Recurring concern

Inadequate supervision and monitoring of prisoners

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First reported 30 Oct 2013•Latest report 29 Jun 2026

Definition

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.

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
34

Distinct published reports

Individual concerns
49

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
62

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service12
Ministry of Justice10
NHS England3
Bedford Prison2
Care UK2
Dorset Healthcare University NHS Foundation Trust2
HM Inspectorate of Prisons2
Home Office2
Swaleside Prison2
Avon and Wiltshire Mental Health Partnership NHS Trust1
Birmingham Community Healthcare NHS Foundation Trust1
Birmingham Prison1
Cardiff Prison1
Central and North West London NHS Foundation Trust1
David Ake & Co1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester City

    AI-generated summary

    Craig Douglas Bell · 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

    Craig Douglas Bell was found dead in his cell at HMP Manchester on 13 December 2012 after taking his own life by hanging using a self-constructed ligature. He had a history of self-harm and suicidal ideation and was subject to ACCT procedures. The principal concerns included inadequate sharing of risk information, insufficient senior psychiatric involvement in discharge planning, the lack of a graduated risk-management plan, and limited availability of safer or CCTV-monitored cells for prisoners at risk of suicide.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to use CCTV monitoring as an adjunct to ACCT observation procedures

    Wider context from the report

    “6. In 2011 there were a limited number of cells which had been fitted with CCTV monitoring cameras. Very sadly Anthony Raymond Gillard was found dead in such a cell on the 24 December 2011 but that the use of CCTV was not part of his observation regime although he was subject to ACCT procedures. No one looked at or considered the CCTV pictures until after his death but they clearly demonstrated that he had been suffering the effects of over sedation from opiate drugs which no witness had seen or noticed. The use of CCTV monitored cells was discontinued after his death and was not available at the time of Mr Bell’s death. One reason given was that if they were used it required a Prison Officer to be monitoring the CCTV images constantly 24 hours a day. They could , of course , be used as an adjunct or in addition to usual ACCT observation procedures. This would not require constant CCTV monitoring. NOMS have replied to the court’s Regulation 28 PFD report and a copy is attached. I am concerned that if such cells/facilities are not provided and used then there is a risk that prisoners on ACCT’s will continue to be able to kill themselves. The same considerations would apply nationally to the entire HMPS estate. I attach copies of the NOMS response to my Regulation 28 PFD and letter under paragraphs 37/38 of the Chief Coroner’s guidance in relation to Mr Gillard’s death. ”

    Source location

    Craig Douglas Bell · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  2. North Northumberland

    AI-generated summary

    Vincent Oliver · 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

    Vincent Oliver was serving a prison sentence at HMP Northumberland when his lifeless body was discovered in his cell on 4 July 2013, shortly after the cells were unlocked. The principal concern was that the prison officer unlocking his cell did not obtain a response or check his physical well-being before moving on, and that cell-unlocking procedures had not been followed on other occasions. The inquest concluded that he died from natural causes, namely ischaemic heart disease and coronary artery atheroma.

    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 each prisoner during cell unlocking and roll checks

    Wider context from the report

    “The prison officer unlocking Mr Oliver’s cell on 4th July 2013 at approximately 5.40 p.m. for the evening meal did not check on his physical well-being by getting a response from him, before moving on to the next cell. This led to Mr Oliver, who had died some time earlier and was affected by rigor mortis, being found by another prisoner when he entered Mr Oliver’s cell. There has been a number of other occasions at the prison when appropriate cell unlocking procedures have not been followed and the Prisons and Probation Ombudsman has made recommendations about this previously. I understand that a Prison Director’s Order has been issued requiring that on roll check Prison Officers must obtain a response from each prisoner to ensure their physical presence and well-being. My understanding of the procedures is that there is no current requirement for the Officer completing the roll check to record on the roll check report that he or she has complied with the requirements of the above Order. ”

    Source location

    Vincent Oliver · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Cardiff & the Vale of Glamorgan

    AI-generated summary

    Christopher Shapley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Christopher Shapley was arrested on 17 September 2013, remanded in custody, and taken to HMP Cardiff after treatment at hospital for alcohol withdrawal symptoms and fitting. He was placed alone in a cell and found hanged during morning checks on 20 September 2013. Concerns included incomplete transfer of information about his hospital treatment and self-harm risks, insufficient assessment of risk factors, inadequate efforts to arrange a shared cell, and inadequate handover and night-time observations.

    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

    Absence of formal regular night checks for vulnerable prisoners

    Wider context from the report

    “(4) The jury were concerned that the handover arrangements for Christopher Shapley were not adequate to identify him as a prisoner who might benefit from increased observations, and that formal regular checks should have been put in place during the night. The jury were told of new arrangements that had come into force very shortly after Christopher Shapley’s death (such as an A4 warning sheet on the cell door of every first night prisoner). The risks to vulnerable prisoners such as Christopher Shapley have been highlighted in a number of previous reports from the Cardiff Coroner to HMP Cardiff (e.g. into the death of Andrew Paul Hawkins – inquest 12th and 14th June 2012) and such arrangements should be robust and permanent. ”

    Source location

    Christopher Shapley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Liverpool

    AI-generated summary

    Damion Anthony Andre Martin · 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

    Damion Anthony Andre Martin was remanded to HMP Liverpool on 6 December 2011 and was found hanging in the toilet area of his cell on 11 December 2011; attempts to resuscitate him were unsuccessful. The report raised concerns about the identification of domestic-abuse-related suicide risk during reception, basic life-support refresher training, the restricted view into the toilet area, and whether a prison officer completed a roll-check visit.

    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 visit the prisoner’s cell during a roll check

    Wider context from the report

    “Notwithstanding documentation to the contrary, a prison officer upon his roll check at approximately 5.15am did not visit Mr Martin’s cell. ”

    Source location

    Damion Anthony Andre Martin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026