entry arrangements for non-prison premises where prison cell entry is not the bounded safety process.
- Reports
- 9
- Individual concerns
- 11
- Date range
- 2014–2026
- Stated actions
- 20
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised2
Failure to record the cell-entry escalation process in policy
Failure to maintain prison and healthcare staff awareness of the cell-entry escalation process
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Delays in entering cells when observation panels are obscured and the prisoner does not respond
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Communicate required staff actions for blocked observation panels through briefings, notices, governor orders and induction training for new staff and OSGs.
Stated by HM Prison and Probation Service
-
Concerns raised2
Failure of lone prison officers to enter cells during emergencies
Inadequate guidance and training for prison officers on emergency cell entry
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.4
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Action
Issue a notice reminding staff to raise medical emergency alarms, assess risks dynamically, enter cells when safe, and take immediate life-preserving action.
Stated by HM Prison and Probation Service -
Action
Reinforce medical-emergency response requirements through wing briefings and the Governor’s full staff briefing.
Stated by HM Prison and Probation Service -
Action
Issue the film ‘Responding to emergency situations’ nationally to help prison staff respond when prisoners have ligatured.
Stated by HM Prison and Probation Service
-
Action
Show the emergency-response film to groups of HMP Gartree staff during briefing sessions.
Stated by HM Prison and Probation Service
-
Concerns raised1
Failure to provide timely training and guidance on entering a cell during a medical emergency
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.6
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Action
Make the emergency response video available to staff and deliver it through foundation training for new officers.
Stated by HM Prison and Probation Service -
Action
Show the emergency response video to all existing staff through Safety Critical training.
Stated by HM Prison and Probation Service -
Action
Show the emergency response video annually to all staff.
Stated by HM Prison and Probation Service
-
Action
Brief staff at the beginning of night duty on Code Blue, Code Red and entering cells during medical emergencies, with Safety and Security quality assurance checks.
Stated by HM Prison and Probation Service -
Action
Train staff through the local programme on when entering a cell during patrol state is appropriate and necessary.
Stated by HM Prison and Probation Service -
Action
Issue guidance on emergency response procedures to staff every six months.
Stated by HM Prison and Probation Service
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Concerns raised1
Unclear cell-entry criteria for prison officers during life-threatening emergencies
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Implement an annual staff training plan covering emergency codes, medical emergencies and when officers should enter cells, with training repeated at least twice yearly.
Stated by HM Prison and Probation Service
-
Concerns raised1
Delays in obtaining backup for emergencies on SACU during patrol state
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
-
Action
Provide additional SACU staffing resources above national benchmarking requirements.
Stated by HM Prison and Probation Service -
Action
Conduct a SACU pilot evaluating operational processes and health support to inform a safe, integrated workforce model.
Stated by HM Prison and Probation Service -
Action
Review contingency plans to incorporate incident learning and prompt consideration of regime levels and available resources during simultaneous incidents.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Not entering the cell alone followed the correct procedure and was not criticised, despite the delayed arrival of assistance.
Stated by HM Prison and Probation Service
-
Concerns raised1
Lack of anti-barricade doors in some prison wings
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Review the ACCT form and safer custody policy to address emergency access and anti-barricade doors in prisoner-location decisions.
Stated by HM Prison and Probation Service -
Action
Ensure the revised ACCT form and accompanying policy direct staff to consider emergency access, including anti-barricade doors, when locating prisoners on ACCT.
Stated by HM Prison and Probation Service -
Action
Include emergency-access and anti-barricade-door considerations in training for ACCT case managers.
Stated by HM Prison and Probation Service
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Concerns raised1
Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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.2
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Action
Reinforce Local Security Strategy procedures for responding to potentially life-threatening situations in cells.
Stated by HM Prison and Probation Service and Ministry of Justice and Ranby Prison -
Action
Test all staff annually on their knowledge of the Local Security Strategy.
Stated by HM Prison and Probation Service and Ministry of Justice and Ranby Prison
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The remaining seven concerns were matters for HM Prison Service and other parties, so the Trust could not respond to them.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised1
Inflexible cell-entry requirements during urgent safeguarding concerns
This report raised 27 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026