Recurring concern

Inadequate emergency access during barricade incidents

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First reported 21 Jun 2017•Latest report 22 Jan 2025

Definition

What this concern includes

Includes failures of policies, staff training, risk-based arrangements, doors, keys, equipment, maintenance or operational procedures specifically dedicated to preventing or enabling emergency access during barricade incidents in residential, custodial or care settings.

Not included

Excludes generic emergency response deficiencies not specifically linked to barricaded rooms or cells.
Excludes unrelated obstruction of venue entry or general building access.
Excludes generic staffing, documentation, communication or training deficiencies unless they are directly tied to managing barricade incidents.

Reports: 5
Individual concerns: 6
Date range: 2017–2025
Stated actions: 5

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Ministry of Justice3

Central and North West London NHS Foundation Trust1

Department of Health and Social Care1

GeoAmey PECS Limited1

Hampshire and Isle of Wight Constabulary1

HM Prison and Probation Service1

North East London NHS Foundation Trust1

Winchester 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.

22 Jan2025
Manchester South
Concerns raised2
1. Lack of staff training for incidents of residents barricading themselves into rooms
2. Failure to implement a policy for incidents of residents barricading themselves into rooms at Approved Premises
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 1
1. Action
  Complete sign-off, issue barricade guidance to Approved Premises staff, and obtain their acknowledgement of receipt and understanding.
  Stated by Ministry of JusticeStated in progress
AI-generated summary

Nathan Harry SHEPHERD · 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

Nathan Harry Shepherd died in hospital on 16 January 2024 after being found suspended from a ligature in his room at approved premises, following an unsuccessful attempt to gain immediate entry because the room had been barricaded. The inquest concluded that the death was suicide, with medical cause of death recorded as hypoxic brain injury and hanging. Concerns included the lack of policies and training for barricaded-room incidents, movable furniture that enabled barricading, ligature points, inadequate assurance of agency staff first-aid and CPR capability, and ineffective sharing of risk 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 staff training for incidents of residents barricading themselves into rooms
Wider context from the report
“1. The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at Approved Premises. This meant that staff did not have training on how to deal with a situation. The inquest was told that the Probation Service were now developing such a policy but it had not been signed off or rolled out to staff. ”
Source location
Nathan Harry SHEPHERD · Prevention of Future Deaths report
Page 2 · 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
Failure to implement a policy for incidents of residents barricading themselves into rooms at Approved Premises
Wider context from the report
“1. The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at Approved Premises. This meant that staff did not have training on how to deal with a situation. The inquest was told that the Probation Service were now developing such a policy but it had not been signed off or rolled out to staff. ”
Source location
Nathan Harry SHEPHERD · 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
Complete sign-off, issue barricade guidance to Approved Premises staff, and obtain their acknowledgement of receipt and understanding.

Verbatim wording from the response
“The Barricade Guidance referred to in evidence given at the Inquest hearing has now been finalised and is going through the final stages of sign off prior to issue to all approved premises staff on 1st August 2025. This guidance will form part of the Safe Working Practice document and staff will be required to acknowledge receipt and their understanding by the end of September 2025. This will be overseen by all Approved Premises Managers.”

Source location
Response from HMPPS
Page 1 · response
Published 22 January 2025
Open published response
28 Apr2023
East London
Concerns raised1
1. Failure to use the anti-barricade key to access a barricaded room
This report raised 14 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 1
1. Action
  Include anti-barricade-key use in resuscitation drills and audit staff awareness of its function.
  Stated by North East London NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Concerns about care provision and coordination are mainly for the NHS Trust to address.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Winbourne Gregory Charles · 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

Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.

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 the anti-barricade key to access a barricaded room
Wider context from the report
“4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include; a. A ward emergency bell was not sounded, b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles. c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination, d. Duty doctors were not called promptly, e. Oxygen administration was delayed, f. An on-site defibrillator was not used by staff g. Staff could or would not provide a clear and relevant history to paramedics. ”
Source location
Winbourne Gregory Charles · 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 anti-barricade-key use in resuscitation drills and audit staff awareness of its function.

Verbatim wording from the response
“7. All bunches of keys have an anti barricade key on them. Key audits have taken place in 2023”

Source location
NELFT NHS Foundation Trust Action Plan
Page 5 · response
Published 5 May 2023
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
Concerns about care provision and coordination are mainly for the NHS Trust to address.

Verbatim wording from the response
“Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 5 May 2023
Open published response
26 Feb2019
Staffordshire South
Concerns raised1
1. Lack of appropriately located equipment for barricade situations involving non-dual-opening cell doors
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.
AI-generated summary

Christopher Andrew MOSS · 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 Andrew MOSS was a serving prisoner at HMP Featherstone who died on 18 February 2017 from a self-inflicted incision to his left wrist. The principal concern was that appropriate equipment was not initially available to open the cell door during the barricade incident, raising a concern about whether prisons should check that suitable equipment is available for their particular doors.

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 appropriately located equipment for barricade situations involving non-dual-opening cell doors
Wider context from the report
“At the incident when Christopher died initially a hydraulic jack to open the cell door was summoned to the scene when the appropriate equipment was not available (it did in fact arrive very soon afterwards). I am aware that there is a gradual process in the prison estate to move towards cell doors that can be opened outwards if necessary in addition to normally opening inwards. My concern however is that for doors that are not dual opening prisons should have appropriate equipment available to deal with barricade situations. Should there be a check or audit to ensure that the correct equipment for the relevant doors are located appropriately at prisons? ”
Source location
Christopher Andrew MOSS · Prevention of Future Deaths report
Page 1 · concerns
Open source report
13 Sep2017
Liverpool and the Wirral
Concerns raised1
1. 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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. 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 ServiceStated in progress
2. 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 ServiceStated planned
3. Action
  Include emergency-access and anti-barricade-door considerations in training for ACCT case managers.
  Stated by HM Prison and Probation ServiceStated planned
AI-generated summary

Sam MOLYNEUX · 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

Sam Molyneux, a prisoner at HMP Liverpool, was found hanging from a ligature in his cell on 1 April 2016 and was pronounced dead at 22:55. The inquest identified a failure to open an ACCT, concerns about the response to assaults and possible bullying, and a delay in accessing him because the cell door could be barricaded.

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 anti-barricade doors in some prison wings
Wider context from the report
“During the course of the inquest it became apparent that in old prisons not all wings have been adapted to have anti-barricade doors. In this case Mr Molyneux had barricaded his door and this delayed prison staff gaining access to him during a Code Blue Situation. He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death. Local directions in the Prison during the inquest have addressed this situation in HMP Liverpool at Walton. That said HM Prison and Probation service might wish to consider amending “Management of Prisoners at risk of harm to self, to others and from others (Safer Custody)” to include consideration of where reasonably practicable avoiding locating prisoners behind a door which is not designed to circumvent barricading. ”
Source location
Sam MOLYNEUX · 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
Review the ACCT form and safer custody policy to address emergency access and anti-barricade doors in prisoner-location decisions.

Verbatim wording from the response
“Wherever possible, we should avoid using such cells to accommodate prisoners identified as being at risk of self-harm or suicide. As you know, the ACCT process includes consideration by the case review team of the most appropriate location for the prisoner. Both the design of the ACCT form and the content of PSI 64/2011 Safer Custody are currently under review, and we will ensure that the revised version of the form and accompanying policy direct staff to have regard to the issue of emergency access – including the presence of an anti-barricade door – when making decisions about the location of a prisoner on an ACCT. We will also include this in the training that is provided for ACCT case managers.”

Source location
2017-0340-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 13 September 2017
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
Ensure the revised ACCT form and accompanying policy direct staff to consider emergency access, including anti-barricade doors, when locating prisoners on ACCT.

Verbatim wording from the response
“Wherever possible, we should avoid using such cells to accommodate prisoners identified as being at risk of self-harm or suicide. As you know, the ACCT process includes consideration by the case review team of the most appropriate location for the prisoner. Both the design of the ACCT form and the content of PSI 64/2011 Safer Custody are currently under review, and we will ensure that the revised version of the form and accompanying policy direct staff to have regard to the issue of emergency access – including the presence of an anti-barricade door – when making decisions about the location of a prisoner on an ACCT. We will also include this in the training that is provided for ACCT case managers.”

Source location
2017-0340-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 13 September 2017
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
Include emergency-access and anti-barricade-door considerations in training for ACCT case managers.

Verbatim wording from the response
“Wherever possible, we should avoid using such cells to accommodate prisoners identified as being at risk of self-harm or suicide. As you know, the ACCT process includes consideration by the case review team of the most appropriate location for the prisoner. Both the design of the ACCT form and the content of PSI 64/2011 Safer Custody are currently under review, and we will ensure that the revised version of the form and accompanying policy direct staff to have regard to the issue of emergency access – including the presence of an anti-barricade door – when making decisions about the location of a prisoner on an ACCT. We will also include this in the training that is provided for ACCT case managers.”

Source location
2017-0340-Response-by-HM-Prison-Probation-Service
Page 2 · response
Published 13 September 2017
Open published response
21 Jun2017
Central Hampshire
Concerns raised1
1. Failure of regular maintenance checks to identify defective anti-barricade doors
This report raised 12 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.
AI-generated summary

Michael Folley · 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 Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.

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 regular maintenance checks to identify defective anti-barricade doors
Wider context from the report
“I heard evidence that every effort was made to gain quick access into Mr Folley self once it became apparent that he had barricaded the door. This was significantly hindered by painting the screws on the anti-barricade plate but significantly, by the fact that even when the plate was removed the bar would not open outwards towards this landing due to a brick hanging down in the door frame. Whilst it has to be accepted that Winchester prison is not a modern prison nevertheless this should have been picked up during regular maintenance checks. I was shown some records this tended to imply that either checks had not been carried out on a regular basis or the checks themselves were not adequate. Either way this is of concern. ”
Source location
Michael Folley · Prevention of Future Deaths report
Page 7 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of staff training for incidents of residents barricading themselves into rooms

Failure to implement a policy for incidents of residents barricading themselves into rooms at Approved Premises

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

Concerns raised1

Failure to use the anti-barricade key to access a barricaded room

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of appropriately located equipment for barricade situations involving non-dual-opening cell doors

Concerns raised1

Lack of anti-barricade doors in some prison wings

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

Concerns raised1

Failure of regular maintenance checks to identify defective anti-barricade doors

Actions described in response 1

Actions described in response 1

Respondent positions 1

Actions described in response 3