Recurring concern

Inadequate supervision and monitoring of prisoners

First to latest report 30 Oct 2013 — 29 Jun 2026

Reports that mention this concern
34
Times this concern has been raised
49
Stated actions linked to this concern
62

What this concern includes

Includes failures of prison staff supervision, staff-prisoner engagement, welfare checks, observation or equivalent monitoring where these controls are intended to identify or respond to risks to prisoners, including failures arising during or after handover between custodial settings.

What is not included
  • Excludes illicit drug supply reduction and other substance-control strategies unless the assertion specifically concerns supervision or monitoring of prisoners.
  • Excludes generic staffing, accommodation or regime deficiencies that are not directly tied to inadequate prisoner supervision or monitoring.
  • Excludes healthcare assessment, treatment and clinical observation concerns unless the assertion concerns custodial supervision or monitoring rather than clinical care.
  • Excludes failures of information sharing, reception processing or documentation where the primary unsafe condition is information transfer or administrative processing rather than supervision or monitoring.

Reports and published responses 34 reports

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

  1. Lancashire and Blackburn with Darwen

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    Johnpaul Digweed · 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

    Johnpaul Digweed died by suicide by hanging in his cell at HMP Garth between 17:06 on 12 April 2024 and 11:31 on 13 April 2024. The concerns included failures to open an ACCT process after incidents of self-harm, inadequate assurance about staff training and information-sharing, and welfare observations not being carried out in accordance with prison procedures, including when observation panels were obscured.

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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

    Welfare-check instructions failing to require visual checks of prisoners

    Wider context from the report

    “2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not aware of the instructions which were issued by email. As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff. In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths ”

    Source location

    Johnpaul Digweed · Prevention of Future Deaths report
    Page 2 · concerns

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    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure removal of coverings from cell-door observation panels

    Wider context from the report

    “2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not aware of the instructions which were issued by email. As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff. In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths ”

    Source location

    Johnpaul Digweed · Prevention of Future Deaths report
    Page 3 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce daily mandatory knowledge-check sessions for operational and non-operational staff, recording attendance, completion and understanding to reinforce ACCT and welfare-check practice.

    Verbatim wording from the response

    “The prison have begun introducing daily knowledge check sessions for both operational and non-operational staff, and additional staffing resources are being secured to support the delivery of this initiative. Attendance and completion of the knowledge check sessions will be required and formally recorded, with staff providing written confirmation they have attended a session, and that the content is understood. A training log will be maintained by the prison’s Learning and Capabilities Team to monitor attendance and completion rates.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 3 September 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Reissue the Governor’s Order reminding staff of mandatory instructions for prisoner wellbeing and responding to blocked observation panels.

    Verbatim wording from the response

    “Furthermore, to reinforce local guidance a Governor’s Order has been reissued reminding staff of the mandatory instructions in place in line with PSI 75/2011, and the requirement to ensure the wellbeing of prisoners and action to be taken should a blocked observation panel be discovered.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 3 September 2026

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  2. Cumbria

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    Nigel John KEENAN · 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

    Nigel John Keenan died by hanging at HMP Haverigg between 8 pm on 12 March 2025 and 4:20 am on 13 March 2025; the inquest concluded suicide. Concerns included the lack of seven-day mental health support at the prison, limited staffing for constant observation, and a possible incentive for prisoners in crisis to minimise their suicidal intent.

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    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient staffing capacity for constant observation of prisoners in crisis

    Wider context from the report

    “In the course of hearing evidence in this inquest I was told that: 1) Mental health provision is only commissioned within HMP Haverigg during the week and is not available at the weekends. I was told that in the event that a prisoner experienced a crisis during the weekend they would be cared for by prison staff using the ACCT procedure, but that mental health input would not be available until Monday morning. 2) Because HMP Haverigg is a Category D 'open' prison it has far fewer staff available to monitor prisoners. As such it is not able to place prisoners on 'constant watch'. As a result if a prisoner requires very regular or constant observation (as a result of being in crisis) they would have to be transferred to a closed prison. 3) This means that prisoners who are in crisis have something of an incentive to deny their intent to self harm because to admit it would result in their being transferred to a closed prison. I am concerned that the decision not to commission 7 day a week mental health support at HMP Haverigg is therefore counterproductive. Because of the limited number of prison officers at the establishment it gives rise to a higher risk than would be the case at a closed prison. In particular, it risks providing an incentive for prisoners in crisis to play down the true extent of their situation. ”

    Source location

    Nigel John KEENAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Milton Keynes

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    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.

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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

    Weak supervision and staff-prisoner engagement

    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

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    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Inadequate welfare observations

    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

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Escalate concerns about vulnerable patients and recommend enhanced observation where necessary.

    Verbatim wording from the response

    “Concern 4: Blocked observation panels and inadequate visual welfare checks We are supporting prison colleagues by escalating concerns about vulnerable patients including making recommendations for enhanced observation where necessary.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 2 · response
    Published 26 March 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Subject people experiencing prolonged isolation to structured review, including mental-health assessment and ongoing welfare monitoring where required.

    Verbatim wording from the response

    “Concern 5: Management of self-isolation, debt, fear and vulnerability We are working with staff to ensure that individuals identified as experiencing prolonged isolation are subject to structured review processes, including mental health assessment and ongoing welfare monitoring, where required. Concerns relating to isolation, debt and vulnerability are raised by staff within regular multidisciplinary forums and more complex cases are reviewed regularly.”

    Source location

    Response from Central & North West London NHS Foundation Trust
    Page 2 · response
    Published 26 March 2026

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    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

  4. Kent and Medway

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    Thomas Daniel RUGGIERO · 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

    Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing himself and died later that day. The report identifies concerns about the emergency cell bell system, incomplete ACCT documentation, confusion over calling a “code blue”, and staffing, experience and communication at the prison, with risks to future prisoners remaining.

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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

    Failure of landing officers to intervene in poor behaviour at prisoners' cell doors

    Wider context from the report

    “(4) Staffing / Experience / Communication etc. The evidence was that in November 2024, up to (and possibly more than) 90% of prison officers at HMP Swaleside were new in post and still in their probationary period. I was told in evidence by a Supervising Officer (SO) that on 16 November 2024, he 'possibly did not have the right mix of staff in terms of skills and experience to keep the wing safe'. In this inquest, the jury found that, "the communication between prison staff was insufficient and lacked clarity. Opportunities to increase formal observations or notify health care were missed. Staff communications failed to relay the severity and complete scope of the situation." The CCTV evidence clearly showed other prisoners regularly at Mr Ruggiero's cell door, silencing the call bell, banging and kicking at the door (including the wielding of a crutch to hit the door and observation panel), and verbally harassing Mr Ruggiero. The evidence from an SO was that he gave landing officers a clear instruction to intervene; however, it appeared that this did not happen. I was told that the level of officers still in their probationary period has now reduced. I was also told that additional staff training is now in place to address matters such as assertiveness, and that there is also an action plan (albeit I was not shown this). I was also made aware of the "Urgent Notification' (UN) from HM Chief Inspector of Prisons in relation to HMP Swaleside (December 2025), which included in the rationale, "Staff, many of whom lacked experience, were not confident in challenging poor behaviour and there was a lack of order and control." While some action has been taken, I am not sufficiently reassured that this has addressed the concern and I therefore consider that the risks remain. ”

    Source location

    Thomas Daniel RUGGIERO · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Bedfordshire and Luton

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    Edward James HANDS · 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

    Edward James Hands, known as Eddie, died in his cell at HMP Bedford on 16 February 2024 after consuming methadone and developing aspiration pneumonitis. The inquest identified failures in follow-up care, monitoring, escalation, and the implementation of the Under the Influence protocol, with confusion between prison and healthcare staff about their responsibilities.

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    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to observe and monitor prisoners suspected to be under the influence of illicit substances

    Wider context from the report

    “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”

    Source location

    Edward James HANDS · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a single agreed UTI protocol standardising responsibilities, observations, escalation routes and handover expectations.

    Verbatim wording from the response

    “Following the conclusion of the inquest HMP Bedford and NHFT carried out a joint review of the UTI policies and protocols in place. This review resulted in the removal of any previous conflicting guidance and implementation of a single UTI protocol with standardisation of responsibilities, including observation requirements, escalation routes, and handover expectations. This protocol has been agreed by both parties and is to be followed by both operational and healthcare staff at HMP Bedford.”

    Source location

    Response from HM Prison & Probation Service
    Page 1 · response
    Published 23 February 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide staff guidance on recognising UTI signs, initiating the protocol, completing observations and undertaking follow-up checks.

    Verbatim wording from the response

    “• Staff have been given guidance on recognising signs of being UTI, initiating the protocol, completing observations, and ensuring follow up checks are undertaken.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 23 February 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Appoint a substance misuse lead to conduct daily assurance and visit suspected UTI cases to support consistent protocol adherence.

    Verbatim wording from the response

    “• A newly appointed substance misuse lead carries out daily assurance and visits all suspected UTI cases, ensuring consistency between operational and healthcare colleagues and consistent adherence to the UTI protocol.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 23 February 2026

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Assure documentation and observations, record improvement needs, and escalate issues concerning timescales or procedures to senior leaders.

    Verbatim wording from the response

    “• Assurance of documentation and observations is completed to ensure compliance of timescales and escalation procedures. Where this identifies areas requiring improvement a record is made and the issue escalated to both prison and healthcare senior leaders to be addressed as appropriate.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 23 February 2026

    Open published response

  6. Bedfordshire and Luton

    AI-generated summary

    Steven HART · 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

    Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.

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    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to carry out required observations at the appropriate level and standard

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”

    Source location

    Steven HART · Prevention of Future Deaths report
    Page 3 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce quality assurance for ACCT observations through regular CCTV sampling and review, escalation and investigation of discrepancies.

    Verbatim wording from the response

    “In addition, a robust quality assurance process has been introduced for ACCT observations. This includes regular sampling and review of CCTV footage to confirm that ACCT observations are being completed and recorded in accordance with local policy. Where discrepancies are identified, they are escalated and investigated in line with the national protocol, with referrals to the police where appropriate.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 3 October 2025

    Open published response

  7. Suffolk

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    Martin COLLINS · 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

    Martin Collins, a 66-year-old male serving a prison sentence, died by suicide after being found suspended in his cell at HMP Highpoint on 25 November 2023. The report raises concerns that the prison telephone system could not automatically identify unusually high call volumes and alert staff or healthcare, potentially missing opportunities to identify risk triggers and intervene.

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    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to monitor prisoners' telephone-call volumes for high or unusual patterns

    Wider context from the report

    “The available telephone system for prisoners does not presently have the capability, in an automated manner, to recognise high or unusual volumes of calls by prisoners - and then to notify prison staff or healthcare in the event of such a pattern. This is despite the fact that the data on telephone calls made by a particular prisoner is available and is readily capable of being obtained, such that patterns of calls could be monitored manually by staff. The lack of system for monitoring of volumes of prisoners' telephone calls may lead to missed opportunities to identify risk triggers and so missed opportunities to intervene and prevent suicide. ”

    Source location

    Martin COLLINS · Prevention of Future Deaths report
    Page 3 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Assess technically feasible options for adding call-volume monitoring within the ongoing telephony development project.

    Verbatim wording from the response

    “I can confirm that initial discussions have taken place between HMPPS and BT, our telephony contractor, to explore whether technically feasible options available are viable given the additional considerations of introducing additional monitoring layers. This work will be included as part of an ongoing development project.”

    Source location

    Response from HM Prison & Probation Service
    Page 1 · response
    Published 9 October 2025

    Open published response

  8. Birmingham and Solihull

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    Gavin James WHEALE · 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

    Gavin James Wheale was found unresponsive in a care and separation unit cell at HMP Birmingham on 8 August 2024 and was pronounced dead shortly afterwards. The medical cause of death was mixed drug interactions involving morphine, cocaine and diazepam. Concerns included unclear guidance for staff where a previously concealed item was allegedly ingested, and reduced monitoring after handover from transport and police custody to the prison.

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    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 equivalent monitoring for prisoners after handover from constant supervision

    Wider context from the report

    “2. Evidence was heard from WMP and GEOAmey staff dealing with their required procedures where a person in their custody, in this instance Mr Wheale, was known or suspected of concealing items; both organisations required constant supervision and handcuffing. My concern is that upon handover to HMP Birmingham prisoners who have previously been under constant supervision, with their movement restricted, enter a regime with no equivalent levels of monitoring rendering HMP Birmingham unable to fully discharge their duty of care to that prisoner. ”

    Source location

    Gavin James WHEALE · Prevention of Future Deaths report
    Page 2 · concerns

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    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Issue staff guidance requiring fully documented risk assessments and recorded risk-management actions for prisoners entering HMP Birmingham under constant supervision.

    Verbatim wording from the response

    “You also raise a concern regarding the management of prisoners who enter the prison on high levels of monitoring. In response to this, HMP Birmingham will be issuing guidance to staff to ensure that a fully documented risk assessment is completed for any prisoner entering the establishment under constant supervision, whether due to secreted items or other reasons - to ensure that the individual is managed effectively and safely, clearly documenting the actions to be taken to manage any associated risks.”

    Source location

    Response from HM Prison and Probabtion Service
    Page 1 · response
    Published 16 July 2025

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  9. Nottinghamshire

    AI-generated summary

    Anthony Binfield · 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 died from ligature asphyxiation inside his cell at HMP Lowdham Grange on 6 March 2023. Prison staff delayed entering the cell for 11 minutes after finding the observation panel covered and receiving no response. The principal concerns were unsafe and policy-inconsistent management of covered cell observation panels, an embedded staff practice of delaying entry, and repeated notices failing to address the issue.

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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

    Failure to keep cell observation panels clear and challenge prisoners who cover them

    Wider context from the report

    “(1) Prison staff failing to manage the covering of cell observation panels in a safe way that is compliant with the policy and guidance issued by the prison over many years. I am taking the exceptional step of writing to you formally before the conclusion of the inquest as I am so concerned by the evidence called to date regarding the custom and practice of officers when discovering obscured cell observation panels at night. There is a dangerous culture of staff assuming the prisoner has obscured the observation panel for privacy purposes or as a form of protest against the regime. This neglects the obvious and very real risk that the prisoner is seeking to harm themselves, without detection. The HMPPS Safety Notice, issued in February 2018, made clear that cell observation panels are a vital tool in keeping prisoners safe and must be kept clear at all times in order to preserve life. The custom and practice of seeking to visualise the prisoner via the inundation unit hole (and other means, such as the side of the door) has developed over time and is now an embedded culture accepted by many officers as a response to this occurrence. This practice leads to delay in entering the cell, risks lives and is contrary to policy. This is not a new issue for the prison and hence my concern that the prison has failed to tackle this issue over many years. In August 2020, a prisoner died at HMP Lowdham Grange as a result of drug use. When officers conducted a welfare check they found his cell observation panel to be obscured. Contrary to policy and guidance, Prison staff delayed entering the cell while they fetched the inundation unit key to attempt to observe inside the cell. The Prison and Probation Ombudsman made a recommendation to the Prison Director that they should ensure that observation panels are kept clear, and that staff actively challenge prisoners who cover them. In response, the Prison Director issued a notice to staff in January 2021 reminding staff of the need to treat any prisoner as unresponsive if they fail to acknowledge the officer, and to call a code blue. A similar notice was issued in April 2021, reminding staff of the need to perform a dynamic risk assessment and enter the cell in a quick and safe manner when there is no response to asking the prisoner to remove the offending item. The notice was re-issued in November 2021, and after the inquest in approximately April 2023. Despite these multiple notices, a number of witnesses who remain members of staff at the prison (now under HMPPS employ) reported being unaware of the expected procedure when faced with an obscured cell observation panel until attending Anthony’s inquest in December 2024. It is clear that the issuing of staff notices has not addressed the problem of prisoner's covering their cell hatches, nor the unsafe custom and practice of staff leaving the cell and thereby delaying safe entry. ”

    Source location

    Anthony Binfield · Prevention of Future Deaths report
    Page 2 · concerns

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    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in entering cells when observation panels are obscured and the prisoner does not respond

    Wider context from the report

    “(1) Prison staff failing to manage the covering of cell observation panels in a safe way that is compliant with the policy and guidance issued by the prison over many years. I am taking the exceptional step of writing to you formally before the conclusion of the inquest as I am so concerned by the evidence called to date regarding the custom and practice of officers when discovering obscured cell observation panels at night. There is a dangerous culture of staff assuming the prisoner has obscured the observation panel for privacy purposes or as a form of protest against the regime. This neglects the obvious and very real risk that the prisoner is seeking to harm themselves, without detection. The HMPPS Safety Notice, issued in February 2018, made clear that cell observation panels are a vital tool in keeping prisoners safe and must be kept clear at all times in order to preserve life. The custom and practice of seeking to visualise the prisoner via the inundation unit hole (and other means, such as the side of the door) has developed over time and is now an embedded culture accepted by many officers as a response to this occurrence. This practice leads to delay in entering the cell, risks lives and is contrary to policy. This is not a new issue for the prison and hence my concern that the prison has failed to tackle this issue over many years. In August 2020, a prisoner died at HMP Lowdham Grange as a result of drug use. When officers conducted a welfare check they found his cell observation panel to be obscured. Contrary to policy and guidance, Prison staff delayed entering the cell while they fetched the inundation unit key to attempt to observe inside the cell. The Prison and Probation Ombudsman made a recommendation to the Prison Director that they should ensure that observation panels are kept clear, and that staff actively challenge prisoners who cover them. In response, the Prison Director issued a notice to staff in January 2021 reminding staff of the need to treat any prisoner as unresponsive if they fail to acknowledge the officer, and to call a code blue. A similar notice was issued in April 2021, reminding staff of the need to perform a dynamic risk assessment and enter the cell in a quick and safe manner when there is no response to asking the prisoner to remove the offending item. The notice was re-issued in November 2021, and after the inquest in approximately April 2023. Despite these multiple notices, a number of witnesses who remain members of staff at the prison (now under HMPPS employ) reported being unaware of the expected procedure when faced with an obscured cell observation panel until attending Anthony’s inquest in December 2024. It is clear that the issuing of staff notices has not addressed the problem of prisoner's covering their cell hatches, nor the unsafe custom and practice of staff leaving the cell and thereby delaying safe entry. ”

    Source location

    Anthony Binfield · 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 blocked observation panels in the Incentives Policy Framework, with warnings, loss of privileges and formal sanctions for continued obstruction.

    Verbatim wording from the response

    “I have received assurances from the Governing Governor of HMP Lowdham Grange that since the prison formally became a public sector prison in August 2024, action has been taken to increase staff confidence, skills and understanding of relevant policies and procedures. The prison recognises the inherent risks of blocked observation panels and has taken a number of proactive steps to ensure that staff and prisoners understand the importance of the panels remaining uncovered at all times. There is now a specific”

    Source location

    Response from HMPPS
    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

    Communicate required staff actions for blocked observation panels through briefings, notices, governor orders and induction training for new staff and OSGs.

    Verbatim wording from the response

    “It is crucial that staff carry out regular safety checks on prisoners when they are locked in their cells. Every time staff approach a prisoner’s cell they must ensure that the observation panel is clear of obstruction in case of an emergency situation. The obscuring of observation panels is a constant challenge across the prison estate as prisoners continue to cover and block observation panels for a variety of reasons, including for privacy and decency. However, HMPPS has a clear stance on the issue and all prisons must set out to staff what action should be taken if an observation panel is found to be covered or blocked.”

    Source location

    Response from HMPPS
    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

    Communicate the importance and consequences of keeping observation panels clear to prisoners through video messages.

    Verbatim wording from the response

    “It is vital that prisoners also recognise the importance of observation panels remaining clear and the consequences they could face if they choose to block them. This message has been conveyed to the prisoner population through video messages over the last 12 months, with the most recent video message published in January 2025.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 13 February 2025

    Open published response

  10. Avon

    AI-generated summary

    Kayleigh Ann MELHUISH · 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

    Kayleigh Ann Melhuish died on 7 July 2022 after being found hanging in her cell at HMP Eastwood Park and later taken to hospital. The report identifies concerns about staff understanding of neurodiversity, completion of ACCT care plans and support actions, use of constant supervision, and a ligature point in Residential Unit 3. The inquest concluded that suspension by a ligature contributed to the death 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

    Lack of understanding of when and how constant supervision can be used

    Wider context from the report

    “1. To HMP Eastwood Park and The Ministry of Justice - training issues in relation to the following areas for new and existing staff: a. Neurodiversity, I am told 75% of women in prison have mental health or neurodiverse issues, this training is not mandatory; b. ACCT, there was little understanding of the requirement to complete or review the care plan and support actions at every ACCT review not just the planned reviews; c. Little or no understanding of when constant supervision can be used and how is it used; ”

    Source location

    Kayleigh Ann MELHUISH · 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 Eastwood Park procedures for constant supervision and communicate resulting changes through staff briefings.

    Verbatim wording from the response

    “In the light of your comments the local procedures in relation to constant supervision at Eastwood Park will be reviewed. The Governor expects to complete this work within a month and any changes will be communicated through staff briefings. Additionally at a national level”

    Source location

    Response from HMPPS/MoJ and HMP Eastwood Park
    Page 2 · response
    Published 9 December 2024

    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

    Develop national guidance for prisons on constant supervision.

    Verbatim wording from the response

    “the Safety Group is currently undertaking work to develop further guidance for prisons on constant supervision, which is planned for completion by the end of March 2026.”

    Source location

    Response from HMPPS/MoJ and HMP Eastwood Park
    Page 3 · response
    Published 9 December 2024

    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