Recurring concern

Failure to provide prisoners with a safe and sufficiently accessible prison regime

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First reported 3 May 2016•Latest report 24 Mar 2026

Definition

What this concern includes

Includes failures in the provision and operation of prison regimes where restrictions, unlocking arrangements, staffing directly tied to regime delivery, regime access, welfare-monitoring opportunities or related operational controls leave prisoners without a safe and sufficiently accessible regime.

Not included

  • Excludes generic prison staffing shortages, training, leadership or supervision deficiencies unless they directly impair safe delivery of the prison regime.
  • Excludes clinical treatment, medication, ACCT, segregation, cell-entry and other separately named prison safety systems unless the assertion specifically identifies their effect on safe prison-regime provision.
  • Excludes ordinary restrictions or routine regime arrangements where no safety consequence or continuing deficiency is identified.
  • Excludes failures in prison security, transfers or release planning where the unsafe condition is not the provision or operation of the prison regime.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2016–2026

First to latest report issue date

Stated actions
3

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 Service5
Ministry of Justice3
NHS England2
Nottinghamshire Healthcare NHS Foundation Trust2
Central and North West London NHS Foundation Trust1
HM Inspectorate of Prisons1
Lowdham Grange Prison1
Nottingham Prison1
Prisons and Probation Ombudsman1
Serco Group plc1
Sodexo1
Woodhill 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.

  1. Milton Keynes

    AI-generated summary

    Ronald William MEIKLE · 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

    Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

    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

    Restricted prison regimes

    Wider context from the report

    “Concern 10: Staffing, supervision and regime limitations The evidence before the court, including wider inspection material, raised concern that staffing pressures, weak supervision, poor staff-prisoner engagement, restricted regimes, and inadequate welfare observations may materially increase the risk of undetected drug use, delayed discovery of collapsed prisoners and failure to identify vulnerable men in need of intervention. ”

    Source location

    Ronald William MEIKLE · Prevention of Future Deaths report
    Page 3 · 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

    Healthcare services alone cannot mitigate all risks within custody.

    Verbatim wording from the response

    “Thank you for bringing your concerns to our attention. While healthcare services alone cannot mitigate all risks within custody, the Trust is committed to learning from Mr Meikle’s death and to strengthening how vulnerability is identified and responded to across Health and Justice services. Should you have any questions or comments, please do not hesitate to contact me.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 3 · response
    Published 26 March 2026

    Open published response
  2. Nottinghamshire

    AI-generated summary

    Anthony Binfield and 2 others · 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

    Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous deaths.

    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

    Inadequate prison and healthcare staffing levels

    Wider context from the report

    “The inadequate prison and healthcare staffing levels led to a restricted regime and healthcare provision. The prison was unable to offer keywork to all men, and the mental health team could no longer offer a named nurse service. Both of these aspects of care are fundamental to supporting the most vulnerable prisoners. ”

    Source location

    Anthony Binfield and 2 others · 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

    Promote prison nursing recruitment through the ‘We Are Prison Nurses’ campaign and its recruitment resources.

    Verbatim wording from the response

    “To help address workforce demands within prisons, nursing within the criminal justice system (CJS) needs to be widely promoted as a career option and NHS England is supporting this promotion with the ‘We Are Prison Nurses’ campaign and nursing preceptorship (a period of structured transition where newly qualified nurses are supported by an experienced practitioner).”

    Source location

    Response from NHS England
    Page 1 · response
    Published 13 February 2025

    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

    Provide recruitment, retention and staffing support to improve workforce levels at Lowdham Grange.

    Verbatim wording from the response

    “Since taking over the management of Lowdham Grange HMPPS has taken a number of steps to improve recruitment and retention, including the provision of additional support to the prison to undertake recruitment activity.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 13 February 2025

    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

    Ringfence key safety tasks and safer-custody staff against future resourcing pressures.

    Verbatim wording from the response

    “We know that you will share a copy of this response with the families, and we would like to again express our sincere condolences for their loss. Following the inquests Sodexo have ringfenced key safety tasks and safer custody staff in the event of changes in resourcing pressures. The implementation of learning from these sad deaths is a priority.”

    Source location

    Response from Sodexo
    Page 3 · response
    Published 13 February 2025

    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

    Healthcare staffing is the responsibility of the healthcare provider, which has responded separately.

    Verbatim wording from the response

    “As heard at the inquest, the transition detailed above significantly impacted on a challenging recruitment picture and the low staffing levels along with a reduction in staff with a significant length of service and experience. As you are aware, healthcare staffing is a matter for the healthcare provider, who have responded separately.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 13 February 2025

    Open published response
  3. West London

    AI-generated summary

    Matthew Paul Braben · 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

    Matthew Paul Braben died by asphyxia at HMP Wormwood Scrubs on 16 August 2021 after being found in his cell with his neck, wrists and ankles tied. The report identified concerns including failures to identify and respond to suicide risk, inadequate communication and record-keeping, failures relating to ACCT processes, and the impact of prisoners being held in their cells for up to 23 hours a day.

    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

    Shortage of gym instructors

    Wider context from the report

    “5. The manner of training of gym instructors which entails potential trainees having to attend training at a distant location for significant period of times rather than locally as well as the length of the course, both of which serve as significant disincentives for staff to be trained as gym instructors. The shortage of gym instructors leads directly to more prisoners being kept in their cells for up to 23 hours a day, with a negative effect on their mental health. ”

    Source location

    Matthew Paul Braben · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Wiltshire and Swindon

    AI-generated summary

    Calam Atour · 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

    Calam Atour died by suicide in his room at Erlestoke House on 13 May 2015, after hanging himself by a ligature from the window. The inquest identified concerns about staffing shortages, medical support and coordination, the ACCT process, and the adequacy of monitoring and responses to suicide risk. The report also raised concerns that staffing levels and the way staffing requirements were assessed could create unsafe conditions for prisoners and prison officers.

    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 operational prison staffing for safe custody and officer safety

    Wider context from the report

    “I. I am concerned that unless the staffing number issue is resolved that when Alfred & Wessex Units reopen next year it will again create a significant staffing issues and a reduction of around 20% in operational personnel. I am concerned that this level of reduction has the potential and propensity to create an unsafe system of work for the prison officers (I heard during the course of the Inquest that 1 officer who was due to attend Court to give evidence sadly was the victim of a serious assault whilst on duty at Erlestoke recently). I am concerned that with a reduction in operational staff members that there is a risk that such assaults will increase. Such assaults can result in serious injury or even worse death. I am also concerned as regards the welfare of the prisoners and as regards the ability of the prison officers as a result of the pressure on their numbers to safeguard the lives of those in prison insofar as reasonable practicable against the risk of prisoners harming themselves or others or even taking their own lives. It was clear that there was a huge amount of reliance of goodwill amongst prison staff but with the continuing pressure on staffing the reality I heard is that the goodwill gets eroded overtime, as the ability to function in the workplace becomes increasingly pressurised and more stressful. The position is not sustainable long term. ”

    Source location

    Calam Atour · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  5. Nottinghamshire

    AI-generated summary

    Shalan Blackwood · 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

    Shalan Blackwood died at HMP Nottingham on 5 August 2015 as a result of bleeding from a duodenal ulcer. The report identified concerns about inadequate care and supervision for prisoners with complex physical or mental health needs, insufficient staffing for prisoners in segregation requiring a four-person unlock, unclear decision-making tools, widespread use of New Psychoactive Substances, and insufficient recognition of urgent physical symptoms obscured by mental health issues.

    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 prison staffing for proper regimes and unlocking of prisoners requiring four person unlocks in the Segregation Unit

    Wider context from the report

    “2. That at present, if a prisoner is assessed as needing a four person unlock, and is within the Segregation Unit, there are insufficient prison staff to provide him with a proper regime and to unlock him after lunchtime, for example to allow ”

    Source location

    Shalan Blackwood · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026