First reported 30 Oct 2013•Latest report 18 Jul 2025
Definition
What this concern includes
Includes failures in prison roll-check processes, including alignment of local policy with officer training, clear procedural requirements, officer understanding, correct performance of roll counts, and dedicated assurance that required roll-check steps are completed.
Not included
Excludes general prison observation, welfare-check, staffing or training deficiencies unless they directly concern the prison roll-check process.
Excludes ACCT observations, medical assessments and other prisoner-monitoring processes that are not roll checks or roll counts.
Excludes failures to record compliance with roll checks where no broader roll-check process failure is supported.
Excludes generic policy or training inconsistencies unrelated to prison roll checks.
Reports
7
Distinct published reports
Individual concerns
8
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
14
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 Service4
Belmarsh Prison1
Department of Health and Social Care1
Government Legal Department1
HM Prison Service1
Ministry of Justice1
National Offender Management Service Equality, Rights and Decency Group1
Northumberland Prison1
Oxleas NHS Foundation Trust1
Swaleside Prison1
Executive agency4
Prison or young offender institution3
Sub-organisation2
Ministerial department1
NHS trust1
Non-ministerial department1
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.
Inner West London
Concerns raised1
Ongoing challenges in prison officer checks of roll calls and ACCT observations
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 concerns
Each 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
Action
Brief prison staff on roll-check responsibilities, including timely completion and obtaining a wellbeing response from each prisoner.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Action
Implement monthly assurance checks comparing documented ACCT observations with CCTV footage and take action on non-compliance.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
HM Prison and Probation Service or the Ministry of Justice is responsible for addressing concerns about prison staff knowledge, checks and suicide prevention observations.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East Sussex
Concerns raised2
Confusion about when full prisoner roll checks are required
Failure by staff to understand the importance of completing every required roll check
This report raised 3 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Action
Review the roll-check process against new staffing profiles and regime planning.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Issue a staff notice communicating learning from the inquest about roll checks after the review is complete.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Review and clarify the roll-check local operating procedure, including required times and recording arrangements.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Publish staff notices reinforcing the importance of completing roll checks and prompting key safety observations.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Continue taking appropriate action, including disciplinary action where necessary, when staff fail to meet roll-check expectations.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Deliver further bite-size roll-check training sessions, prioritising staff who previously lacked the training.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Provide on-the-job roll-check support and training through standards coaching team staff shadowing officers at HMP Lewes.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing roll-check assurance measures and staff accountability are considered sufficient; staff must be trusted to perform required duties.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Mid Kent and Medway
Concerns raised1
Failure to align local roll-check policy with entry-level officer training
This report raised 3 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.
Inner South London
Concerns raised1
Lack of robust management audit of nightly roll checks
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Require a discipline officer to remain on the wing until each night OSG roll check is completed, recorded, signed and reported, with spot checks of compliance.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 15 February 2021.
Action
Review the quality-assurance processes for roll checks with the LTHSE safety team.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2021.
Action
Visit Belmarsh to identify further roll-check improvements and test compliance with the new process and Local Security Strategy.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 15 February 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Routine CCTV monitoring cannot be used to assure roll checks because CCTV is authorised only for specified safety, security or investigative circumstances.
Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
North Northumberland
Concerns raised1
Failure to obtain a response from each prisoner during cell unlocking and roll checks
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 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.
West Yorkshire (East)
Concerns raised1
Failure of Prison Officers to follow the correct procedure for roll counts of trainees
This report raised 3 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Brief all staff on the importance of conducting roll checks.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 February 2014.
Action
Conduct covert managerial checks of roll checks.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 February 2014.
Liverpool
Concerns raised1
Failure to visit the prisoner’s cell during a roll check
This report raised 3 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.
Pin
Get email alerts
Request correction
Includes failures in prison roll-check processes, including alignment of local policy with officer training, clear procedural requirements, officer understanding, correct performance of roll counts, and dedicated assurance that required roll-check steps are completed.
