Recurring concern

Unsafe emergency response during lone working

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First reported 16 Mar 2016•Latest report 14 Oct 2024

Definition

What this concern includes

Includes failures of controls specifically dedicated to managing emergencies during lone working, including safe staffing arrangements, emergency access and entry guidance, communication or assistance arrangements, escalation procedures, and the ability to sustain emergency intervention.

Not included

  • Excludes generic staffing shortages, supervision or training deficiencies unless they directly concern emergency safety during lone working.
  • Excludes ordinary lone-working concerns where no emergency response or immediate-assistance risk is identified.
  • Excludes emergency-response failures in adequately staffed settings where lone working is not a material part of the unsafe condition.
  • Excludes unrelated failures of clinical treatment, equipment or premises access unless they are specifically part of the lone-working emergency-response control.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2016–2024

First to latest report issue date

Stated actions
8

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 Service3
NHS England3
Ministry of Justice2
Care Quality Commission1
Cygnet Health Care Limited1
Department of Health and Social Care1
Future Health and Social Care Association C.I.C.1
NHS Birmingham and Solihull Integrated Care Board1
Nottinghamshire Healthcare NHS Foundation Trust1
Prisons and Probation Ombudsman1
Ranby Prison1

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. 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 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

  2. 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

  3. South Yorkshire (Western)

    AI-generated summary

    Chelsea Blue Louise Mooney · 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

    Chelsea Blue Louise Mooney died two days after tying two non-fixed ligatures while in hospital, following inadequate observations and delays in the emergency response. Principal concerns included insufficient review of her diagnosis, inadequate exploration of allegations and information-sharing decisions, a failure to learn from previous ligature incidents, uncertainty among staff about responding to her, and delays and poor coordination during the final emergency 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 to equip staff to respond to a crisis when alone with a young person

    Wider context from the report

    “6. Male staff were nervous and uncertain of how to approach Chelsea when they were alone. Clear guidance needed to be made available to them on how to deal with this. Although in evidence staff said that if there was an emergency they would attend even if alone this was not the case in practice as the male member of staff sought female support before recognising that Chelsea was in crisis. ”

    Source location

    Chelsea Blue Louise Mooney · 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

    Use dedicated response staff, radios and alarms so observation staff can maintain checks while other incidents are managed.

    Verbatim wording from the response

    “28. Certain staff members carry radios that are allocated to security, response (which does not include the staff member carrying out the observations), nurse in charge and any staff member on 1:1 or above. All staff members carry an alarm and every ward has a ‘response’ member of staff allocated that can attend to any incident in the hospital. This is again emphasised in training to avoid any future delays. This process allows the staff member who has identified the incident to step back if required and/or carry on with the checks without impacting on a young person’s safety.”

    Source location

    Response from Cygnet Health Care
    Page 8 · response
    Published 3 October 2022

    Open published response

  4. Birmingham and Solihull

    AI-generated summary

    Simon Anthony Graham · 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

    Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention training.

    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

    Continuation of lone working during emergencies

    Wider context from the report

    “2. Concern 1: At any one time only one support worker is working. The death of Simon Graham identified a number of concerns arising from lone working during an emergency: A) Upon concern being raised by Simon Graham’s wife, the support worker was prevented from promptly checking on his wellbeing because he was with another resident at the medicine cupboard. He had to finish with the other resident and ensure the medicine cupboard was left secure. This caused a delay of about 10-15 minutes before the support worker could check on Simon Graham. Further delay was then caused by confusion over rooms – see below. B) After forcing entry and finding Simon Graham hanging and in cardiac arrest the support worker got him down and commenced CPR. He had to call for help from other residents but no one came. He had to break-off CPR for at least 80 seconds when he ran down three flights of stairs to answer the door thinking it was an ambulance (it was in fact the deceased’s wife). I heard evidence that the lone working still exists because the current financial contract with the NHS is insufficient to cover the cost of a second support worker, despite Future Care & Social Care Association wanting to end lone working. ”

    Source location

    Simon Anthony Graham · 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

    Work with partners to address recruitment and retention challenges so services are appropriately resourced.

    Verbatim wording from the response

    “8.1.9 Working with partners to help address challenges in recruiting and retaining staff, to ensure services are appropriately resourced.”

    Source location

    Birmingham-and-Solihull-CCG-Response
    Page 9 · response
    Published 4 October 2018

    Open published response

  5. 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
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Data last updated 7 September 2026