Recurring concern

Insufficient prison staffing capacity for safe regime operation and incident response

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First reported 3 Sep 2014•Latest report 24 Mar 2026

Definition

What this concern includes

Includes deficiencies in prison staffing establishment, benchmarks, deployment or coverage where they directly impair safe operation of the prison regime, welfare monitoring, emergency response or incident management, including pressure from changing prisoner cohorts, contraband or substance-related incidents.

Not included

  • Excludes staffing deficiencies in healthcare, care homes, police call-handling or other non-prison services unless the assertion explicitly concerns prison staffing.
  • Excludes failures of staff competence, training or supervision when staffing capacity is not the shared unsafe condition.
  • Excludes restricted regimes, observation failures or delayed responses when they are asserted without a direct prison staffing-capacity deficiency.
  • Excludes generic workforce or resource shortages that are not tied to safe prison regime operation or incident response.
Reports
9

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
22

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 Service7
Ministry of Justice3
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham Prison1
Lowdham Grange Prison1
NHS England1
Nottinghamshire Healthcare NHS Foundation Trust1
Serco Group plc1
Sodexo1

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. Kent and Medway

    AI-generated summary

    Thomas Daniel RUGGIERO · 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 Daniel Ruggiero, a 39-year-old man serving a prison sentence at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing himself and died later that day. The report raised concerns about insufficient communication between prison staff and the wider prison estate’s high levels of inexperienced officers, linked to recruitment and retention issues.

    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 numbers of experienced prison officers across the prison estate

    Wider context from the report

    “(1) The evidence was that in November 2024, up to (and possibly more than) 90% of prison officers at HMP Swaleside were new and still in their probationary period. I was told in evidence by a Supervising Officer (SO) that on 16 November 2024, he 'possibly did not have the right mix of staff in terms of skills and experience to keep the wing safe'. In this inquest, the jury found that, "the communication between prison staff was insufficient and lacked clarity". I was told that the level of officers still in their probationary period has now reduced. I was also made aware of the 'Urgent Notification' (UN) from HM Chief Inspector of Prisons in relation to HMP Swaleside (December 2025), which included in the rationale, "Staff, many of whom lacked experience, were not confident in challenging poor behaviour and there was a lack of order and control." This suggests to me that the issue is ongoing. When exploring the evidence further, I was told that issues relating to the recruitment and retention of prison officers were significant and that this is not something that it is confined only to HMP Swaleside. There was evidence that this is a much wider issue. Without sufficient numbers of experienced prison officers across the prison estate, the staffing issues seen in this particular inquest are likely not isolated. I highlight to you my concern that high levels of inexperienced staff will undoubtedly contribute to future deaths of those in custody. ”

    Source location

    Thomas Daniel RUGGIERO · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Birmingham and Solihull

    AI-generated summary

    Derrion Jack ADAMS · 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

    Derrion Adams died at HMP Birmingham on 31 October 2024 after being found unresponsive in his cell and subsequently being pronounced deceased following a cardiac arrest. The report states that his death was due to toxicity from a substance. The principal concerns were the availability of drugs and contraband in the prison, surges in drug-related incidents, and staffing levels that were insufficient to ensure his cell call bell was answered within the target time, delaying identification and response.

    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 staffing benchmarks to account for operational pressures from contraband and psychoactive substance incidents

    Wider context from the report

    “6. The evidence was that HMP Birmingham is operating at its target staffing figures and has measures in place to deploy extra staff to areas of need in response to incidents. Additionally it is hoped that the introduction of tamper-proof vapes will limit use of psychoactive substances. However, my concern is that the current target staffing figures, which are based on historic bench marking and apply nationally, do not take into consideration the additional challenges to prison staff from contraband entering prisons via drones and, in particular, the burden placed on staff as a consequences of prisoners using psychoactive substances and other drugs. This concern is underlined by the fact that the staffing on the wing was not sufficient to ensure the call bell for Derrion's cell was answered within the target time resulting in a delay in identifying and responding to his cardiac arrest. 7. My overall concern is that current staffing benchmarks may not reflect the escalating operational pressures caused by the security threat from ████████ and intermittent surges in psychoactive substance incidents, leaving prison staff safety and welfare, and that of staff, at significant risk. ”

    Source location

    Derrion Jack ADAMS · 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 a review of adult public-sector prison staffing models, including operational pressure impacts on daily resourcing.

    Verbatim wording from the response

    “Recent work has been completed to review the underpinning staffing model for adult public sector prisons, including HMP Birmingham. This review has included consideration of the impact that changes to operational pressures have had on daily resourcing requirements. New models are currently at the implementation planning stage and remain subject to final decisions.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 19 November 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

    Develop implementation plans for new adult public-sector prison staffing models, subject to final decisions.

    Verbatim wording from the response

    “Recent work has been completed to review the underpinning staffing model for adult public sector prisons, including HMP Birmingham. This review has included consideration of the impact that changes to operational pressures have had on daily resourcing requirements. New models are currently at the implementation planning stage and remain subject to final decisions.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 19 November 2025

    Open published response
  3. Nottinghamshire

    AI-generated summary

    Anthony Binfield and 2 others · 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

    Anthony Binfield, David William Richards and Rolandas Karbauskas died at HMP Lowdham Grange in March 2023 after using ligatures; Anthony’s and Rolandas’s deaths were suicides, while David’s death was accidental. The report identified missed opportunities to recognise and share risk information, shortcomings in prison and healthcare staffing, training and systems, and concerns about prisoner transfers, isolation, the prison contract transfer, and learning from previous deaths.

    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

    Inadequate prison and healthcare staffing levels

    Wider context from the report

    “The inadequate prison and healthcare staffing levels led to a restricted regime and healthcare provision. The prison was unable to offer keywork to all men, and the mental health team could no longer offer a named nurse service. Both of these aspects of care are fundamental to supporting the most vulnerable prisoners. ”

    Source location

    Anthony Binfield and 2 others · 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

    Promote prison nursing recruitment through the ‘We Are Prison Nurses’ campaign and its recruitment resources.

    Verbatim wording from the response

    “To help address workforce demands within prisons, nursing within the criminal justice system (CJS) needs to be widely promoted as a career option and NHS England is supporting this promotion with the ‘We Are Prison Nurses’ campaign and nursing preceptorship (a period of structured transition where newly qualified nurses are supported by an experienced practitioner).”

    Source location

    Response from NHS England
    Page 1 · response
    Published 13 February 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

    Provide recruitment, retention and staffing support to improve workforce levels at Lowdham Grange.

    Verbatim wording from the response

    “Since taking over the management of Lowdham Grange HMPPS has taken a number of steps to improve recruitment and retention, including the provision of additional support to the prison to undertake recruitment activity.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 13 February 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

    Ringfence key safety tasks and safer-custody staff against future resourcing pressures.

    Verbatim wording from the response

    “We know that you will share a copy of this response with the families, and we would like to again express our sincere condolences for their loss. Following the inquests Sodexo have ringfenced key safety tasks and safer custody staff in the event of changes in resourcing pressures. The implementation of learning from these sad deaths is a priority.”

    Source location

    Response from Sodexo
    Page 3 · response
    Published 13 February 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

    Healthcare staffing is the responsibility of the healthcare provider, which has responded separately.

    Verbatim wording from the response

    “As heard at the inquest, the transition detailed above significantly impacted on a challenging recruitment picture and the low staffing levels along with a reduction in staff with a significant length of service and experience. As you are aware, healthcare staffing is a matter for the healthcare provider, who have responded separately.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 13 February 2025

    Open published response
  4. Buckinghamshire

    AI-generated summary

    Haik Patrick NIKOLYAN · 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

    Haik Patrick NIKOLYAN committed suicide and was found unresponsive in his cell at HMYOI Aylesbury in the early hours of 11 March 2019. The inquest identified concerns including failures to protect him from harm, withdrawal of depression medication without documented risk assessment or enhanced monitoring, bullying and exploitation, ineffective safeguarding and communication, and inadequate consideration of his Autism Spectrum Disorder.

    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 general staffing levels for operating the daily regime, training and responding to individual incidents

    Wider context from the report

    “The evidence heard at this Inquest in July 2023 indicates that general staffing levels are likely to impact upon the operation of the daily regime, training and reaction to individual incidents, against a background of increasing levels of violence and access to illicit substances, resulting from the changing cohort of longer-term and older prisoners within this Category C institution. ”

    Source location

    Haik Patrick NIKOLYAN · 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 staffing requirements and redistribute available resources at HMP Aylesbury.

    Verbatim wording from the response

    “To support Aylesbury’s function as a category C trainer prison, a review of all staffing requirements was undertaken which has enabled Governors to review and distribute the resources available more effectively. The staffing position at HMP Aylesbury has notably improved and the now small number of vacancies for Band 3 Officers includes some staff who are currently undergoing training. A number of recruitment initiatives have taken place, with more planned for the coming months, to continue to fill vacancies in other key posts, such as instructors and probation POMs.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 22 September 2023

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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 recruitment initiatives to fill vacancies in instructors, probation POMs and other key posts.

    Verbatim wording from the response

    “To support Aylesbury’s function as a category C trainer prison, a review of all staffing requirements was undertaken which has enabled Governors to review and distribute the resources available more effectively. The staffing position at HMP Aylesbury has notably improved and the now small number of vacancies for Band 3 Officers includes some staff who are currently undergoing training. A number of recruitment initiatives have taken place, with more planned for the coming months, to continue to fill vacancies in other key posts, such as instructors and probation POMs.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 22 September 2023

    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

    Provide priority recruitment-marketing support to HMP Aylesbury and improve staff engagement channels with the establishment.

    Verbatim wording from the response

    “At national level we are taking all necessary steps to improve the staffing position across the country, and we are seeing the impact of that work. Substantial levels of support has been provided to HMP Aylesbury as one of the highest priority prisons for recruitment marketing. In addition, the Prison Resourcing Communications team are working closely with the establishment to improve their staff engagement channels, including their staff newsletter, to increase staff pride and morale to help reduce attrition.”

    Source location

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

    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

    Launch a national television and radio recruitment advertising campaign for HMPPS.

    Verbatim wording from the response

    “In September 2023, the Ministry of Justice launched its first ever large-scale TV and radio advert to support recruitment across England and Wales, aiming to attract new recruits to a career in HMPPS, while getting the public to rethink what working in the prison and probation service involves, all under the slogan “An extraordinary job done by someone like you”.”

    Source location

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

    Staffing at HMP Aylesbury has notably improved, with only a small number of Band 3 officer vacancies, some involving staff undergoing training.

    Verbatim wording from the response

    “To support Aylesbury’s function as a category C trainer prison, a review of all staffing requirements was undertaken which has enabled Governors to review and distribute the resources available more effectively. The staffing position at HMP Aylesbury has notably improved and the now small number of vacancies for Band 3 Officers includes some staff who are currently undergoing training. A number of recruitment initiatives have taken place, with more planned for the coming months, to continue to fill vacancies in other key posts, such as instructors and probation POMs.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 22 September 2023

    Open published response
  5. Mid Kent and Medway

    AI-generated summary

    Liam Ryan Wayne Bentley · 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

    Liam Ryan Wayne Bentley was a serving prisoner at HMP Swaleside who had a history of self-harm and expressed fears about other prisoners and suicidal thoughts. He later took his own life, although his intention was unclear. The report identified concerns about inadequate psychological support, failures in self-harm monitoring and care planning, ineffective communication, and staff shortages and training gaps.

    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 prison staffing levels

    Wider context from the report

    “(1) There was evidence from prison staff from which it was concluded by the jury that the safety of deceased was compromised as a result in staff shortages (2) The current complement of Band 2 Operational Support Group staff is 71% this is predicted to further reduce to 54%, the current complement of Band 3 Prison Officers is 68% this is predicted to further reduce to 46%. ”

    Source location

    Liam Ryan Wayne Bentley · 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

    Continue monitoring staffing levels and provide short-term tactical staffing support through overtime and detached-duty staff.

    Verbatim wording from the response

    “Ensuring that prisons are sufficiently resourced is fundamental to ensuring that we are delivering quality outcomes for offenders. We continue to monitor staffing levels at HMP Swaleside and, as in other establishments, look to provide short-term tactical support where possible. Where establishments feel that their staffing levels will affect stability or regime, there are a number of ways they can maximise the use of their own resource and seek support from other establishments in the short term, through processes managed nationally at agency level. These include overtime payments and support via detached duty staff from other prisons.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 7 July 2023

    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

    Introduce a colleague mentor scheme supporting staff new to the prison service during their early careers.

    Verbatim wording from the response

    “In addition to short-term support, we are seeking to improve the staffing position at HMP Swaleside through a range of interventions across pay, recruitment and retention. This”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 7 July 2023

    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

    Support recruitment of Armed Forces veterans and their spouses into frontline roles through Advance into Justice.

    Verbatim wording from the response

    “HMP Swaleside is supported by recruitment interventions including Advance into Justice which supports Armed Forces veterans and their spouses into frontline roles; Prison Officer ‘Futures’ where new recruits are recruited directly to establishments with a strong track record of recruitment but, for the first 23 months, they will be expected to be deployed at a named establishment elsewhere to temporarily reduce their vacancy position; and our National First Time Officer scheme which recruits officers nationally sending them to a prison which has difficulty recruiting, with additional financial support. We also use locally targeted P​​R activity, including a new recruitment ‘landing page’ specific to the prison, where prospective staff can view videos of frontline officers from Swaleside to understand what it is like to work there.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 7 July 2023

    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

    Recruit new officers through the Prison Officer Futures scheme and deploy them temporarily to establishments with staffing vacancies.

    Verbatim wording from the response

    “HMP Swaleside is supported by recruitment interventions including Advance into Justice which supports Armed Forces veterans and their spouses into frontline roles; Prison Officer ‘Futures’ where new recruits are recruited directly to establishments with a strong track record of recruitment but, for the first 23 months, they will be expected to be deployed at a named establishment elsewhere to temporarily reduce their vacancy position; and our National First Time Officer scheme which recruits officers nationally sending them to a prison which has difficulty recruiting, with additional financial support. We also use locally targeted P​​R activity, including a new recruitment ‘landing page’ specific to the prison, where prospective staff can view videos of frontline officers from Swaleside to understand what it is like to work there.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 7 July 2023

    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

    Recruit officers nationally through the National First Time Officer scheme and deploy them to prisons experiencing recruitment difficulty with additional financial support.

    Verbatim wording from the response

    “HMP Swaleside is supported by recruitment interventions including Advance into Justice which supports Armed Forces veterans and their spouses into frontline roles; Prison Officer ‘Futures’ where new recruits are recruited directly to establishments with a strong track record of recruitment but, for the first 23 months, they will be expected to be deployed at a named establishment elsewhere to temporarily reduce their vacancy position; and our National First Time Officer scheme which recruits officers nationally sending them to a prison which has difficulty recruiting, with additional financial support. We also use locally targeted P​​R activity, including a new recruitment ‘landing page’ specific to the prison, where prospective staff can view videos of frontline officers from Swaleside to understand what it is like to work there.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 7 July 2023

    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

    Use locally targeted recruitment activity, including a Swaleside-specific recruitment landing page featuring frontline officer videos.

    Verbatim wording from the response

    “HMP Swaleside is supported by recruitment interventions including Advance into Justice which supports Armed Forces veterans and their spouses into frontline roles; Prison Officer ‘Futures’ where new recruits are recruited directly to establishments with a strong track record of recruitment but, for the first 23 months, they will be expected to be deployed at a named establishment elsewhere to temporarily reduce their vacancy position; and our National First Time Officer scheme which recruits officers nationally sending them to a prison which has difficulty recruiting, with additional financial support. We also use locally targeted P​​R activity, including a new recruitment ‘landing page’ specific to the prison, where prospective staff can view videos of frontline officers from Swaleside to understand what it is like to work there.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 7 July 2023

    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

    Deliver the 2023/24 pay award, including specified increases for operational support grades and prison officers.

    Verbatim wording from the response

    “The 2023/24 pay award will deliver a pay increase of £2,000 for our lowest paid staff, Band 2 Operational Support Grades, as well as a 7% pay increase for Band 3-5 prison officers. HMP Swaleside is also in receipt of a market supplement, which means Band 3 officers working at the prison receive more pay in order to attract and retain more staff. We hope that this significant investment, which builds on progress from last year’s pay award, will have a positive impact on recruitment and retention.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 7 July 2023

    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

    Provide a market supplement for Band 3 officers working at HMP Swaleside to support recruitment and retention.

    Verbatim wording from the response

    “The 2023/24 pay award will deliver a pay increase of £2,000 for our lowest paid staff, Band 2 Operational Support Grades, as well as a 7% pay increase for Band 3-5 prison officers. HMP Swaleside is also in receipt of a market supplement, which means Band 3 officers working at the prison receive more pay in order to attract and retain more staff. We hope that this significant investment, which builds on progress from last year’s pay award, will have a positive impact on recruitment and retention.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 7 July 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

    The cited staffing figures do not represent HMP Swaleside’s current or future staffing position because recruitment, retention and deployment actions are underway.

    Verbatim wording from the response

    “Firstly, I thought it might be helpful to clarify the figures on staffing levels that you have referred to in your report. HMPPS carry out a lot of work to understand reasonable worst case and likely staffing scenarios for prisons, and look to ensure that action is taken to intervene where the recruitment and retention positions look challenging. This includes deploying staff from other sites to supplement the staffing group directly employed at the prison. These figures do not represent the current or future staffing position at HMP Swaleside, in part due to the actions undertaken locally and nationally to improve recruitment and retention.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 7 July 2023

    Open published response
  6. County Durham and Darlington

    AI-generated summary

    Michael Raymond SMITH · 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 Raymond SMITH entered HMP Durham on 10 July 2020, was transferred to SACU after being found to have packages concealed internally, and was discovered self-suspended on 11 July; he died in hospital on 13 July 2020. The principal concerns included the absence of medical and mental health assessments, inadequate staffing while he was subject to three-man unlock, delays in responding to the suspension, and weaknesses in SACU record keeping and multidisciplinary oversight.

    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 staffing for safe operation of the three-man unlock on SACU

    Wider context from the report

    “Between his arrival in SACU at 18.37 on 10 July 2020 and his being discovered self suspended with a ligature at 17.45 on 11 July 2020 there, Michael was subject to a 3 man unlock. On the morning of 11 July, a Saturday, there were 3 officers on duty on SACU. This did permit his cell to be unlocked for a meal to be delivered and for a cursory one and a half minute conversation with a nurse that fell short, on her evidence, of an actual medical examination. On the afternoon of 11 July there were only one or (briefly) two officers on SACU duty per the staff duty log, albeit, as CCTV footage shows, more officers did attend intermittently for specific tasks. The SACU staff duty log shows only one officer on duty for the whole afternoon to 17.00. In any event medical assessments of Michael were not undertaken at any stage while he was on SACU, the reason being given that he was on three man unlock. It appears that there were never sufficient staff available for a dedicated medical assessment to be undertaken. This notwithstanding that evidence from prison officers and a nurse was that during the course of the afternoon Michael`s presentation had become “angrier” and “bizarre”. In fact, it is now known, he had been ingesting toxic amounts ████████, an unlicensed drug, he had secreted into the prison (his being detected at reception as plugged lead him to SACU). ████████ is a highly potent ████████ which effects judgement and lowers inhibitions. The jury subsequently concluded that the absence of medical, and mental health, assessments, and the use of the ████████ (which was never diagnosed), contributed to the Michael`s death. From 17.00, when patrol state commenced, there was clearly only one officer on duty and present. When she discovered Michael self suspended that officer made a perfectly defensible dynamic assessment, electing not to enter the cell unsupported. She made ready to enter for when back up arrived. In the event, partly because there was another discipline incident unfolding on a different wing, this took 2-3 minutes. There were only 16 prison officers available while on patrol state across the entire prison, and they were already at full stretch, and probably beyond it (the Tactical Resources Unit from Doncaster were en route). The evidence was that without knowing precisely when Michael self-suspended any such delay could not be held, on a balance of probabilities, to have entered the chain of causation death. However, the fact remains that there was a delay consequent to Michael being on a three man unlock but there being only a single officer available on SACU while in patrol state. It is reasonable to conjecture that this could have made the difference between life and death in this case, and the repetition of these circumstances could well do so in future. In your response dated 15 November 2021 to the Regulation 28 report of HM Assistant Coroner James Thompson of 21 September 2021 following the Inquest into the death of Charlie Brian Todd at HMP Durham, you wrote, amongst other things: “There is clear management oversight of the SACU”. This is not what the evidence in the instance case showed. Rather, what it made clear was that: 1) the SACU staff log plus CCTV further demonstrated that officers, including officers not posted to SACU, but covering for a shift, were required to allocate various task between themselves on an ad-hoc basis” was an ongoing problem, and this appears to be still ongoing; 2) NOMIS record keeping was unhelpfully sparse (“you would expect more” was the evidence of SACU manager); 3) the daily log was under-utilised as a multi-disciplinary tool, and this appears to be ongoing. You also stated: “I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU`s regime”. This, too, is clearly not the case. Staffing levels remain the same. Safeguarding of prisoners is comprised as a consequence. With a three man unlock imposed, there should be three officers available at all times to ensure safety. Staffing levels at HMP Durham should be increased. ”

    Source location

    Michael Raymond SMITH · 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

    Provide additional SACU staffing resources above national benchmarking requirements.

    Verbatim wording from the response

    “I note that you have referred to a Regulation 28 response relating to an earlier death at HMP Durham. I would like to clarify that this response was sent after Mr Smith’s death, which means the additional resources that were created by the Governor would not have been implemented prior to the death of Mr Smith. However, I can assure you these additional measures do remain in place at the present time which means that the staffing levels within the SACU at Durham are currently above those required by national benchmarking, the tool by which staffing levels are measured. I would also reiterate that the day-to-day running of the unit is overseen by a dedicated Custodial Manager (CM), responsible for the allocation of tasks and performance management of the officers working there.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 4 January 2023

    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

    Conduct a SACU pilot evaluating operational processes and health support to inform a safe, integrated workforce model.

    Verbatim wording from the response

    “It may also be helpful for me to explain that where prisoners are subject to a three person unlock and staff are not readily available to facilitate this, then additional staff can be drawn from across the prison to assist. I acknowledge that at the time did not happen when Mr Smith required a medical assessment and accept staff did not take the necessary actions to ensure Mr Smith could be seen by a medical practitioner. However, the Governor is confident that where this situation arises in the future the resources are in place to respond effectively. A SACU pilot, which is looking at both operational processes within the SACU and the health support provided, is due to conclude in June 2023. This will assist in developing a new workforce model to support the delivery of a safe, integrated holistic approach to the care and management of those residing and working in segregation units.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 4 January 2023

    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 contingency plans to incorporate incident learning and prompt consideration of regime levels and available resources during simultaneous incidents.

    Verbatim wording from the response

    “Unfortunately we must accept that there will be occasions where staff may have to deal with several incidents at once and that these may be taking place in other areas of the prison. We also know that at the time of Mr Smith’s death, resources were being affected due to Durham being a Covid outbreak site. However, HMP Durham will review its contingency plans to incorporate the learning from this incident so that prompts are given to those responsible for managing protracted events to consider regime levels and available resources across the prison, to allow for the appropriate deployment of staff should other incidents occur at the same time.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 4 January 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

    Current SACU staffing exceeds national benchmarks and existing management arrangements are considered sufficient, so staffing increases are not indicated.

    Verbatim wording from the response

    “I note that you have referred to a Regulation 28 response relating to an earlier death at HMP Durham. I would like to clarify that this response was sent after Mr Smith’s death, which means the additional resources that were created by the Governor would not have been implemented prior to the death of Mr Smith. However, I can assure you these additional measures do remain in place at the present time which means that the staffing levels within the SACU at Durham are currently above those required by national benchmarking, the tool by which staffing levels are measured. I would also reiterate that the day-to-day running of the unit is overseen by a dedicated Custodial Manager (CM), responsible for the allocation of tasks and performance management of the officers working there.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 4 January 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

    Existing arrangements allow additional prison staff to assist with three-person unlocks, and resources are considered sufficient to respond effectively in future.

    Verbatim wording from the response

    “It may also be helpful for me to explain that where prisoners are subject to a three person unlock and staff are not readily available to facilitate this, then additional staff can be drawn from across the prison to assist. I acknowledge that at the time did not happen when Mr Smith required a medical assessment and accept staff did not take the necessary actions to ensure Mr Smith could be seen by a medical practitioner. However, the Governor is confident that where this situation arises in the future the resources are in place to respond effectively. A SACU pilot, which is looking at both operational processes within the SACU and the health support provided, is due to conclude in June 2023. This will assist in developing a new workforce model to support the delivery of a safe, integrated holistic approach to the care and management of those residing and working in segregation units.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 4 January 2023

    Open published response
  7. West Yorkshire Eastern

    AI-generated summary

    Robert Scott McLoughlin · 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

    Robert Scott McLoughlin, an inmate at HMP Leeds, was found suspended by a ligature on 20 February 2016 and died in hospital on 25 February 2016. The report raised concerns about very low staffing levels, including the absence of a Landing Officer, resulting in ACCT reviews not taking place for several hours.

    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 staffing levels for required prison operations

    Wider context from the report

    “(1) The staffing levels at HMP Leeds were very low. On the evening of the 19th February 2016 when Mr McLoughlin self-harmed there was one Officer Support Grade on his wing. In addition there were only six Prison Officers on the night shift. On the morning of the 20th February 2016 the staffing levels were such that there was no Landing Officer on Mr McLoughlin’s landing. As a result ACCT reviews did not take place between approximately 0730 hours and 1340 hours. ”

    Source location

    Robert Scott McLoughlin · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  8. Wiltshire and Swindon

    AI-generated summary

    Calam Atour · 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

    Calam Atour died by suicide in his room at Erlestoke House on 13 May 2015, after hanging himself by a ligature from the window. The inquest identified concerns about staffing shortages, medical support and coordination, the ACCT process, and the adequacy of monitoring and responses to suicide risk. The report also raised concerns that staffing levels and the way staffing requirements were assessed could create unsafe conditions for prisoners and prison officers.

    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 operational prison staffing for safe custody and officer safety

    Wider context from the report

    “I. I am concerned that unless the staffing number issue is resolved that when Alfred & Wessex Units reopen next year it will again create a significant staffing issues and a reduction of around 20% in operational personnel. I am concerned that this level of reduction has the potential and propensity to create an unsafe system of work for the prison officers (I heard during the course of the Inquest that 1 officer who was due to attend Court to give evidence sadly was the victim of a serious assault whilst on duty at Erlestoke recently). I am concerned that with a reduction in operational staff members that there is a risk that such assaults will increase. Such assaults can result in serious injury or even worse death. I am also concerned as regards the welfare of the prisoners and as regards the ability of the prison officers as a result of the pressure on their numbers to safeguard the lives of those in prison insofar as reasonable practicable against the risk of prisoners harming themselves or others or even taking their own lives. It was clear that there was a huge amount of reliance of goodwill amongst prison staff but with the continuing pressure on staffing the reality I heard is that the goodwill gets eroded overtime, as the ability to function in the workplace becomes increasingly pressurised and more stressful. The position is not sustainable long term. ”

    Source location

    Calam Atour · Prevention of Future Deaths report
    Page 3 · 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 account for prisoner type when determining safe staffing levels

    Wider context from the report

    “III. It was also brought to my attention that in terms of benchmarking on the previous occasion, that it did not take into account the type of prisoners that may be sent to a particular prison. Insofar as Erlestoke is concerned, due to its rehabilitation categorisation and as regards the training and courses made available to prisoners that a considerable number of the prisoners at Erlestoke are either “lifers” or on an indeterminate prison sentence, both of these, of course, relate to serious crimes. I am concerned that not taking into account the type of prisoner when determining safe/efficient numbers of personnel could lead to a lower than safe number of personnel available for duty. This concerns overlaps and dovetails with my concern at para I. above. ”

    Source location

    Calam Atour · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  9. Birmingham and Solihull

    AI-generated summary

    Yohannes Kidane · 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

    Yohannes Kidane was remanded into custody at Birmingham Prison and was found in his cell with a noose around his neck after previous self-harm incidents. CPR was provided, but he was declared dead on 19 December 2013. The concerns included insufficient night staffing in the healthcare wards, compromised ACCT observations, and the impact of staff not taking breaks on prisoner care and staff wellbeing.

    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 night staffing to enable staff comfort breaks

    Wider context from the report

    “(3) When I asked how staff took breaks at night I was told staff did not take breaks during the night. I am concerned about the impact this would have on the care and wellbeing of prisoners and on the staff. Staff must need to take comfort breaks throughout the night which would add an additional burden on the already stretched staffing levels. ”

    Source location

    Yohannes Kidane · Prevention of Future Deaths report
    Page 1 · 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

    Liaise with Birmingham Community Healthcare Trust and G4S regarding night staffing levels and additional overnight support.

    Verbatim wording from the response

    “In order to respond to the concerns that you have raised, the Trust has liaised with Birmingham Community Healthcare Trust (who provide physical healthcare on Ward 1 of the healthcare centre) and G4S who provide healthcare prison officers in the”

    Source location

    2014-0392-Response-by-Birmingham-Solihull-NHS
    Page 1 · response
    Published 3 September 2014

    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

    Continue pursuing Commissioner funding for an additional Ward 2 staff member.

    Verbatim wording from the response

    “I am disappointed to report that we asked our Commissioner to attend two meetings regarding funding of an extra staff member for Ward 2. They declined to attend”

    Source location

    2014-0392-Response-by-Birmingham-Solihull-NHS
    Page 3 · response
    Published 3 September 2014

    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 night staffing and break-cover arrangements are considered sufficient, with additional staff available for high ACCT numbers or continuous supervision.

    Verbatim wording from the response

    “Staff breaks at night The Night Orderly Officer arranges cover for breaks with the staff on duty at the beginning of each night shift. If there is a particularly high number of prisoners subject to Assessment, Care in Custody and Teamwork (ACCT) process in one location, the Night Orderly Officer may choose to locate an additional member of staff in that area. This is not common practice as night staffing levels are assessed as sufficient, but it is an option that can be used. If there”

    Source location

    2014-0392-Response-by-NOMS
    Page 1 · response
    Published 3 September 2014

    Open published response
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Data last updated 7 September 2026