Recurring concern

Unreliable emergency cell-entry arrangements in prisons

First to latest report 28 Dec 2014 — 7 Apr 2026

Reports that mention this concern
9
Times this concern has been raised
11
Stated actions linked to this concern
20

What this concern includes

Includes failures in prison arrangements for deciding, authorising, escalating, coordinating and carrying out emergency or urgent cell entry, including entry criteria, dynamic risk assessment, night or patrol-state procedures, staffing requirements, communication between prison and healthcare staff, and escalation when responsible staff disagree or cannot enter.

What is not included
  • Excludes general prison healthcare, emergency-response or cell-security deficiencies where the failure does not concern entering a cell to provide urgent care or assistance.
  • Excludes generic staff training or policy deficiencies unless they directly impair the emergency cell-entry process.
  • Excludes ordinary access-control, sanitation-room or prison-door maintenance failures unless they specifically prevent or delay emergency entry into a prisoner's cell.
  • Excludes failures occurring after staff have safely entered the cell, including subsequent clinical assessment or treatment.
  • Excludes broader emergency forced-entry arrangements for non-prison premises where prison cell entry is not the bounded safety process.

Reports and published responses 9 reports

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

  1. Inner South London

    AI-generated summary

    Mark Robert 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

    Mark Robert Smith, who was detained at HMP Thameside, died after an epileptic seizure led to cardiac arrest. The report describes concerns about medication prescribing and administration, hospital-to-prison discharge and communication, access to his cell, observation arrangements and records, staffing, and the lack of equipment for resuscitation.

    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 record the cell-entry escalation process in policy

    Wider context from the report

    “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group). ”

    Source location

    Mark Robert Smith · Prevention of Future Deaths report
    Page 4 · 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 maintain prison and healthcare staff awareness of the cell-entry escalation process

    Wider context from the report

    “(3) Healthcare staff may be unable to enter a prisoner’s cell at night and monitor them in a situation which may not constitute a “medical emergency” but in which a patient nevertheless requires attention; a patient could decline and the situation become life threatening. I have received detail from Serco of “an escalation process” if Oscar 1 and Hotel 1 cannot agree about entry to a cell and I have been told this has been “recommunicated” to all staff. However, this is not recorded in a policy. I am concerned about awareness of the process for all prison and healthcare staff including on an ongoing basis. (Serco and Practice Plus Group). ”

    Source location

    Mark Robert Smith · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  2. Nottinghamshire

    AI-generated summary

    Anthony Binfield · 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 died from ligature asphyxiation inside his cell at HMP Lowdham Grange on 6 March 2023. Prison staff delayed entering the cell for 11 minutes after finding the observation panel covered and receiving no response. The principal concerns were unsafe and policy-inconsistent management of covered cell observation panels, an embedded staff practice of delaying entry, and repeated notices failing to address the issue.

    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

    Delays in entering cells when observation panels are obscured and the prisoner does not respond

    Wider context from the report

    “(1) Prison staff failing to manage the covering of cell observation panels in a safe way that is compliant with the policy and guidance issued by the prison over many years. I am taking the exceptional step of writing to you formally before the conclusion of the inquest as I am so concerned by the evidence called to date regarding the custom and practice of officers when discovering obscured cell observation panels at night. There is a dangerous culture of staff assuming the prisoner has obscured the observation panel for privacy purposes or as a form of protest against the regime. This neglects the obvious and very real risk that the prisoner is seeking to harm themselves, without detection. The HMPPS Safety Notice, issued in February 2018, made clear that cell observation panels are a vital tool in keeping prisoners safe and must be kept clear at all times in order to preserve life. The custom and practice of seeking to visualise the prisoner via the inundation unit hole (and other means, such as the side of the door) has developed over time and is now an embedded culture accepted by many officers as a response to this occurrence. This practice leads to delay in entering the cell, risks lives and is contrary to policy. This is not a new issue for the prison and hence my concern that the prison has failed to tackle this issue over many years. In August 2020, a prisoner died at HMP Lowdham Grange as a result of drug use. When officers conducted a welfare check they found his cell observation panel to be obscured. Contrary to policy and guidance, Prison staff delayed entering the cell while they fetched the inundation unit key to attempt to observe inside the cell. The Prison and Probation Ombudsman made a recommendation to the Prison Director that they should ensure that observation panels are kept clear, and that staff actively challenge prisoners who cover them. In response, the Prison Director issued a notice to staff in January 2021 reminding staff of the need to treat any prisoner as unresponsive if they fail to acknowledge the officer, and to call a code blue. A similar notice was issued in April 2021, reminding staff of the need to perform a dynamic risk assessment and enter the cell in a quick and safe manner when there is no response to asking the prisoner to remove the offending item. The notice was re-issued in November 2021, and after the inquest in approximately April 2023. Despite these multiple notices, a number of witnesses who remain members of staff at the prison (now under HMPPS employ) reported being unaware of the expected procedure when faced with an obscured cell observation panel until attending Anthony’s inquest in December 2024. It is clear that the issuing of staff notices has not addressed the problem of prisoner's covering their cell hatches, nor the unsafe custom and practice of staff leaving the cell and thereby delaying safe entry. ”

    Source location

    Anthony Binfield · 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

    Communicate required staff actions for blocked observation panels through briefings, notices, governor orders and induction training for new staff and OSGs.

    Verbatim wording from the response

    “It is crucial that staff carry out regular safety checks on prisoners when they are locked in their cells. Every time staff approach a prisoner’s cell they must ensure that the observation panel is clear of obstruction in case of an emergency situation. The obscuring of observation panels is a constant challenge across the prison estate as prisoners continue to cover and block observation panels for a variety of reasons, including for privacy and decency. However, HMPPS has a clear stance on the issue and all prisons must set out to staff what action should be taken if an observation panel is found to be covered or blocked.”

    Source location

    Response from HMPPS
    Page 1 · response
    Published 13 February 2025

    Open published response

  3. Leicester City and South Leicestershire

    AI-generated summary

    Stephen Anthony SLEAFORD · 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

    Stephen Anthony Sleaford, a prisoner at Gartree Prison, was found with a ligature around his neck in his cell on 27 October 2022 and was pronounced dead at 08:01. The concerns included inadequate first-aid and CPR training for prison officers, gaps in the earliest emergency response, obscured cell observation panels, and unclear guidance about entering cells during emergencies.

    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 lone prison officers to enter cells during emergencies

    Wider context from the report

    “5) I am concerned that there is no, or no adequate, clear understanding by, and/or clear guidance and training provided to, prison officers around when they should enter a prison cell when it is reasonably believed that a prisoner requires immediate care or assistance due to an emergency, medical or otherwise. Evidence indicated that a ‘dynamic risk assessment’ could be undertaken by any officer who was acting/operating alone, when considering necessary and immediate entry into a cell, whereas the majority of evidence aired was that officers would ‘never’ enter a prison cell when working alone, due to fears for own safety. ”

    Source location

    Stephen Anthony SLEAFORD · 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

    Inadequate guidance and training for prison officers on emergency cell entry

    Wider context from the report

    “5) I am concerned that there is no, or no adequate, clear understanding by, and/or clear guidance and training provided to, prison officers around when they should enter a prison cell when it is reasonably believed that a prisoner requires immediate care or assistance due to an emergency, medical or otherwise. Evidence indicated that a ‘dynamic risk assessment’ could be undertaken by any officer who was acting/operating alone, when considering necessary and immediate entry into a cell, whereas the majority of evidence aired was that officers would ‘never’ enter a prison cell when working alone, due to fears for own safety. ”

    Source location

    Stephen Anthony SLEAFORD · 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

    Issue a notice reminding staff to raise medical emergency alarms, assess risks dynamically, enter cells when safe, and take immediate life-preserving action.

    Verbatim wording from the response

    “In respect of staff response in a medical emergency, HMP Gartree has issued a Notice to Staff reminding staff of the process of unlocking a cell at night when working alone and the need to take immediate action to preserve life. Staff were reminded of the need to immediately raise the alarm by calling a medical emergency response code and inform the control room of the exact location so staff, including healthcare staff, can respond. Before entering a cell alone staff must undertake a dynamic risk assessment, which includes assessing the situation in the cell (for example if there is more than one occupant), considering the condition of the prisoner, and any risk to the safety and security of the prisoner and themselves. If they consider it is safe to do so, staff must enter the cell immediately and take action to preserve life.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 15 October 2024

    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

    Reinforce medical-emergency response requirements through wing briefings and the Governor’s full staff briefing.

    Verbatim wording from the response

    “In addition to the Notice to Staff, the requirements above will be reiterated via wing briefings and during the Governor’s full staff briefing.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 15 October 2024

    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

    Issue the film ‘Responding to emergency situations’ nationally to help prison staff respond when prisoners have ligatured.

    Verbatim wording from the response

    “HMPPS recently issued a new film: ‘Responding to emergency situations’, designed to help staff to understand what they need to do when they find a prisoner who has ligatured. The film has been made available to all prisons and is targeted at all staff who have face-to-face contact with prisoners, including OSGs and staff completing night duties who may need to respond to a medical emergency. All new officers are shown the film during their foundation training and HMP Gartree intends to show it to groups of staff in briefing sessions.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 15 October 2024

    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

    Show the emergency-response film to groups of HMP Gartree staff during briefing sessions.

    Verbatim wording from the response

    “HMPPS recently issued a new film: ‘Responding to emergency situations’, designed to help staff to understand what they need to do when they find a prisoner who has ligatured. The film has been made available to all prisons and is targeted at all staff who have face-to-face contact with prisoners, including OSGs and staff completing night duties who may need to respond to a medical emergency. All new officers are shown the film during their foundation training and HMP Gartree intends to show it to groups of staff in briefing sessions.”

    Source location

    Response from HMPPS
    Page 2 · response
    Published 15 October 2024

    Open published response

  4. Staffordshire and Stoke-on-Trent

    AI-generated summary

    Luke Mikael PEARCE · 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 Pearce was found hanging in his cell at HMP/YOI Swinfen Hall on 6 April 2023 and was pronounced dead after staff and paramedics performed CPR. The report identified delays in entering the cell, removing the ligature and starting CPR, and raised concerns that relevant emergency training and guidance, including the use of Code Blue and Code Red communications, was not being delivered to appropriate staff in a timely manner.

    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 timely training and guidance on entering a cell during a medical emergency

    Wider context from the report

    “That relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency, and the appropriate use of Code Blue and Code Red communications in a medical emergency, is not being delivered in a timely manner to appropriate staff. ”

    Source location

    Luke Mikael PEARCE · 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

    Make the emergency response video available to staff and deliver it through foundation training for new officers.

    Verbatim wording from the response

    “During the inquest, evidence was heard concerning the new national video that was launched in January 2024. The video includes a demonstration on how staff should respond to an emergency situation, which includes instructions on when to enter a cell in an emergency and the appropriate use of Code Blue and Code Red communications. This video has been made available to all HMPPS staff, including Officer Support Grades (OSGs) and staff completing night duties who may need to respond to a medical emergency. Since January 2024, the video has been delivered to all new officers via foundation training and has been shared locally with Governing Governors.”

    Source location

    Response from HMPPS/YOI Swinfen Hall
    Page 1 · response
    Published 20 May 2024

    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

    Show the emergency response video to all existing staff through Safety Critical training.

    Verbatim wording from the response

    “I have received assurance from the Governor of HMP/YOI Swinfen Hall that the emergency response training video is being shown to all existing members of staff as part of their Safety Critical training, with the view for this to be achieved by March 2025. Going forward, HMP/YOI Swinfen Hall will also ensure that the video is shown annually to all staff.”

    Source location

    Response from HMPPS/YOI Swinfen Hall
    Page 1 · response
    Published 20 May 2024

    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

    Show the emergency response video annually to all staff.

    Verbatim wording from the response

    “I have received assurance from the Governor of HMP/YOI Swinfen Hall that the emergency response training video is being shown to all existing members of staff as part of their Safety Critical training, with the view for this to be achieved by March 2025. Going forward, HMP/YOI Swinfen Hall will also ensure that the video is shown annually to all staff.”

    Source location

    Response from HMPPS/YOI Swinfen Hall
    Page 1 · response
    Published 20 May 2024

    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

    Brief staff at the beginning of night duty on Code Blue, Code Red and entering cells during medical emergencies, with Safety and Security quality assurance checks.

    Verbatim wording from the response

    “Additionally, Custodial Managers have been instructed to brief all staff at the beginning of night duty about the use of Code Blue and Code Red and entering cells in a medical emergency, which will be subject to quality assurance checks by both the Safety and Security departments. As part”

    Source location

    Response from HMPPS/YOI Swinfen Hall
    Page 1 · response
    Published 20 May 2024

    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

    Train staff through the local programme on when entering a cell during patrol state is appropriate and necessary.

    Verbatim wording from the response

    “of HMP/YOI Swinfen Hall’s local training programme, staff will be trained to understand when it is appropriate and necessary to enter a cell during patrol state and guidance on emergency response procedures will be issued to staff every 6 months.”

    Source location

    Response from HMPPS/YOI Swinfen Hall
    Page 2 · response
    Published 20 May 2024

    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

    Issue guidance on emergency response procedures to staff every six months.

    Verbatim wording from the response

    “of HMP/YOI Swinfen Hall’s local training programme, staff will be trained to understand when it is appropriate and necessary to enter a cell during patrol state and guidance on emergency response procedures will be issued to staff every 6 months.”

    Source location

    Response from HMPPS/YOI Swinfen Hall
    Page 2 · response
    Published 20 May 2024

    Open published response

  5. Nottinghamshire

    AI-generated summary

    Alexander Michael BRAUND · 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

    Alexander Michael Braund was a 25-year-old remand prisoner at HMP Nottingham who became acutely unwell with an undetected atypical pneumonia and died on 10 March 2020 after cardiac arrest and withdrawal of life support. The principal concerns included failures in NEWS2 assessment and monitoring, the absence of a joint healthcare and prison-staff care plan, delays in entering his cell and calling a medical emergency code, and potential weaknesses in the integrity of amended electronic medical records.

    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

    Unclear cell-entry criteria for prison officers during life-threatening emergencies

    Wider context from the report

    “3. (HM PRISON SERVICE) There continues to be a misunderstanding across discipline staff as to what constitutes a CODE BLUE/CODE RED situation, and in what circumstances a cell can be entered by a prison officer for the purpose of preserving life, despite this having been enshrined in Prison Service Instruction for many years. I heard evidence from the PCO that he erroneously believed it was necessary for 3 discipline staff to be present before a cell door could be opened during night state even in circumstances where Alex was collapsed and unresponsive on the floor. This is not the first-time issues of this nature have been identified at HMP Nottingham. Indeed, successive Prison and Probation Ombudsman reports have recommended that the Governor take action to address these issues since the cluster of deaths in 2017/2018, and while the prison has been subject to Urgent Notification procedures. I heard evidence from a medical expert that post-cardiac arrest, every minute which elapses without appropriate CPR and defibrillator use reduces the patient’s chances of survival. Timely life support is critical, and staff must be clear on when to call a medical emergency code, and when to enter the cell, subject to their dynamic risk assessment. ”

    Source location

    Alexander Michael BRAUND · 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

    Implement an annual staff training plan covering emergency codes, medical emergencies and when officers should enter cells, with training repeated at least twice yearly.

    Verbatim wording from the response

    “A number of new measures including a robust training programme have been implemented to address these concerns. An annual training plan for staff has been introduced, and this includes training on the role of staff during a medical emergency, including the specific issues of the correct use of the emergency codes and the expectations about when staff should enter a cell during a patrol state. Staff received this training in May and September 2022 and it will be repeated at least twice yearly. An additional measure introduced in February 2022 is for all staff who join HMP Nottingham, irrespective of their grade or department, to be given a pocket size card that clearly explains the codes and what to do in an emergency.”

    Source location

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

    Delays in obtaining backup for emergencies on SACU during patrol state

    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

    Not entering the cell alone followed the correct procedure and was not criticised, despite the delayed arrival of assistance.

    Verbatim wording from the response

    “You rightly point out that during patrol/night state, when prisoners would be locked behind their door, one officer is allocated to the SACU. However where an emergency response is required staff must undertake a dynamic risk assessment before entering a cell alone. This is the position throughout the prison during this time and would be the practice whether the person is subject to a three person unlock or not, although that information is likely to form part of the risk assessment. I do note that the decision not to enter the cell alone was not criticised and the correct procedure was followed. As you will be aware there was an unusual combination of circumstances ongoing within other parts of the prison at the time which meant the arrival of assistance was slightly delayed.”

    Source location

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

    Open published response

  7. Liverpool and the Wirral

    AI-generated summary

    Sam MOLYNEUX · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of anti-barricade doors in some prison wings

    Wider context from the report

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

    Source location

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

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

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

    Verbatim wording from the response

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

    Source location

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

    Open published response

  8. Nottinghamshire

    AI-generated summary

    Steven James May · 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

    Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.

    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

    Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone

    Wider context from the report

    “(8) The hesitancy of the first member of prison staff on the scene to enter the deceased’s cell in apparent adherence to an instruction not to enter cells alone; ”

    Source location

    Steven James May · 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

    Reinforce Local Security Strategy procedures for responding to potentially life-threatening situations in cells.

    Verbatim wording from the response

    “HMP Ranby has reinforced the relevant elements of its LSS, and issued a staff notice to this effect on 9 September 2015. All staff have been given access to the LSS and their knowledge of it will be tested annually.”

    Source location

    Steven-May-Response
    Page 3 · response
    Published 16 March 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

    Test all staff annually on their knowledge of the Local Security Strategy.

    Verbatim wording from the response

    “HMP Ranby has reinforced the relevant elements of its LSS, and issued a staff notice to this effect on 9 September 2015. All staff have been given access to the LSS and their knowledge of it will be tested annually.”

    Source location

    Steven-May-Response
    Page 3 · response
    Published 16 March 2016

    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 remaining seven concerns were matters for HM Prison Service and other parties, so the Trust could not respond to them.

    Verbatim wording from the response

    “The Trust cannot respond to the other 7 concerns highlighted in the Prevent Future Death report as they are matters for HM Prison Service and/or other parties.”

    Source location

    2016-0109-Response-by-Nottingham-Healthcare-NHS-Trust
    Page 4 · response
    Published 16 March 2016

    Open published response

  9. Mid Kent and Medway

    AI-generated summary

    Alex Kelly · 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

    Alex Kelly, a vulnerable 15-year-old looked-after child, died in hospital after suspending himself from a ligature made from his shoelaces while detained at Cookham Wood Young Offenders Institution. The report identified concerns about the lack of a forensic psychiatric assessment, failures in communication and information sharing, weaknesses in the ACCT safeguarding process, conflicts between disciplinary procedures and suicide prevention, and inadequate management of his medication and welfare.

    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

    Inflexible cell-entry requirements during urgent safeguarding concerns

    Wider context from the report

    “Re: Secretary of State for Justice Alex Kelly a vulnerable looked after child of 15 years with complex unresolved emotional issues and unmanaged mental health issues was sentenced to a Detention and Training Order to be served at a Young Offender’s Institution without the benefit of a forensic psychiatric assessment. Whilst I heard evidence from a psychiatrist associate of Cookham Wood YOI that the mental health in-reach team were able to address Alex’s mental health needs whilst in custody, I am aware of the deaths of a number of other children in custody who similarly had not had forensic psychiatric assessments and it is for this reason I am reporting the concern. Whilst hearing evidence in relation to lessons learned I heard from the Service Manager of Medway Youth Offending Team that they have now secured the services of a psychiatric mental health nurse to assist them in the effective management of the young people for whom they have responsibilities which I was told was proving effective and is to be continued. Alex Kelly was under an ACCT between the 23rd December 2011 and 3rd January 2012 and 6th January 2012 until his death. During the operation of the ACCT there was a continued conflict between the ACCT process and disciplinary procedures; outside agencies and carers were not asked to contribute; specific acts by Alex were seen as obstructive/challenging behaviour rather than signs of distress or a means of communicating that he needed help (his foster carers who had not been asked to contribute had some experience of Alex using non-verbal methods of communication); the ACCT reviews tended to focus on addressing specific or recent behaviours rather than the reason for the behaviour; although Alex was frequently mentioned at weekly safer regimes multidisciplinary meetings, a holistic approach was never adopted as to how he could best be supported or whether the YOI could support his needs. Re: Tower Hamlets 1. Allocation a) Alex Kelly was without a named social worker for a period of two months at a time when he was in danger of being sent to custody and after he was sent to custody. Difficulties in allocation were not escalated to senior management 2. IT a) Social workers did not transfer documentation including emails onto Framework in a timely manner or at all b) There was no system in place for ensuring that urgent electronic communications were flagged/diverted when the recipient was absent from work 3. Custody a) Social workers did not all appear to appreciate that their responsibilities as Corporate Parent included a role in a looked after child’s welfare whilst in custody Re: Medway Youth Offending Team 1. Involvement with other agencies a) Shortcomings in other agencies which affected the ability of the YOT to manage the young person were not brought to the attention of management 2. Placement within the Secure Estate a) There were inconsistencies in recommendations as to placement in a STC/YOI which were not reconciled b) Youth Offending Team keyworkers did not all appear to appreciate that their responsibilities included a role in the young person’s welfare whilst in custody c) Members of the Youth Offending Team did not all appear to appreciate that the Youth Offending Team could initiate a transfer within the secure estate 3. Caseworker based at Cookham Wood YOI a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person b) Although involved in the ACCT reviews the caseworker was unaware of the range of options available to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews c) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release Re: Cookham Wood YOI 1. Communication with outside agencies a) Outside agencies sharing responsibility of the welfare of a young person in custody and foster carers were not kept informed of significant events, asked to participate in ACCT reviews or asked for input into the management of the young person 2. ACCT a) Officers were inconsistent in the recording of significant events; entries being made in either the wing observation log, ACCT ongoing record or not at all b) At least one officer did not appear to appreciate the importance of significant incidents/disclosures or report them c) Significant events in a lengthy ongoing record were not highlighted and therefore not obvious to officers reviewing safeguarding provisions d) Officers were unaware of the need to involve outside agencies in the ACCT review process, the range of options available to them to safely manage the young person including requests to transfer to a different type of secure accommodation and the use of enhanced reviews e) The safer regimes meetings were not provided with all relevant information and were not used to their full effect. The minutes of the meetings were not fully recorded f) A holistic approach was not taken to the safe management of the young person during ACCT reviews or Safer Regimes meetings when it was apparent that he was struggling with the regime and that interventions were not working 3. Conflict between Regimes a) Officers did not always seek advice before placing the young person on report for tattooing when there was an indication in the ACCT documentation that adjudication awards would lead to a heighted risk of self-harm b) There was a conflict between the use of a behaviour improvement plan and adjudications which was not recognised at the time 4. Early Release a) Paperwork was not submitted for early release on the basis of non-compliance with the regime and concerns about absence of a placement without consultation with any person responsible for making decisions in relation to early release 5.Cell entry a) There appeared to be an inflexible approach to cell entry requiring the presence of three prison officers even though YOI was in patrol state and concerns were sufficient to require entry Re: Healthcare at Cookham Wood NB: the service provider has changed since the death of Alex Kelly. The new provider is in the process of determining the systems and procedures being put in place at Cookham Wood 1. Sharing of Information a) Officers concerned with the management of the young person were not informed in terms of his non-compliance with medication and the potential effect of the failure to take the medication 2. Medication management a) a)Medication was found stockpiled in the young person’s cell; staff dispensing medication had not ensured it had been taken when it was probably recorded as having been taken b) b)Any failure to take medication was not sufficiently flagged for healthcare/prison staff to deal with the issue 3.Recording of information a) Not all occasions when the young person was seen by the in-reach team were recorded on System One ”

    Source location

    Alex Kelly · Prevention of Future Deaths report
    Page 3 · 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