Recurring concern

Insufficient resourcing of prison self-harm prevention functions

First to latest report 20 Sep 2016 — 20 May 2026

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
3

What this concern includes

Includes staffing, resource and capacity deficiencies in prison functions specifically responsible for preventing or managing prisoner self-harm, including Safer Custody and officer resources for self-harm prevention duties, where the deficiency limits the function's ability to identify risk and provide protective action.

What is not included
  • Excludes general prison staffing or regime-capacity deficiencies that are not specifically tied to prisoner self-harm prevention functions.
  • Excludes failures in ACCT, observation, risk assessment, training or information sharing where resourcing of the self-harm prevention function is not the shared unsafe condition.
  • Excludes healthcare staffing shortages unless they directly concern a prison self-harm prevention function.
  • Excludes individual self-harm incidents or outcomes without an identified continuing resourcing or capacity deficiency.

Reports and published responses 3 reports

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

  1. Nottinghamshire

    AI-generated summary

    Ricky Crosher and Matthew Osborne · 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

    Ricky Crosher and Matthew Osborne were prisoners at HMP Lowdham Grange who died by suicide in October and November 2023, respectively. Both had been identified as at increased risk of suicide and self-harm and placed on ACCT plans, but the plans and welfare checks were not managed in accordance with policy. The report identified concerns about Safer Custody staffing and systems, the safety and management of the Care and Separation Unit, learning from deaths, retention of evidence, and cooperation between prison and healthcare staff.

    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 maintain an appropriately staffed and resourced Safer Custody function

    Wider context from the report

    “1. Failure to have in place an appropriately staffed and resourced Safer Custody function ”

    Source location

    Ricky Crosher and Matthew Osborne · 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

    Complete and ringfence the Safer Custody Safety team to maintain consistent visibility and support for vulnerable prisoners.

    Verbatim wording from the response

    “Your first concern is around staffing and resource within the Safer Custody function at HMP Lowdham Grange. As of March 2026, the Safety team now has a full complement of staff, and to enable the team to be consistently visible across the establishment, the resource has been ringfenced, meaning that staff cannot be redeployed to carry out alternative routine duties. This ensures the staff in the team have the opportunity to actively engage with the most vulnerable prisoners and ensure that appropriate support is consistently provided.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 28 July 2026

    Open published response

  2. 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

  3. Leicester City and South Leicestershire

    AI-generated summary

    Liam Adrian John Lambert · 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 Adrian John Lambert was a young offender at Glen Parva Young Offenders Institution who died after ligaturing himself in a single cell on the evening of 19 March 2015. The report identified concerns about bullying and assaults, inadequate completion and use of the ACCT self-harm documentation, its inappropriate closure, prison resourcing, and delays in the emergency response and access for paramedics.

    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 resourcing for officers’ duties to keep prisoners safe from self-harm

    Wider context from the report

    “3. The Governor provided evidence that resourcing was affecting the ability of officers to carry out their duties regarding keeping prisoners safe from self harm. In this particularly vulnerable population of young men, their safety is paramount and this should be the first consideration. ”

    Source location

    Liam Adrian John Lambert · 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

    Consider increasing Glen Parva’s benchmark operating level by 12 prison officers through the submitted business case.

    Verbatim wording from the response

    “Staffing levels in public sector prisons have been set through a benchmarking process, designed to provide sufficient staff for the prison to operate safely, decently and securely. The Governor has raised concerns about the staffing level at Glen Parva, and recently submitted a business case to increase by 12 prison officers the benchmark operating level set for the prison. This is under consideration. Moreover, the prison has frequently been operating below this level, as there are currently a number of staff vacancies, most significantly at prison officer and operational support grade levels, and these are having an impact on the regime. Where there are insufficient staff available to deliver the new benchmarked regime, proportionate curtailments to the regime are made.”

    Source location

    2016-0335-Response-by-NOMS
    Page 2 · response
    Published 20 September 2016

    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

    Employ over 400 additional prison officers in ten particularly challenging prisons by March 2017 to provide dedicated regular one-to-one support.

    Verbatim wording from the response

    “In the light of the evidence of increased violence and higher levels of self-inflicted deaths in prisons, the Secretary of State for Justice recently announced that an additional 2,500 more prison officers will be employed across the prison estate by the end of 2018. This includes an immediate investment of £14m to bring over 400 additional prison officers into ten particularly challenging prisons by March 2017. This will allow every offender to have a dedicated prison officer offering regular, one-to-one support.”

    Source location

    2016-0335-Response-by-NOMS
    Page 2 · response
    Published 20 September 2016

    Open published response

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