Recurring concern

Unreliable prison cell safety inspection and risk-assessment processes

First to latest report 21 Jun 2017 — 3 Mar 2026

Reports that mention this concern
5
Times this concern has been raised
6
Stated actions linked to this concern
7

What this concern includes

Includes dedicated prison processes for inspecting cell fabric and related safety features, assessing changing cell risks, recording and communicating findings, assigning remedial action and checking that identified concerns are addressed. This includes the anchor's failure of daily and weekly cell fabric checks and the separate failure to maintain robust cell-safety audits and act on identified concerns.

What is not included
  • Excludes the underlying presence of a ligature point or other cell hazard when no failure of the prison cell inspection, risk-assessment or follow-up process is identified.
  • Excludes generic prison staffing, communication, training or maintenance deficiencies unless they directly impair prison cell safety inspection, risk assessment or follow-up.
  • Excludes broader suicide and self-harm prevention, prisoner observation or ACCT failures where the prison cell inspection and risk-assessment process is not the deficient control.
  • Excludes ward, hospital, residential and non-prison premises inspections unless the assertion explicitly concerns the same prison cell safety process.

Reports and published responses 5 reports

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

  1. Inner North London

    AI-generated summary

    Mujahid Adam · 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

    Mujahid Adam died by suicide after being found hanging in his prison cell on 15 March 2025; he was declared dead on 21 March 2025 at University College Hospital. The concerns included inadequate and non-contemporaneous recording of 15-minute observations, no clear definition of what constituted an observation, delays in calling Code Blue and cutting him down, and disrepair in the cell that allowed access to ligature material.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of daily accommodation and fabric checks to identify disrepair in special cells

    Wider context from the report

    “(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made. Despite daily AFCs, that disrepair was not noted although this was a special cell. ”

    Source location

    Mujahid Adam · Prevention of Future Deaths report
    Page 4 · 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

    Remind Pentonville staff to complete daily accommodation fabric checks, including checks for items that could be used to ligature.

    Verbatim wording from the response

    “In response to concerns about the condition of constant supervision cells at HMP Pentonville, I can confirm that a bid has been submitted to upgrade these cells to ligature resistant specifications. This work will address any disrepair and reduce opportunities for prisoners to use the fabric of the accommodation to ligature. In addition, staff at HMP Pentonville have been reminded of their responsibility to complete daily accommodation fabric checks. These are physical checks of all prisoner living areas, including cells, to ensure that the area is clean, decent and fit for purpose. They are also valuable opportunities for staff to identify anything that raises suspicion, including items that can be used to ligature.”

    Source location

    2026-0125 - Response from HMPPS
    Page 2 · response
    Published 9 March 2026

    Open published response

  2. 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.

    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

    Delays in addressing identified cell-safety concerns

    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

    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

    Restore ligature-resistant cells to serviceable condition using approved lockable observation hatches.

    Verbatim wording from the response

    “I can confirm that interim measures have been put in place at HMP Bedford to ensure that the ligature-resistant (LR) cells are now serviceable. The LR cell observation panels have temporarily been replaced with an approved lockable observation hatch. A full review of all LR doors has been completed, alongside an urgent assessment of the current door and observation panel design. Additionally, Government Facilities Services Limited has undertaken a further review of the locking mechanism within the LR cell observation panels to ensure they remain fully serviceable. In the longer term, a proposal to replace the existing LR cell observation panels with a model that meets current safety specifications – designed to reduce the risk of prisoners from opening them inside the cell - has been issued for tender.”

    Source location

    Response from HM Prison & Probation Service
    Page 1 · response
    Published 3 October 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

    Carry out daily accommodation fabric checks with additional scrutiny for cell damage or deterioration.

    Verbatim wording from the response

    “Furthermore, the prison is taking a more proactive approach to identifying cell defects. Daily accommodation fabric checks (AFCs) are in place and carried out consistently throughout the establishment. AFCs are now subject to additional scrutiny and are designed to incorporate checks to identify any damage or deterioration of individual cells. Should a significant defect be identified during these checks, the cell will be immediately taken out of use until remedial work has been carried out and the cell is returned to a serviceable condition. Where a cell requires remedial work, the process is documented and monitored to ensure a timely resolution and accountability.”

    Source location

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

    Remove cells with significant defects from use and document and monitor remedial work until they are serviceable.

    Verbatim wording from the response

    “Furthermore, the prison is taking a more proactive approach to identifying cell defects. Daily accommodation fabric checks (AFCs) are in place and carried out consistently throughout the establishment. AFCs are now subject to additional scrutiny and are designed to incorporate checks to identify any damage or deterioration of individual cells. Should a significant defect be identified during these checks, the cell will be immediately taken out of use until remedial work has been carried out and the cell is returned to a serviceable condition. Where a cell requires remedial work, the process is documented and monitored to ensure a timely resolution and accountability.”

    Source location

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

    Open published response

  3. Nottinghamshire

    AI-generated summary

    Wyndham Richard Thomas · 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

    Wyndham Richard Thomas was a serving prisoner who was found unconscious in his cell after ligating on 4 November 2018 and died in hospital on 6 November 2018. The substantive concerns were the absence of in-cell ligature-point risk assessments and maps, and the lack of designated safer cells at HMP Nottingham, which reduced opportunities to mitigate the risk of self-harm and death by ligature asphyxiation.

    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 in-cell ligature point risk assessments

    Wider context from the report

    “1. There is a lack of local and national system of in-cell ligature point risk assessments, and no ligature point maps available to staff. The Prison Staff caring for Wyndham were not aware of the location of known ligature points within the cell. This meant that suspicion was not drawn when Wyndham was seen positioned in an area which had access to a ligature point. ”

    Source location

    Wyndham Richard Thomas · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing observation escalation and gated-cell relocation are relied on to manage high-risk prisoners.

    Verbatim wording from the response

    “With regards to your concerns pertaining to in-cell ligature point risk assessments and the availability of ligature point maps, we expect staff to be aware of the potential for a prisoner to be equally at risk of ligaturing at any position in the cell, as well as to the possibility that a ligature point may not be used in all circumstances that require immediate action to preserve life. Prisoners assessed as high risk of suicide should either have their observation level increased or they should be relocated into a gated cell, if doing so would not be detrimental to the prisoner’s welfare.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 29 December 2023

    Open published response

  4. Birmingham and Solihull

    AI-generated summary

    SAIFUR RAHMAN · 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

    Saifur Rahman was found in cardiac arrest in his cell at HMP Birmingham on 20 January 2021, was taken to hospital after resuscitation, and died on 23 January 2021. The post-mortem recorded hypoxic/ischaemic encephalopathy associated with external neck compression, and the jury found that his intention was to commit suicide. The report raised concerns about delayed emergency calls, inadequate records of cell history, insufficient cell risk assessments, and the lack of a formal process for prison and mental health staff to inspect and act on cell risks.

    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 a formal process for communicating and acting on prison cell risk assessment results

    Wider context from the report

    “4. Prison ████████ risk assessment: the evidence revealed that dynamic daily and weekly prison officer cell fabric checks did not identify the risks within cell H3-15. The evidence from the mental health trust was that as their risk assessment is annual and the environment on ward 2 and ward 3 is dynamic and can quickly change, the prison needs to undertake its own ████████ risk assessment. I was provided with a verbal undertaking that the head of safer custody will undertake the first annual prison cell ████████ risk assessment visually inspecting all 15 x 2 cells 6 months after the NHS risk assessment, and delegate twenty monthly thereafter, resulting in alternating 6 monthly risk assessments. My ongoing concern is that there is no formalised process and consideration needs to be given to how results of the prison ████████ risk assessment is communicated to, and acted upon, by the mental health trust. ”

    Source location

    SAIFUR RAHMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of daily and weekly cell fabric checks to identify risks

    Wider context from the report

    “4. Prison ████████ risk assessment: the evidence revealed that dynamic daily and weekly prison officer cell fabric checks did not identify the risks within cell H3-15. The evidence from the mental health trust was that as their risk assessment is annual and the environment on ward 2 and ward 3 is dynamic and can quickly change, the prison needs to undertake its own ████████ risk assessment. I was provided with a verbal undertaking that the head of safer custody will undertake the first annual prison cell ████████ risk assessment visually inspecting all 15 x 2 cells 6 months after the NHS risk assessment, and delegate twenty monthly thereafter, resulting in alternating 6 monthly risk assessments. My ongoing concern is that there is no formalised process and consideration needs to be given to how results of the prison ████████ risk assessment is communicated to, and acted upon, by the mental health trust. ”

    Source location

    SAIFUR RAHMAN · 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

    Formalise the risk-assessment process with the prison by placing it on the Local Delivery Board meeting agenda.

    Verbatim wording from the response

    “In order for this reassurance to be given, the Trust did consider future planning and resourcing to ensure that this would be completed. This takes place each year and the risk assessments for the prison are part of the Audit schedule for the Trust. In respect of formalising the process with the prison, the Trust’s Head of Healthcare at HMP Birmingham has emailed the Local delivery Board to ask that this matter is placed on the agenda for the meeting on 16th June 2022. This will ensure that the process is formalised. Commissioners will also be present at this meeting.”

    Source location

    Response from BSMHFT
    Page 2 · response
    Published 26 May 2022

    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

    Visit cells six months after NHS assessments to identify and minimise obvious ligature points.

    Verbatim wording from the response

    “Finally, you have queried the process for cell ligature risk assessments following evidence heard at the inquest. This process has since been reviewed internally and the introduction of a formalised process is currently underway with the Health and Safety team, in partnership with the NHS. The prison will be accountable for visiting the cell six months after the NHS assessment to confirm that any obvious ligature points are identified and minimised as best as possible.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 26 May 2022

    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

    Review ligature-resistant cells, including cell standards and regular maintenance requirements.

    Verbatim wording from the response

    “On a national level, HMPPS is undertaking a review of ligature-resistant cells, which will include an assessment of the cell standards and regular maintenance to ensure that they do not deviate from the required standard over time.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 26 May 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The prison, not the Trust, is responsible for implementing actions from prison risk assessments, including repairs and fabric upgrades.

    Verbatim wording from the response

    “This gives us some concern as the wording suggests that the Trust has some element of control or can take action on any Risk Assessment carried out by the Prison. It was agreed in evidence at the inquest that any actions developed within Risk Assessments carried out by either BSMHFT or the Prison, would need to be taken by the Prison and not BSMHFT, as the Trust has no control to make any repairs or fabric upgrades within the prison. The prison are ultimately responsible for any actions, although we also monitor these through regular meetings with the prison. I would be grateful if you can make any necessary amendments to this point as we consider it is misleading.”

    Source location

    Response from BSMHFT
    Page 2 · response
    Published 26 May 2022

    Open published response

  5. Central Hampshire

    AI-generated summary

    Michael Folley · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

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

    Source location

    Michael Folley · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

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