Recurring concern

Unreliable crisis telephone access for prisoners

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First reported 30 Jun 2014•Latest report 20 Mar 2026

Definition

What this concern includes

Includes failures of prison arrangements specifically intended to provide or enable timely telephone access for prisoners in crisis or needing emotional support, including access after cell lockdown, handset provision, staff-assisted access, family-contact routes and access to crisis-support services.

Not included

  • Excludes general prison telephone availability or routine prisoner communications where no crisis, emotional-support or safety need is identified.
  • Excludes the content or quality of family, Samaritans or other support conversations after reliable telephone access has been provided.
  • Excludes generic staffing, communication, emotional-support or family-involvement deficiencies unless they directly impair crisis-related prison telephone access.
  • Excludes physical ligature hazards from telephone equipment where telephone access is not the unsafe condition.
  • Excludes broader mental-health, suicide-prevention or family-contact processes when the specific deficiency is not unreliable telephone access for a prisoner in crisis.
Reports
3

Distinct published reports

Individual concerns
3

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
3

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 Service2
Ministry of Justice2
Elmley Prison1
Hindley Prison1
Lincoln Prison1
Youth Justice Board for England and Wales1

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. Greater Lincolnshire

    AI-generated summary

    Luke Owen ASHCROFT · 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

    Luke Ashcroft was admitted to Lincoln County Hospital from HMP Lincoln after being found unconscious in his cell in the Care and Separation Unit. His death was confirmed on 1 July 2020, with the post-mortem finding hypoxic brain injury consistent with ligature application. The inquest identified concerns about missed healthcare opportunities, inadequate information sharing and risk mitigations, shortcomings in the ACCT plan, and failures to carry out required observations; it also raised concerns about the safety and availability of corded telephone access in the unit.

    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 ensure reliable telephone access after CSU cell lockdown

    Wider context from the report

    “My concerns are twofold. Firstly, whilst not directly relevant to the death of Luke Ashcroft, I am concerned about the clear and obvious risks of self harm posed by the provision of a corded telephone, secured at one end, suspended at head height in a cell commonly occupied by prisoners, who may seek to self harm. I was told that the cell J109 had no ligature points and that the door was fitted with anti ligature fittings. As a consequence, that was the only method of securing telephone access. That same issue may extend to other cells in the CSU. Whether at head height or otherwise, the provision of a corded phone may well be an issue in potential cases of self harm and appears incongruous in comparison with other steps taken to ensure safety within that cell. The risks of an inmate utilising that cord in an act of self harm are self evident. Secondly, the mechanism of provision of telephone access on CSU appears to require a prisoner requesting such provision before the cells are locked down. Thereafter, whilst a request can be made by a prisoner, telephone provision may depend upon the availability of additional officers to attend whilst the cell is unlocked and the telephone provided. That is not certain to take place. Given the proper availability to prisoners in crisis of freephone access to Samaritans and similar services, the possible absence of a handset to access such services is a matter of concern. ”

    Source location

    Luke Owen ASHCROFT · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review current Care and Separation Unit telephony arrangements.

    Verbatim wording from the response

    “The establishment has undertaken a review of the current telephony arrangements within the CSU. While the relocation of telephone sockets within cells has been considered, this would require significant structural alteration and capital investment. The Governor of HMP Lincoln is therefore developing a formal business case to assess the feasibility, proportionality, and associated operational and security risks of implementing such a longer-term solution.”

    Source location

    Response from HM Prison and Probation Service
    Page 1 · response
    Published 26 March 2026

    Open published response

  2. Mid Kent and Medway

    AI-generated summary

    James Devenny · 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

    James Devenny died in his cell at HMP Elmley on 2 September 2019, having been found hanging from a light fitting using a bedsheet ligature. The jury identified concerns including staff not being aware of his previous self-harm history, the absence of a medical assessment before his separation from other prisoners, an inappropriate response to mental health referrals, and inadequate access to phones and support services. The report also records concerns about prison officers not being routinely briefed about prisoners’ previous significant self-harm and related patterns of thoughts, feelings, events and behaviours.

    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 direct and immediate access to telephone, listening and chaplaincy support for prisoners

    Wider context from the report

    “(1) In the absence of telephones which are installed directly into the cell, there is no direct means for a prisoner to contact the Samaritans. In the event that a prisoner does not have access to a telephone they are reliant on staff to convey them to a telephone so they may call. There is a particular difficulty in respect of prisoners who are deemed to pose a risk of violence and who may not be able to immediately access a telephone, a listener or a member of Chaplaincy. ”

    Source location

    James Devenny · 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 in-cell telephony at HMP Elmley, resolving handset supply issues except for Care and Separation Unit and healthcare in-patients.

    Verbatim wording from the response

    “At the time of Mr Devenny’s death, in-cell telephony had only recently been introduced at HMP Elmley, and there were initially some supply issues which meant that not all cells were equipped with the necessary handsets. These have now been resolved, and with the exception of those in the Care and Separation Unit (CSU) and Healthcare in-patients, all those in custody at HMP Elmley now have in-cell phones.”

    Source location

    2021-0179-Response-from-HMPPS_Published
    Page 1 · response
    Published 27 May 2021

    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

    Maintain dedicated Samaritans phones in wing offices, updating them for visibility, programming them exclusively for Samaritans, and checking their operation.

    Verbatim wording from the response

    “All people in custody across the prison estate are able to call Samaritans without charge using a pin number given out on induction and widely circulated around the prison. In the event that in-cell telephony is unavailable, individuals can also request the dedicated Samaritans phones that are held in each wing office and are taken to people in their cells. These phones have been updated, and the handsets are now bright green, as a visual association with the colours used by the Samaritans and to make them more visible to staff so that they can be quickly identified and provided once requested. These phones are programmed with only the Samaritans phone number and staff check them regularly to ensure that they are in full working order.”

    Source location

    2021-0179-Response-from-HMPPS_Published
    Page 1 · response
    Published 27 May 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

    Existing arrangements provide access to Samaritans by in-cell phones or dedicated wing phones when in-cell telephony is unavailable.

    Verbatim wording from the response

    “At the time of Mr Devenny’s death, in-cell telephony had only recently been introduced at HMP Elmley, and there were initially some supply issues which meant that not all cells were equipped with the necessary handsets. These have now been resolved, and with the exception of those in the Care and Separation Unit (CSU) and Healthcare in-patients, all those in custody at HMP Elmley now have in-cell phones.”

    Source location

    2021-0179-Response-from-HMPPS_Published
    Page 1 · response
    Published 27 May 2021

    Open published response

  3. Manchester West

    AI-generated summary

    Jake Reginald Hardy · 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

    Jake Reginald Hardy, a 17-year-old detained at HM YOI Hindley, died on 20 January 2012 after being found partially suspended by a ligature in his cell. The report describes failures to identify, record and respond to his vulnerabilities, self-harm risk and reports of verbal bullying, including failures in safeguarding, ACCT care planning, supervision and overnight risk assessment. Concerns also included ligature points in cells, inadequate personal officer support, staff training and communication systems, and limited access to family telephone support.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a system for timely telephone contact with family during crisis or emotional need

    Wider context from the report

    “5. The children and young persons detained at HM YOI Hindley are provided with a weekly credit which they may use to telephone family or other approved numbers. Calls are made from a communal telephone located in the association area of a wing. Prison staff have a discretion to permit further calls to be made from an office telephone for good reason. I was told that in-cell telephony has been introduced in newly built parts of the children and young persons’ estate but it is not available in HM YOI Hindley and other Young Offender Institutes. Currently, therefore, these detainees are not able to speak privately on the telephone and there is no sufficient system in place to ensure that a child or young person in crisis or in need of emotional support (whether by reason of being bullied or experiencing feelings of self-harm or suicide) can speak to a family member without significant delay. ”

    Source location

    Jake Reginald Hardy · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
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Data last updated 7 September 2026