Recurring concern

Insufficient availability of certified safer cells for prisoners at risk of self-harm

First to latest report 9 Mar 2015 — 10 Dec 2025

Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
4

What this concern includes

Includes failures of the provision, certification, availability, location or coverage of safer cells intended for prisoners at risk of suicide or self-harm, including the anchor's absence of nationally certified safer cells and comparable shortages or location gaps across prison wings or units.

What is not included
  • Excludes design, maintenance or ligature-point failures within an existing safer cell when the concern is not the availability or coverage of safer cells.
  • Excludes general prison accommodation shortages or ordinary cell conditions without an explicit safer-cell requirement.
  • Excludes broader suicide and self-harm prevention, observation or ACCT failures unless they specifically concern access to or provision of safer cells.
  • Excludes fire-safer cells and other specialist accommodation designed for a different hazard unless the assertion explicitly concerns certified safer cells for self-harm prevention.

Reports and published responses 5 reports

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

  1. Worcestershire

    AI-generated summary

    Mesut Olgun · 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

    Mesut Olgun sustained significant injuries while being arrested and was later seriously injured in his cell at HMP Hewell on 8 June 2018; he died from those injuries at Alexandra Hospital, Redditch, on 14 June 2018. The inquest concluded that he died as a result of suicide. Concerns included the lack of “Safer Cells” outside the Segregation Unit, failures to carry out most required ACCT observations, and failure to call a Code Blue emergency at the earliest opportunity; the inquest found that the latter two failures possibly caused or contributed to his death.

    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

    Unavailability of Safer Cells outside the Segregation Unit for vulnerable prisoners

    Wider context from the report

    “In his evidence to the inquest, the current Head of Safety at HMP Hewell confirmed that the prison had two “Safer Cells” ( intended to reduce the risk ████████ ), but that these were both located within the prison’s Segregation Unit. He agreed that it would not be appropriate for a new prisoner like Mr. Olgun, who had been identified as a high risk of self-harm and for whom an ACCT document had been opened, to be located on the Segregation Unit on his first night in prison. There are therefore no “Safer Cells” located within the main body of the prison. The cost of converting a cell into a “Safer Cell” is said to be in the region of £70,000, for which funding would have to be sought from H.M. Prison and Probation Service, but HMP Hewell has not made any bid for such funding since Mr. Olgun’s death 7½ years ago. The Head of Safety at the prison also confirmed in evidence that the two available “Safer Cells” have been used to house prisoners within the Segregation Unit who are thought to be at an increased risk of suicide or self-harm. This would suggest that the prison accepts in principle that such cells have a meaningful role to play in reducing such risk. I am concerned that as long as “Safer Cells” are not made available away from the Segregation Unit at HMP Hewell, an important measure for reducing the risk of suicide or self-harm is being withheld from vulnerable prisoners at that prison. ”

    Source location

    Mesut Olgun · 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

    Convert 50 cells to ligature-resistant standard across 13 establishments.

    Verbatim wording from the response

    “At present, HMPPS is nearing completion of a project to convert fifty cells across thirteen establishments, which were selected on the assessed levels of risk at the time. We are hopeful that further installations will be possible in 2026/27, again prioritising locations with the highest assessed level of risk.”

    Source location

    Response from HM Prison & Probation Service
    Page 1 · response
    Published 23 December 2025

    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

    Further expansion of ligature-resistant cell provision is conditional on available resources.

    Verbatim wording from the response

    “It is important to emphasise that an LR cell on its own cannot eliminate risk. The term “ligature-resistant” replaced “safer cell” to reflect the reality that prisoners may still find other means to self-harm. Staff guidance makes clear that LR cells are a valuable measure, but they must be used alongside other forms of support. Where LR cells are unavailable, or where moving a prisoner could increase risk, these alternative measures remain essential. Nonetheless, HMPPS’ ongoing ambition is to strengthen this approach further by expanding LR cell provision wherever resources permit.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 23 December 2025

    Open published response

  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Thomas Victor HUNTLEY · Prevention of Future Deaths report

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

    Report summary

    Thomas Victor Huntley died in HMP Winchester after he was found unresponsive in his cell on 28 May 2020, following a planned act intended to end his life. The inquest identified concerns about missing and inadequately recorded risk information, failures in ACCT documentation and risk assessment, inadequate observations, information sharing between prison and healthcare staff, and ligature risks in cells.

    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 certified Safer Cells for managing ligature risk

    Wider context from the report

    “The final area of concern is the lack of certified Safer Cells at HMP Winchester. The inquest heard evidence that these had either never existed at HMP Winchester or had not done so for many years. The evidence from prison governors was that, generally speaking within the prison estate, they were not used or proved too hard to maintain to the certified standard. However certified Safer Cells is still referred to in PSI 64/2011 as a means of managing risk from ligatures. It was heard in evidence that HMP Winchester experience high levels of self-harm and suicide and yet it did not appear that consideration had been given recently to introducing these. Those representing the HMPSS at the were invited to provide information about the status and use of safer certified cells across the prison estate. No such information has been forthcoming. ”

    Source location

    Thomas Victor HUNTLEY · 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

    Review ligature-resistant cell standards and their use in supporting prisoners in crisis.

    Verbatim wording from the response

    “The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible. The review has included the cell build standards and how they are used to support prisoners in crisis. Our aim is to ensure that cells that are fitted with ligature-resistant features are available as an option for staff managing prisoners in crisis, and that they retain those features in full working order and do not deviate from the standard over time. At this point it is too early to say what new rules may be introduced, such as setting the frequency of maintenance, although we do recognise that cells are subject to constant wear and tear and need frequent attention to keep them up to standard.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 22 November 2023

    Open published response

  3. West Yorkshire Eastern

    AI-generated summary

    Wayne Boughen · 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

    Wayne Boughen was detained at HMP Leeds when he suspended himself from a ligature in his cell on 16 November 2018 and died in hospital the following day. The report raised concerns that HMP Leeds had no certified safer cells meeting national standards, and that he was able to suspend himself using a ligature fashioned from a prison-issued jumper.

    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 provide cells certified as safer cells in accordance with national standards

    Wider context from the report

    “1. At the time of Wayne Boughen’s death, HMP Leeds did not have any cells which were certified safer cells (anti-ligature cells) in accordance with national standards. 2. HMP Leeds still does not have any such certified safer cells. 3. HMP Leeds has a small number of cells which have an increased level of safety as compared with the majority of cells within the prison, but even they do not comply with the certified safer cell standards. ”

    Source location

    Wayne Boughen · 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

    Work with the maintenance contractor to identify further opportunities to reduce ligature points in cells.

    Verbatim wording from the response

    “Many older establishments, including HMP Leeds, are built in a way that it makes it impossible to refurbish most cells in a way that fully meets every aspect of the safer cell specification. For this reason there is no requirement in our policy for prisons to have, or to use, safer cells. Nonetheless the Governor of HMP Leeds is committed to improving the safety of the available accommodation where possible, and will continue to work with Amey, the maintenance contractor, to identify opportunities for further work to reduce the availability of ligature points in cells.”

    Source location

    2021-0217-Response-from-HMPPS_Published
    Page 1 · response
    Published 28 June 2021

    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

    Fully compliant safer cells do not eliminate suicide or self-harm risk and are not sufficient alone to protect prisoners.

    Verbatim wording from the response

    “I fully appreciate your concerns and would like to reassure you that we are committed to ensuring that prisoners in our care, particularly those who are considered to be at a risk of suicide or self-harm, are located in the safest environment possible. We recognise that cell safety is an important part of managing prisoners at risk, and wherever possible new builds and major refurbishment projects are delivered to the published safer cell specification. However we also know that placing someone who has been identified as being at risk in a safer cell that is fully compliant with the standard does not fully eliminate that risk. We therefore believe that whilst safer cells can be of assistance, they are not sufficient on their own to protect prisoners.”

    Source location

    2021-0217-Response-from-HMPPS_Published
    Page 1 · response
    Published 28 June 2021

    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

    Older establishments, including HMP Leeds, cannot refurbish most cells to fully meet every aspect of the safer cell specification.

    Verbatim wording from the response

    “Many older establishments, including HMP Leeds, are built in a way that it makes it impossible to refurbish most cells in a way that fully meets every aspect of the safer cell specification. For this reason there is no requirement in our policy for prisons to have, or to use, safer cells. Nonetheless the Governor of HMP Leeds is committed to improving the safety of the available accommodation where possible, and will continue to work with Amey, the maintenance contractor, to identify opportunities for further work to reduce the availability of ligature points in cells.”

    Source location

    2021-0217-Response-from-HMPPS_Published
    Page 1 · response
    Published 28 June 2021

    Open published response

  4. Manchester City

    AI-generated summary

    Tomasz Nowosad · 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

    Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Insufficient availability of safer cells and CCTV-monitored cells

    Wider context from the report

    “5.14 It is suggested that HMPS should consider increasing the number of Safer cells throughout the whole of the prison and also having more CCTV monitored cells. ”

    Source location

    Tomasz Nowosad · Prevention of Future Deaths report
    Page 7 · 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

    Increase the availability of safer cells for governors wherever possible through the national prison safety programme.

    Verbatim wording from the response

    “Fourth, safer cells (5.13-5.14). You are concerned that more such cells should be available, and that the movement of prisoners who are subject to ACCT from a safer cell to another location should be carefully managed. I understand the importance of reducing access to the means of suicide wherever possible. Physical safety, including increasing the provision of accommodation free of ligature points, is one of the work streams in our national prison safety programme. You will appreciate that large amounts of capital investment are necessary to improve the environment in this way, and we are not able to move as swiftly as we would want to. However, wherever possible we are increasing the numbers of safer”

    Source location

    2019-0445-Response-from-HMPPS
    Page 2 · response
    Published 8 January 2020

    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

    Capital investment requirements prevent safer-cell environmental improvements from progressing as quickly as desired.

    Verbatim wording from the response

    “Fourth, safer cells (5.13-5.14). You are concerned that more such cells should be available, and that the movement of prisoners who are subject to ACCT from a safer cell to another location should be carefully managed. I understand the importance of reducing access to the means of suicide wherever possible. Physical safety, including increasing the provision of accommodation free of ligature points, is one of the work streams in our national prison safety programme. You will appreciate that large amounts of capital investment are necessary to improve the environment in this way, and we are not able to move as swiftly as we would want to. However, wherever possible we are increasing the numbers of safer”

    Source location

    2019-0445-Response-from-HMPPS
    Page 2 · response
    Published 8 January 2020

    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

    Existing ACCT support is considered sufficient to manage acute risk in most cases without additional safer-cell provision.

    Verbatim wording from the response

    “cells available to governors. At HMP Manchester there are currently fourteen safer cells. Ten are in the healthcare unit, five of which are equipped with CCTV. Four non-CCTV cells are around the prison healthcare electro-chronic doors. Whilst there are currently no plans to increase the number of safer cells, we will keep this under review.”

    Source location

    2019-0445-Response-from-HMPPS
    Page 3 · response
    Published 8 January 2020

    Open published response

  5. 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

    Insufficient availability of safer cells across prison wings for prisoners on ACCT

    Wider context from the report

    “5. At the present time the HCC caters for some 22 patient prisoners and has 10 safer cells. I am concerned that the prison has a very limited number of safer cells on a limited number of other wings. At the present time there are no safer cells on all the wings ( invariably single occupancy designed to minimise the risk of using ligatures ). If prisoners are subject to ACCT’s and either transferred from one wing to another or transferred from the HCC to an ordinary wing location ( for what ever reason ) there is no half way house facility providing increased levels of safety. The provision of safer cells has demonstrably reduced the opportunity for fatal self harming in the over whelming majority of cases. Without HMPS investing in the provision of safer cells on every wing or of an increased number of wings there is a concern that prisoners will continue to kill themselves in non safer cells when they are on ACCT’s. The same considerations would apply nationally to the entire HMPS estate. ”

    Source location

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