Recurring concern

Inadequate emergency access during barricade incidents

First to latest report 21 Jun 2017 — 22 Jan 2025

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

What this concern includes

Includes failures of policies, staff training, risk-based arrangements, doors, keys, equipment, maintenance or operational procedures specifically dedicated to preventing or enabling emergency access during barricade incidents in residential, custodial or care settings.

What is not included
  • Excludes generic emergency response deficiencies not specifically linked to barricaded rooms or cells.
  • Excludes unrelated obstruction of venue entry or general building access.
  • Excludes generic staffing, documentation, communication or training deficiencies unless they are directly tied to managing barricade incidents.

Reports and published responses 5 reports

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

  1. Manchester South

    AI-generated summary

    Nathan Harry SHEPHERD · 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

    Nathan Harry Shepherd died in hospital on 16 January 2024 after being found suspended from a ligature in his room at approved premises, following an unsuccessful attempt to gain immediate entry because the room had been barricaded. The inquest concluded that the death was suicide, with medical cause of death recorded as hypoxic brain injury and hanging. Concerns included the lack of policies and training for barricaded-room incidents, movable furniture that enabled barricading, ligature points, inadequate assurance of agency staff first-aid and CPR capability, and ineffective sharing of risk information.

    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 staff training for incidents of residents barricading themselves into rooms

    Wider context from the report

    “1. The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at Approved Premises. This meant that staff did not have training on how to deal with a situation. The inquest was told that the Probation Service were now developing such a policy but it had not been signed off or rolled out to staff. ”

    Source location

    Nathan Harry SHEPHERD · 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 to implement a policy for incidents of residents barricading themselves into rooms at Approved Premises

    Wider context from the report

    “1. The inquest heard evidence that the Probation Service had no policy to cover incidents of residents barricading themselves into rooms at Approved Premises. This meant that staff did not have training on how to deal with a situation. The inquest was told that the Probation Service were now developing such a policy but it had not been signed off or rolled out to staff. ”

    Source location

    Nathan Harry SHEPHERD · 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

    Complete sign-off, issue barricade guidance to Approved Premises staff, and obtain their acknowledgement of receipt and understanding.

    Verbatim wording from the response

    “The Barricade Guidance referred to in evidence given at the Inquest hearing has now been finalised and is going through the final stages of sign off prior to issue to all approved premises staff on 1st August 2025. This guidance will form part of the Safe Working Practice document and staff will be required to acknowledge receipt and their understanding by the end of September 2025. This will be overseen by all Approved Premises Managers.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 22 January 2025

    Open published response

  2. East London

    AI-generated summary

    Winbourne Gregory Charles · 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

    Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.

    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 the anti-barricade key to access a barricaded room

    Wider context from the report

    “4. Failures to respond to an emergency adequately – The Trust described the emergency response as chaotic . Staff agreed that they “panicked” and did not follow policy, specific issues include; a. A ward emergency bell was not sounded, b. An anti-barricade key was not used to open Mr Charles’ door, instead the door was forced open causing a risk of harm to Mr Charles. c. A ligature cutter could not be used promptly as it was secured in a box with a combination lock – staff did not know the combination, d. Duty doctors were not called promptly, e. Oxygen administration was delayed, f. An on-site defibrillator was not used by staff g. Staff could or would not provide a clear and relevant history to paramedics. ”

    Source location

    Winbourne Gregory Charles · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Include anti-barricade-key use in resuscitation drills and audit staff awareness of its function.

    Verbatim wording from the response

    “7. All bunches of keys have an anti barricade key on them. Key audits have taken place in 2023”

    Source location

    NELFT NHS Foundation Trust Action Plan
    Page 5 · response
    Published 5 May 2023

    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

    Concerns about care provision and coordination are mainly for the NHS Trust to address.

    Verbatim wording from the response

    “Your report raises concerns over the provision and coordination of care that Winbourne received at North East London NHS Foundation Trust, which are mainly for the Trust to address. I understand that the Trust has already carefully considered the matters of concern in your report and has provided you with a comprehensive response as well as a copy of its action plan setting out the actions to be taken to improve care quality and patient safety.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 5 May 2023

    Open published response

  3. Staffordshire South

    AI-generated summary

    Christopher Andrew MOSS · 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 Andrew MOSS was a serving prisoner at HMP Featherstone who died on 18 February 2017 from a self-inflicted incision to his left wrist. The principal concern was that appropriate equipment was not initially available to open the cell door during the barricade incident, raising a concern about whether prisons should check that suitable equipment is available for their particular doors.

    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 appropriately located equipment for barricade situations involving non-dual-opening cell doors

    Wider context from the report

    “At the incident when Christopher died initially a hydraulic jack to open the cell door was summoned to the scene when the appropriate equipment was not available (it did in fact arrive very soon afterwards). I am aware that there is a gradual process in the prison estate to move towards cell doors that can be opened outwards if necessary in addition to normally opening inwards. My concern however is that for doors that are not dual opening prisons should have appropriate equipment available to deal with barricade situations. Should there be a check or audit to ensure that the correct equipment for the relevant doors are located appropriately at prisons? ”

    Source location

    Christopher Andrew MOSS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Liverpool and the Wirral

    AI-generated summary

    Sam MOLYNEUX · 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

    Sam Molyneux, a prisoner at HMP Liverpool, was found hanging from a ligature in his cell on 1 April 2016 and was pronounced dead at 22:55. The inquest identified a failure to open an ACCT, concerns about the response to assaults and possible bullying, and a delay in accessing him because the cell door could be barricaded.

    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 anti-barricade doors in some prison wings

    Wider context from the report

    “During the course of the inquest it became apparent that in old prisons not all wings have been adapted to have anti-barricade doors. In this case Mr Molyneux had barricaded his door and this delayed prison staff gaining access to him during a Code Blue Situation. He was not on an ACCT but perhaps should have been given his threats of suicide and self-harm articulated by him in a letter to a Governor on an adjudication the day before his death. Local directions in the Prison during the inquest have addressed this situation in HMP Liverpool at Walton. That said HM Prison and Probation service might wish to consider amending “Management of Prisoners at risk of harm to self, to others and from others (Safer Custody)” to include consideration of where reasonably practicable avoiding locating prisoners behind a door which is not designed to circumvent barricading. ”

    Source location

    Sam MOLYNEUX · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the ACCT form and safer custody policy to address emergency access and anti-barricade doors in prisoner-location decisions.

    Verbatim wording from the response

    “Wherever possible, we should avoid using such cells to accommodate prisoners identified as being at risk of self-harm or suicide. As you know, the ACCT process includes consideration by the case review team of the most appropriate location for the prisoner. Both the design of the ACCT form and the content of PSI 64/2011 Safer Custody are currently under review, and we will ensure that the revised version of the form and accompanying policy direct staff to have regard to the issue of emergency access – including the presence of an anti-barricade door – when making decisions about the location of a prisoner on an ACCT. We will also include this in the training that is provided for ACCT case managers.”

    Source location

    2017-0340-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 13 September 2017

    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

    Ensure the revised ACCT form and accompanying policy direct staff to consider emergency access, including anti-barricade doors, when locating prisoners on ACCT.

    Verbatim wording from the response

    “Wherever possible, we should avoid using such cells to accommodate prisoners identified as being at risk of self-harm or suicide. As you know, the ACCT process includes consideration by the case review team of the most appropriate location for the prisoner. Both the design of the ACCT form and the content of PSI 64/2011 Safer Custody are currently under review, and we will ensure that the revised version of the form and accompanying policy direct staff to have regard to the issue of emergency access – including the presence of an anti-barricade door – when making decisions about the location of a prisoner on an ACCT. We will also include this in the training that is provided for ACCT case managers.”

    Source location

    2017-0340-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 13 September 2017

    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

    Include emergency-access and anti-barricade-door considerations in training for ACCT case managers.

    Verbatim wording from the response

    “Wherever possible, we should avoid using such cells to accommodate prisoners identified as being at risk of self-harm or suicide. As you know, the ACCT process includes consideration by the case review team of the most appropriate location for the prisoner. Both the design of the ACCT form and the content of PSI 64/2011 Safer Custody are currently under review, and we will ensure that the revised version of the form and accompanying policy direct staff to have regard to the issue of emergency access – including the presence of an anti-barricade door – when making decisions about the location of a prisoner on an ACCT. We will also include this in the training that is provided for ACCT case managers.”

    Source location

    2017-0340-Response-by-HM-Prison-Probation-Service
    Page 2 · response
    Published 13 September 2017

    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