Concerns raised 1
Failure to maintain unobscured cell observation panels for routine visual welfare checks View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Stephen Anthony SLEAFORD · 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
Stephen Anthony Sleaford, a prisoner at Gartree Prison, was found with a ligature around his neck in his cell on 27 October 2022 and was pronounced dead at 08:01. The concerns included inadequate first-aid and CPR training for prison officers, gaps in the earliest emergency response, obscured cell observation panels, and unclear guidance about entering cells during emergencies.
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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 maintain unobscured cell observation panels for routine visual welfare checks
Wider context from the report “4) The evidence revealed that despite clear instruction to officers, by way of Notices to Staff from senior management at the prison, to the effect that obscuring cell door observation panels on the inside by prisoners was not permitted practice and was to be challenged and remedied, routine practice by prison officers meant observation panels were permitted to be obscured, without challenge or sanction . This means that a situation prevailed whereby prison officers were unable to routinely see into all cells to check prisoner welfare , but were/are reliant on, and accepted, a verbal response only , which is and remains a significant concern.
” Source location Stephen Anthony SLEAFORD · Prevention of Future Deaths report
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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 Re-issue the notice requiring staff to challenge prisoners blocking observation panels and follow the escalation process.
Verbatim wording from the response “In respect of prisoners blocking observations panels, a notice was re-issued to all staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels and setting out the process for doing so, which includes an escalation process where a prisoner continues to block their observation panel. All operational staff are now required to read and acknowledge their understanding of this process and this is retained by the respective line managers. Operational staff are also asked about their understanding of and knowledge of the correct procedure during their regular performance conversation with their line manager, as a performance expectation.” Source location Response from HMPPS
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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 Require operational staff to read and acknowledge the observation-panel procedure, with managers retaining records of understanding.
Verbatim wording from the response “In respect of prisoners blocking observations panels, a notice was re-issued to all staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels and setting out the process for doing so, which includes an escalation process where a prisoner continues to block their observation panel. All operational staff are now required to read and acknowledge their understanding of this process and this is retained by the respective line managers. Operational staff are also asked about their understanding of and knowledge of the correct procedure during their regular performance conversation with their line manager, as a performance expectation.” Source location Response from HMPPS
Open published response
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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 Check operational staff understanding of the observation-panel procedure during regular performance conversations as a performance expectation.
Verbatim wording from the response “In respect of prisoners blocking observations panels, a notice was re-issued to all staff in October 2024 reminding them of the importance of challenging prisoners who block their observation panels and setting out the process for doing so, which includes an escalation process where a prisoner continues to block their observation panel. All operational staff are now required to read and acknowledge their understanding of this process and this is retained by the respective line managers. Operational staff are also asked about their understanding of and knowledge of the correct procedure during their regular performance conversation with their line manager, as a performance expectation.” Source location Response from HMPPS
Open published response
1 Oct 2024 Brandon Valrick JOHNSON · Prevention of Future Deaths report Inner West London
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Concerns raised 3
Failure to perform robust, timely checks that elicit reliable positive responses or obvious signs of life View source Failure to record and verify positive responses from prisoner life checks View source Failure to ensure staff know how and when to perform prisoner life checks and identify signs of life View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Brandon Valrick JOHNSON · 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
Brandon Valrick JOHNSON died of cardio-respiratory failure at his cell in HMP Wandsworth on 12 September 2019, aged 40. He was not discovered deceased until late afternoon despite several attendances at his cell. The report raised concerns about the robustness, timing, recording, oversight and staff training relating to checks intended to establish that prisoners were alive.
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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 perform robust, timely checks that elicit reliable positive responses or obvious signs of life
Wider context from the report “I am concerned about the robustness of the procedures and processes for checking that prisoners are alive within their cells . My concern arises because I heard evidence that Brandon was not discovered as deceased until the late afternoon of 12ᵗʰ September 2019 despite a number of attendances at his cell by prison officers and other staff. Rigor mortis and pooling of the blood had been identified. I was told various checks had been undertaken since 0430. I was not confident, having heard and assessed the evidence as a whole that staff had sufficient time to properly check on inmates and obtain positive responses or note obvious signs of life . The checks that were made were for a matter of seconds , and I was not satisfied that the signs of life said to have been noted were sufficiently obvious or reliable to have given appropriate reassurance , or that signs of life were actually being looked for rather than as being incidental to other observations .
I am concerned whether all appropriate measures are being taken to perform robust checks at appropriate times that elicit positive responses to indicate that a prisoner remains alive . In addition, I am concerned about how the prison satisfies itself that staff know how and when to perform these checks, what that consists of, and in relation to signs of life/positive response what those are meant to be and where that is set out in the training of staff.
Further if checks are performed which elicit a positive life response how are those recorded, who checks this is being done, in what form and how often.
” Source location Brandon Valrick JOHNSON · Prevention of Future Deaths report
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 record and verify positive responses from prisoner life checks
Wider context from the report “I am concerned about the robustness of the procedures and processes for checking that prisoners are alive within their cells. My concern arises because I heard evidence that Brandon was not discovered as deceased until the late afternoon of 12ᵗʰ September 2019 despite a number of attendances at his cell by prison officers and other staff. Rigor mortis and pooling of the blood had been identified. I was told various checks had been undertaken since 0430. I was not confident, having heard and assessed the evidence as a whole that staff had sufficient time to properly check on inmates and obtain positive responses or note obvious signs of life. The checks that were made were for a matter of seconds, and I was not satisfied that the signs of life said to have been noted were sufficiently obvious or reliable to have given appropriate reassurance, or that signs of life were actually being looked for rather than as being incidental to other observations.
I am concerned whether all appropriate measures are being taken to perform robust checks at appropriate times that elicit positive responses to indicate that a prisoner remains alive. In addition, I am concerned about how the prison satisfies itself that staff know how and when to perform these checks, what that consists of, and in relation to signs of life/positive response what those are meant to be and where that is set out in the training of staff.
Further if checks are performed which elicit a positive life response how are those recorded , who checks this is being done, in what form and how often .
” Source location Brandon Valrick JOHNSON · Prevention of Future Deaths report
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 ensure staff know how and when to perform prisoner life checks and identify signs of life
Wider context from the report “I am concerned about the robustness of the procedures and processes for checking that prisoners are alive within their cells. My concern arises because I heard evidence that Brandon was not discovered as deceased until the late afternoon of 12ᵗʰ September 2019 despite a number of attendances at his cell by prison officers and other staff. Rigor mortis and pooling of the blood had been identified. I was told various checks had been undertaken since 0430. I was not confident, having heard and assessed the evidence as a whole that staff had sufficient time to properly check on inmates and obtain positive responses or note obvious signs of life. The checks that were made were for a matter of seconds, and I was not satisfied that the signs of life said to have been noted were sufficiently obvious or reliable to have given appropriate reassurance, or that signs of life were actually being looked for rather than as being incidental to other observations.
I am concerned whether all appropriate measures are being taken to perform robust checks at appropriate times that elicit positive responses to indicate that a prisoner remains alive. In addition, I am concerned about how the prison satisfies itself that staff know how and when to perform these checks, what that consists of , and in relation to signs of life/positive response what those are meant to be and where that is set out in the training of staff .
Further if checks are performed which elicit a positive life response how are those recorded, who checks this is being done, in what form and how often.
” Source location Brandon Valrick JOHNSON · Prevention of Future Deaths report
Open source report
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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 Local Security Strategy and consult the roll-check policy to maintain focus on correct roll-check completion.
Verbatim wording from the response “HMP Wandsworth’s Local Security Strategy (LSS) provides clear guidance to staff about the manner and processes of roll check completion. The prison is presently reviewing the LSS and will consult the roll check policy as part of this review to ensure that there is continued focus on the importance of staff completing roll checks correctly.” Source location Response from HMPPS
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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 notices, communications and reminders emphasizing clear sight of prisoners and signs of life during roll checks.
Verbatim wording from the response “This prison issued a notice to all staff in March 2021 to remind them of the importance of having clear sight of a prisoner and obtaining signs of life during a roll check. Further communication and reminders have been published since. In 2024 the prison introduced a quality assurance process for roll checks where managers were present during their completion to ensure they were being done effectively. In addition, further support for staff with understanding the importance of roll checks and assisting staff in their effective completion was provided by the Standards Coaching Team, who were deployed to HMP Wandsworth over the summer of 2024.” Source location Response from HMPPS
Open published response
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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 Introduce manager-led quality assurance of roll checks to verify their effective completion.
Verbatim wording from the response “This prison issued a notice to all staff in March 2021 to remind them of the importance of having clear sight of a prisoner and obtaining signs of life during a roll check. Further communication and reminders have been published since. In 2024 the prison introduced a quality assurance process for roll checks where managers were present during their completion to ensure they were being done effectively. In addition, further support for staff with understanding the importance of roll checks and assisting staff in their effective completion was provided by the Standards Coaching Team, who were deployed to HMP Wandsworth over the summer of 2024.” Source location Response from HMPPS
Open published response
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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 Deploy the Standards Coaching Team to support staff understanding and effective completion of roll checks.
Verbatim wording from the response “This prison issued a notice to all staff in March 2021 to remind them of the importance of having clear sight of a prisoner and obtaining signs of life during a roll check. Further communication and reminders have been published since. In 2024 the prison introduced a quality assurance process for roll checks where managers were present during their completion to ensure they were being done effectively. In addition, further support for staff with understanding the importance of roll checks and assisting staff in their effective completion was provided by the Standards Coaching Team, who were deployed to HMP Wandsworth over the summer of 2024.” Source location Response from HMPPS
Open published response
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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 Discuss roll-check completion in daily staff briefings, including challenging obstructed observation panels and requesting support when responses are insufficient.
Verbatim wording from the response “The completion of roll checks is discussed with staff in daily briefings at HMP Wandsworth. Staff are reminded to challenge prisoners who obscure their observation panels and prevent roll checks being completed effectively. They are also briefed on the process for calling for staff support if they are struggling to obtain a sufficient response during a roll check on a prisoner.” Source location Response from HMPPS
Open published response
8 Aug 2024 Sean Martin DAVIES · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 1
Failure to conduct prisoner welfare checks in line with national guidance and local policies View source
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.
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AI-generated summary
Sean Martin DAVIES · 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
Sean Martin Davies, who was serving an indeterminate sentence for public protection at HMP Swaleside, died by suspension in his cell on 25 February 2023. He had expressed hopelessness and left a note linking his death to the IPP sentence. Concerns included risk assessment and management for prisoners subject to IPP sentences, welfare checks not being conducted in line with guidance or policy, and shortcomings in staff training and handovers.
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 conduct prisoner welfare checks in line with national guidance and local policies
Wider context from the report “(2) It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies
” Source location Sean Martin DAVIES · Prevention of Future Deaths report
Open source report
30 Apr 2024 Marlin Burrows · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 1
Lack of clarity about the welfare sheet’s purpose for monitoring prisoners whose health is of concern View source
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.
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AI-generated summary
Marlin Burrows · 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
Marlin Burrows was found collapsed in his cell at HMP Garth on 15 August 2022 and died in the early hours of 16 August 2022 after being semi-conscious for nearly 15 hours. The inquest concluded that he died from multi-organ failure due to serotonin syndrome and drug toxicity, including amitriptyline toxicity. Concerns included unclear welfare-sheet purposes and guidance, poor communication of entries to medical staff, and insufficient joint consideration of the sheet by prison and healthcare services.
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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 Lack of clarity about the welfare sheet’s purpose for monitoring prisoners whose health is of concern
Wider context from the report “(1) The existing welfare sheet lacks clarity as to its exact purpose in terms of monitoring a prisoner whose health is of concern .
” Source location Marlin Burrows · Prevention of Future Deaths report
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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 Work with HMP Garth healthcare staff to develop training and awareness sessions for prison staff on welfare checklist use and guidance.
Verbatim wording from the response “In addition, the Head of Nursing and Quality for the Health & Justice Division at GMMH will work with the Healthcare staff at HMP Garth to develop some training and awareness sessions for prison staff around the use of the welfare checklist and the associated guidance once the national policy is implemented.” Source location Response from Greater Manchester Mental Health
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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 Develop and consult on national guidance for managing prisoners under the influence of illicit substances, incorporating the reported welfare-check concerns.
Verbatim wording from the response “I am pleased to inform you that HMPPS is currently developing national guidance for all staff managing prisoners who are under the influence of illicit substances. The guidance has been developed by the national Substance Misuse Group with contributions from internal and external stakeholders, including from areas such as health, and safety. Its purpose is to provide structured guidance for prisons to support the development of local under the influence guidance that will ensure that there is a consistent and safe response to the management of prisoners. It is important to note that this guidance does not replace healthcare advice and in a medical emergency instructions and advice from healthcare colleagues must be followed as a priority.” Source location Response from HMPPS
Open published response
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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 Produce a standard operating procedure defining prison and healthcare staff responsibilities when conducting welfare checks on prisoners monitored under the influence.
Verbatim wording from the response “In the meantime, I have received assurance from the Governor of HMP Garth that following the inquest meetings have been held between prison and healthcare colleagues to ensure a joined up approach going forward. Once national guidance is available, a standard operating procedure will be produced so that all prison and healthcare staff understand what they are expected to do when carrying out welfare checks on prisoners being monitored under the influence. GMMH have also committed to developing local training and awareness sessions around the use of the welfare check sheet once national guidance has been published.” Source location Response from HMPPS
Open published response
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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 HMPPS is developing national guidance addressing welfare checklist concerns about purpose, completion guidance and joint consideration.
Verbatim wording from the response “Our prison partners have informed us that nationally the picture has changed. His Majesties Prison and Probation Service (HMPPS) are developing national guidance for the management of people under the influence and that this process is currently going through consultation with” Source location Response from Greater Manchester Mental Health
Open published response
12 Mar 2024 Giuseppe TABONE and Andrew EVANS · Prevention of Future Deaths report East Sussex
View report summary
Concerns raised 4
Confusion about when full prisoner roll checks are required View source Insufficient monitoring of staff completion of required prisoner checks View source Failure by staff to understand the importance of completing every required roll check View source
Failure to carry out required prisoner roll checks View source See 1 more concern
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.
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AI-generated summary
Giuseppe TABONE and Andrew EVANS · 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
Giuseppe Tabone and Andrew Evans died at HMP Lewes after intentionally inhaling isotonitazene, a synthetic opioid. Prison staff failed to carry out required roll checks at 7.30pm and 8.45pm on 27 June 2022, and the report raises concerns about staff compliance with, understanding of, and monitoring of required prisoner checks.
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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 Confusion about when full prisoner roll checks are required
Wider context from the report “At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the control room and were not responding to prisoner's cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training.
I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state. The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning. There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check. Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members. I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out. There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out.
” Source location Giuseppe TABONE and Andrew EVANS · Prevention of Future Deaths report
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 Insufficient monitoring of staff completion of required prisoner checks
Wider context from the report “At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the control room and were not responding to prisoner's cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training.
I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state. The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning. There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check. Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members. I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out . There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out.
” Source location Giuseppe TABONE and Andrew EVANS · Prevention of Future Deaths report
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 by staff to understand the importance of completing every required roll check
Wider context from the report “At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the control room and were not responding to prisoner's cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training.
I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state. The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning. There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check . Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members . I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out. There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out.
” Source location Giuseppe TABONE and Andrew EVANS · Prevention of Future Deaths report
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 carry out required prisoner roll checks
Wider context from the report “At the inquest, two prison staff admitted that they had independently failed to carry out the required roll checks on L wing at 7.30pm and 8.45pm on the evening of 27 June 2022. One officer recorded on the wing log book that he had carried out the 7.30pm check, even though he did not do so. The other gave evidence that he did not carry out the 8.45pm check because he was distracted by the day shift officers, who were watching videos in the control room and were not responding to prisoner's cell bell calls. The staff members concerned have been subject to disciplinary proceedings, but continue to work at the prison. It was not possible to say on the evidence whether Andrew or Giuseppe’s lives could have been saved had the required roll checks been carried out. Evidence was given that, since this incident, staff have been provided with ‘bite size’ training on roll checks, although neither of the staff members concerned had received this training.
I remain concerned that there is a risk of future deaths caused by prison staff at HMP Lewes failing to carry out the required checks on prisoners, particularly during the night state . The purpose of roll checks is to ensure that each prisoner is present and alive and well. If a roll check is not carried out, there is a risk that a prisoner in need of medical attention and unable to ring the cell bell could remain undiscovered until the morning . There was confusion from staff at the prison as to when full roll checks are required. Further, I am concerned that staff may know when roll checks are required but not fully understand the importance of carrying out every required check. Both staff members concerned were aware that the roll check was required, but did not carry it out because they thought that checks had been carried out by other staff members. I am also concerned that there are insufficient measures in place to monitor staff to ensure that all required checks are being carried out. There may be lessons that can be learnt from other prisons as to how to ensure checks are always carried out.
” Source location Giuseppe TABONE and Andrew EVANS · Prevention of Future Deaths report
Open source report
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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 roll-check process against new staffing profiles and regime planning.
Verbatim wording from the response “Following the inquest into the deaths of Mr Tabone and Mr Evans, the prison is reviewing roll checks to ensure that processes are in line with new staffing profiles and regime planning which is currently being reviewed and updated. Once this work is complete, a new notice to staff will be issued setting out learning from the inquest around roll checks.” Source location Response from HM Prison and Probation Service
Open published response
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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 a staff notice communicating learning from the inquest about roll checks after the review is complete.
Verbatim wording from the response “Following the inquest into the deaths of Mr Tabone and Mr Evans, the prison is reviewing roll checks to ensure that processes are in line with new staffing profiles and regime planning which is currently being reviewed and updated. Once this work is complete, a new notice to staff will be issued setting out learning from the inquest around roll checks.” Source location Response from HM Prison and Probation Service
Open published response
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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 and clarify the roll-check local operating procedure, including required times and recording arrangements.
Verbatim wording from the response “The Governor of HMP Lewes has informed me that the prison’s LOP on roll checks was reviewed in August 2023 and clearly sets out the times that roll checks are required to be carried out and where staff must sign to confirm that the checks have been completed. The LOP provides guidance on checks during the week, on weekends and during the night state so that staff understand what their duties are at all times.” Source location Response from HM Prison and Probation Service
Open published response
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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 Continue taking appropriate action, including disciplinary action where necessary, when staff fail to meet roll-check expectations.
Verbatim wording from the response “Staff are aware that CCTV is in use around the establishment and that their actions may be scrutinised following an incident such as a death in custody. If staff are found to have failed to carry out the required tasks or when there is a question over their performance and ability there will be a thorough investigation to determine what has happened and to ensure that staff who fail to uphold the values of HMPPS by putting prisoner’s safety at risk are held to account through disciplinary procedures. Staff are aware that failure to carry out the duties entrusted to them will result in disciplinary action, and that, depending on the circumstances, the outcome may range from advice and guidance in order to support them to perform better, to dismissal from the service.” Source location Response from HM Prison and Probation Service
Open published response
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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 Publish staff notices reinforcing the importance of completing roll checks and prompting key safety observations.
Verbatim wording from the response “I am also informed that the prison has published notices to staff highlighting the importance of carrying out roll checks in line with expectations. A notice to staff was issued in August 2023 which prompts staff to consider three points when carrying out roll checks:” Source location Response from HM Prison and Probation Service
Open published response
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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 Deliver further bite-size roll-check training sessions, prioritising staff who previously lacked the training.
Verbatim wording from the response “I can confirm that HMP Lewes has planned further sessions of ‘bite size’ training on roll checks. The two members of staff who gave evidence that they had not received the training will be required to attend as a priority. Additionally, the prison has received support from the standards coaching team, a national resource, which consisted of a team of experienced prison staff shadowing officers at HMP Lewes to provide support and on-the-job training. The team covered roll checks as part of the support.” Source location Response from HM Prison and Probation Service
Open published response
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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 on-the-job roll-check support and training through standards coaching team staff shadowing officers at HMP Lewes.
Verbatim wording from the response “I can confirm that HMP Lewes has planned further sessions of ‘bite size’ training on roll checks. The two members of staff who gave evidence that they had not received the training will be required to attend as a priority. Additionally, the prison has received support from the standards coaching team, a national resource, which consisted of a team of experienced prison staff shadowing officers at HMP Lewes to provide support and on-the-job training. The team covered roll checks as part of the support.” Source location Response from HM Prison and Probation Service
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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 Existing roll-check assurance measures and staff accountability are considered sufficient; staff must be trusted to perform required duties.
Verbatim wording from the response “I understand that evidence was given at the inquest on the assurance measures in place for roll checks at the prison but that you remain concerned that the measures are insufficient. Whilst I am also concerned to learn of instances where staff have not carried out their duties in line with clear expectations, we must be able to trust staff to carry out the required tasks that are fundamental to their role. HMP Lewes also holds a daily briefing which provides an opportunity to update and remind staff of the duties to be carried out as well as to convey any other important information.” Source location Response from HM Prison and Probation Service
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17 Jan 2023 John Allen Martin HENDERSON · Prevention of Future Deaths report Mid Kent and Medway
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Concerns raised 2
Failure to provide closer monitoring for prisoners with seizure activity View source Failure to conduct start-of-day prisoner welfare checks View source
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.
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AI-generated summary
John Allen Martin HENDERSON · 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
John Allen Martin Henderson was found dead in his bunk at HMP Rochester on 27 May 2021. The inquest recorded natural causes, namely ischaemic heart disease, following a fatal haemorrhage into the wall of the left circumflex artery. Concerns included delayed medical investigations, the absence of a welfare check at the start of the day, and a lack of a clear process for sharing relevant medical information with front-line prison staff.
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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 provide closer monitoring for prisoners with seizure activity
Wider context from the report “During the course of evidence, I also established that John was not being monitored any more
closely than other prisoners due to his seizure activity . That was confirmed by ████████
████████ in the course of their evidence. They indicated to me that sometimes they
will be asked to monitor prisoners more closely but this had not been applied to John .
Likewise, nobody had checked the welfare of John at the start of the day on 27 May 2021.
” Source location John Allen Martin HENDERSON · Prevention of Future Deaths report
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 conduct start-of-day prisoner welfare checks
Wider context from the report “During the course of evidence, I also established that John was not being monitored any more
closely than other prisoners due to his seizure activity. That was confirmed by ████████
████████ in the course of their evidence. They indicated to me that sometimes they
will be asked to monitor prisoners more closely but this had not been applied to John.
Likewise, nobody had checked the welfare of John at the start of the day on 27 May 2021 .
” Source location John Allen Martin HENDERSON · Prevention of Future Deaths report
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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 Personal Management Plans to obtain consent, share relevant medical alerts and guidance, record required observations, and review at multidisciplinary prison meetings.
Verbatim wording from the response “Since this inquest, Oxleas NHS Foundation Trust has worked closely with HMPPS to introduce a Personal Management Plan (PMP) which provides a way of sharing information between healthcare staff and prison officers.” Source location Response from Oxleas Forensic and Offender Healthcare Services
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7 Apr 2022 Nicholas Tom Rose · Prevention of Future Deaths report Dorset
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Concerns raised 1
Failure to require an appropriate verbal response during welfare checks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Nicholas Tom Rose · 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
Nicholas Tom Rose, a serving prisoner at HMP Guys Marsh, was found deceased in his cell on 19 May 2019 after consuming “Spice”, with the medical cause of death involving airway obstruction and aspiration of gastric content. The report raised concern that accepting a “grunt” as a verbal response during a welfare check may provide insufficient information to assess a prisoner's welfare and could contribute to future deaths if the practice continued.
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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 require an appropriate verbal response during welfare checks
Wider context from the report “i. I am concerned that accepting a “grunt” as a verbal response to a welfare check does not fulfil the requirement as set out in the Notice to Prison Officers mentioned above. Such a response gives very limited information upon which a prison officer can assess a prisoner’s welfare . Accepting such a response potentially loses sight of the purpose of a welfare check, which must be to check that the prisoner is alive, immediately safe and well; that is, that they are conscious, breathing, not in a state of distress, not in a state of intoxication and that there are not any other factors that might require immediate intervention to prevent harm. A verbal response to a welfare check allows a prison officer to assess if a prisoner has responded in an appropriate manner, giving an indication as to whether the prisoner retains the cognitive function to provide an appropriate response. A “grunt” does not allow such an assessment . Therefore, I have a concern that future deaths could occur if accepting such a response remains the accepted practice .
” Source location Nicholas Tom Rose · Prevention of Future Deaths report
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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 Publish reminders requiring verbal welfare-check responses and cell access when no response is obtained.
Verbatim wording from the response “I understand that evidence was given at the inquest that HMP Guys Marsh’s local arrangement is that staff must receive a verbal response from prisoners during welfare checks and unlock, and that notices to staff and prisoners have been issued setting out this requirement. I have received assurance from the Governing Governor that further notices to staff and prisoners were published in May 2022, following the inquest, to serve as a reminder of the expectations during welfare checks that a verbal response must be obtained, not a grunt, and that if a verbal response is not obtained then staff must access the cell to check on the welfare of the prisoner.” Source location Response from HM Prison and Probation Service
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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 Conduct and record daily compliance observations of welfare checks, with monthly assurance review and performance-management challenge for failures.
Verbatim wording from the response “Notices to staff and prisoners will now be re-published regularly and compliance checks are carried out by wing Custodial Managers (CMs) who observe officers unlocking prisoners to ensure that welfare checks are being carried out correctly, and this is recorded each day in wing diaries. A review of the assurance checks is carried out on a monthly basis by the Head of Residence and any” Source location Response from HM Prison and Probation Service
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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 Train new prison officers to conduct roll-check, unlock and welfare checks, emphasising confirmation of prisoner safety and welfare.
Verbatim wording from the response “Prison officers undertaking initial training (currently known as New Officer Apprentices) are trained to conduct checks and the training emphasises the requirement for officers to confirm the safety and welfare of prisoners during roll checks, unlocks, and welfare checks.” Source location Response from HM Prison and Probation Service
Open published response
30 Nov 2021 Connor Arthur Steven Hout · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 2
Failure to obtain a response from all prisoners during welfare checks View source Lack of clearly understood systems for assuring prisoner wellbeing during or shortly after unlock View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Connor Arthur Steven Hout · 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
Connor Arthur Steven Hout, aged 24, was found deceased in his prison cell on 10 June 2019 after several brief observations by prison officers during the morning. The report identified that welfare checks did not require officers to obtain a response or engage with prisoners, including those who appeared to be asleep, creating a risk that prisoners in distress or otherwise causing concern could be missed.
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 obtain a response from all prisoners during welfare checks
Wider context from the report “The evidence revealed prison officers are not obtaining, nor did the prison systems require them to obtain, a response from all prisoners during welfare checks . More specifically, during the morning unlock they are not required to, and therefore do not necessarily seek to, obtain a response or otherwise engage with prisoners . In particular, no response is required, and therefore not sought, from prisoners who appear to be asleep in bed , notwithstanding the requirements of PSI 75/2011 (Residential Services).
The PSI sets out the fact that residential prison staff play a key role in spotting any signs of distress and will often be the first to pick up information or signs, and should accordingly engage with prisoners in such a way that facilitates the identification of any concerns or distress.
Further, paragraph 2.3 of the PSI, namely, “Output No. 3 Prisoners are supported and their daily needs are met” states that prisons are required to have, “clearly understood systems in place for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock”.
In the absence of such systems prisoners in distress, or otherwise a cause for concern, may be missed.
” Source location Connor Arthur Steven Hout · Prevention of Future Deaths report
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 Lack of clearly understood systems for assuring prisoner wellbeing during or shortly after unlock
Wider context from the report “The evidence revealed prison officers are not obtaining, nor did the prison systems require them to obtain, a response from all prisoners during welfare checks. More specifically, during the morning unlock they are not required to, and therefore do not necessarily seek to, obtain a response or otherwise engage with prisoners. In particular, no response is required, and therefore not sought, from prisoners who appear to be asleep in bed, notwithstanding the requirements of PSI 75/2011 (Residential Services).
The PSI sets out the fact that residential prison staff play a key role in spotting any signs of distress and will often be the first to pick up information or signs, and should accordingly engage with prisoners in such a way that facilitates the identification of any concerns or distress.
Further, paragraph 2.3 of the PSI, namely, “Output No. 3 Prisoners are supported and their daily needs are met” states that prisons are required to have, “clearly understood systems in place for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock” .
In the absence of such systems prisoners in distress, or otherwise a cause for concern, may be missed .
” Source location Connor Arthur Steven Hout · Prevention of Future Deaths report
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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 Issue a Governor’s Order requiring staff to obtain verbal responses from prisoners who are or appear awake during roll checks and unlocking procedures.
Verbatim wording from the response “In January 2020, and in response to the PPO’s investigation, HMP Wakefield issued a Governor’s Order that set out in expectation that staff should obtain a verbal response from all prisoners who are or appear to be awake when conducting roll checks and unlocking procedures, to avoid waking sleeping prisoners overnight or early in the morning, while ensuring that potential concerns are identified.” Source location 2021-0405-Response-from-HMPPS_Published
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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 Circulate a Notice to Staff reminding staff to assure themselves of prisoners’ wellbeing during or shortly after unlock.
Verbatim wording from the response “Further, and in response to your concerns, the Governor of HMP Wakefield has now circulated a Notice to Staff reminding staff that they should assure themselves of the wellbeing of prisoners during or shortly after unlock. Additionally, your concerns will be discussed with the staff who gave evidence at the inquest to ensure they fully understand the process and their responsibilities during unlock, and know how to take action should they have any concerns about an individual’s welfare.” Source location 2021-0405-Response-from-HMPPS_Published
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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 Discuss the concerns with staff who gave evidence at the inquest to reinforce unlock procedures, responsibilities and welfare escalation.
Verbatim wording from the response “Further, and in response to your concerns, the Governor of HMP Wakefield has now circulated a Notice to Staff reminding staff that they should assure themselves of the wellbeing of prisoners during or shortly after unlock. Additionally, your concerns will be discussed with the staff who gave evidence at the inquest to ensure they fully understand the process and their responsibilities during unlock, and know how to take action should they have any concerns about an individual’s welfare.” Source location 2021-0405-Response-from-HMPPS_Published
Open published response
22 Oct 2021 Anthony John Larcher · Prevention of Future Deaths report Dorset
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Concerns raised 1
Lack of observations and welfare checks for prisoners found under the influence of psychoactive substances View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Anthony John Larcher · 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
On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.
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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 Lack of observations and welfare checks for prisoners found under the influence of psychoactive substances
Wider context from the report “i. There could be future deaths across the prison estate nationally due to a lack of observations and welfare checks upon prisoners who are found under the influence of Spice and I request consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of their Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP) and the Custodial Officer Intermediate Life Support initiative (COILS).
” Source location Anthony John Larcher · Prevention of Future Deaths report
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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 Gather information from regional prison safety groups about local initiatives for observations and welfare checks.
Verbatim wording from the response “The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe.” Source location 2021-0356-Response-from-HMPPS_Published
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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 Discuss nationally rolling out local drug-related safety initiatives with the NHSE/I national team.
Verbatim wording from the response “The first concern you raise is that there could be future deaths across the prison estate due to a lack of observations and welfare checks on prisoners who are found under the influence of illicit psychoactive substances, and you have requested that consideration be given to a national roll out of some of the local initiatives which have been implemented at HMP Guys Marsh. The national Drug Strategy Team have been in touch with regional prison safety groups to gather information on the local initiatives which have been implemented around the country, including those in place at HMP Guys Marsh, and are in talks with NHSE/I national team about rolling out some of these initiatives on a national scale. We are committed to learning from local practices and to use these to inform the development of national policies to drive improvement and work to save lives and keep people safe.” Source location 2021-0356-Response-from-HMPPS_Published
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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 HMPPS is responsible for deciding whether local welfare, substance intervention and life-support processes should be rolled out nationally.
Verbatim wording from the response “1. Consideration be given to the rolling out of the local processes adopted at HMP Guys Marsh, nationally. This includes the roll out of Welfare Checks Policy, the Persistent Psychoactive Substances Intervention Plan (PPSIP), and the Custodial Officer Intermediate Life Support initiatives (COILS).” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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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 Matters of concern i, ii, iii and v do not relate to NHS Digital, so it has no comment on them.
Verbatim wording from the response “We do not consider that matters of concern i, ii, iii or v relate to NHS Digital and thus have no comment on these.” Source location 2021-0356-Response-from-NHS-Digital_Published
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21 Oct 2021 Richard Gordon Franks · Prevention of Future Deaths report West Yorkshire Eastern
View report summary
Concerns raised 1
Failure to conduct timely welfare checks on a prisoner at risk of suicide View source
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.
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AI-generated summary
Richard Gordon Franks · 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
Richard Gordon Franks was remanded in custody at HMP Leeds and was found dead in his cell on 12 April 2019, after appearing distressed and indicating that he was likely to commit suicide if sentenced to imprisonment. The concerns included that this information was not communicated to prison staff, that he mistakenly believed he had received a five-year sentence, and that no checks were made on him for approximately 10 hours.
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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 conduct timely welfare checks on a prisoner at risk of suicide
Wider context from the report “(1) Mr Franks had a known history of self-harming and suicide attempts. His emotional state when seen at court on 11 April 2019 was triggered at least in part to his reaction to a development in the prosecution brought against him which he had not foreseen. His statement that he was likely to commit suicide was not communicated to either the security staff at the court or the prison staff. In consequence, the prison staff had no information concerning the events which took place at court.
(2) Mr Franks somehow perceived that he had been sentenced to five years imprisonment, which was not the case. This false impression caused him to be in distress prior to being locked in his cell around 19:00 hours.
(3) Had information concerning his emotions at court been relayed to the prison staff, this may have triggered a decision to open an ACCT – the process by which a prisoner is subject to increased monitoring and support. In the event no checks were made on him for some 10 hours.
(4) At a previous hearing on 25.02.17 Mr Franks had made a comparable threat to kill himself as a result of what he perceived to be an adverse development in the case brought against him. At that time his signed consent authorising information to be passed to the prison was obtained and communicated to the prison.
(5) The benefit of relaying helpful information to the prison intended to protect Mr Franks, does not seem to involve a breach of professional privilege. It would have been sufficient to request that the prison staff assess Mr Franks for themselves on his return in view of (unspecified) developments at court that day.
” Source location Richard Gordon Franks · Prevention of Future Deaths report
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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.
