Recipient

Bedford Prison

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First report 11 Oct 2017•Latest report 17 Feb 2026

Recipient record

Reports, concerns and published responses

Justice · Prison or young offender institution. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
5

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Bedford Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Bedfordshire and Luton

    AI-generated summary

    Edward James HANDS · 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

    Edward James Hands, known as Eddie, died in his cell at HMP Bedford on 16 February 2024 after consuming methadone and developing aspiration pneumonitis. The inquest identified failures in follow-up care, monitoring, escalation, and the implementation of the Under the Influence protocol, with confusion between prison and healthcare staff about their responsibilities.

    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. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise and escalate clinical deterioration

    Wider context from the report

    “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of frontline staff awareness of roles, responsibilities, response expectations and required paperwork for suspected illicit-substance influence

    Wider context from the report

    “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to observe and monitor prisoners suspected to be under the influence of illicit substances

    Wider context from the report

    “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to align policies and protocols for managing prisoners suspected to be under the influence of illicit substances

    Wider context from the report

    “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to arrange follow-up medical assessment when a prisoner's condition is not improving

    Wider context from the report

    “The evidence at the inquest revealed that the (primary) prison healthcare provider (within the prison) and prison staff are working to different policies and protocols in relation to those suspected to be ‘under the influence of illicit substances’; there is confusion and lack of awareness of those working in the prison as to the role and responsibilities and expectations about how to alert and manage a concern that a prisoner may be under the influence. In this instance this confusion resulted in Eddie not being observed; had these checks and monitoring taken place, it would have been clear Eddie was not improving and that a follow up medical assessment was required. This meant his clinical deterioration was not recognised and escalated. It is understood that the NHFT policy is designed to cover the entire Trust and may well, therefore, have relevance beyond Bedford prison. However, it is essential that the policy is clear on what happens when the individual institutions have their own local protocols. Eddie’s inquest has revealed how clarity on steps and paperwork required under the policy is essential amongst frontline staff to ensure the safest possible environment for prison residents at Bedford Prison. ”
    Open source report

  2. Bedfordshire and Luton

    AI-generated summary

    Steven HART · 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 Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.

    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. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in addressing identified cell-safety concerns

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to remove unsafe cells from use

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure observation panels cannot be opened from inside to create ligature opportunities

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate risk after incidents requiring review of observations or ligature controls

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate relevant risk information through handovers and records

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to carry out required observations at the appropriate level and standard

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to report serious self-harm incidents and trigger further assessment

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”
    Open source report

  3. Bedfordshire and Luton

    AI-generated summary

    Ezra Mathew TAMIEM · 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

    Ezra Mathew Tamiem was detained at HMP Bedford and held in the healthcare wing because of concerns about his mental state and suicide risk. He was found hanging in his cell on 15 July 2020 and was confirmed deceased by paramedics. The concerns included a ligature point in the cell and a serious failure of the required observation procedure, with only two of five recorded observations performed.

    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. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to design out injury and ligature points from prison cells

    Wider context from the report

    “Mr Tamiem was housed in a cell on the healthcare wing. ████████ Head of Safety at HMP Bedford told the court that was for both security ████████ ████████ gave evidence that this device was in operation throughout the prison except in the refurbished cells and except in the “safer cell”. The safer cell did not have this ligature point. Safer cells are cells with injury and ligature points designed out. ████████ hanged himself and died as a result. ████████ told the court that there were no plans to remedy this and so the risk remains. ”
    Open source report

  4. Bedfordshire and Luton

    AI-generated summary

    Michael BERRY · 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 BERRY was found hanging from a sheet in the Medical Wing of Bedford Prison on 10 March 2017 and later died after life-sustaining treatment was withdrawn following a hypoxic brain injury. The report raised concern that a cell described as a “Reduced Risk Cell” or “Safer Cell” contained an obvious ligature point at an inward-opening window, with possible design solutions to avoid this.

    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. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of Healthcare Cell number 1 to meet reduced-risk cell design expectations

    Wider context from the report

    “(1) Michael was in Healthcare Cell number 1 which throughout the Inquest was described variously as a “Reduced Risk Cell” or “Safer Cell”. It appears that in fact it is not a reduced risk cell but more a “Half Way House” in that the furniture is fixed to the floor. In the cell, however there was a very obvious ligature point that could be avoided, namely the window, which opens inwardly. On the face of it there would appear to be many design solutions that would overcome the need for an opening window that provides such an obvious ligature point. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inward-opening window providing an obvious ligature point in a cell

    Wider context from the report

    “(1) Michael was in Healthcare Cell number 1 which throughout the Inquest was described variously as a “Reduced Risk Cell” or “Safer Cell”. It appears that in fact it is not a reduced risk cell but more a “Half Way House” in that the furniture is fixed to the floor. In the cell, however there was a very obvious ligature point that could be avoided, namely the window, which opens inwardly. On the face of it there would appear to be many design solutions that would overcome the need for an opening window that provides such an obvious ligature point. ”
    Open source report

  5. Bedfordshire and Luton

    AI-generated summary

    Mark Daniel VAGNONI · 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 Daniel Vagnoni, who had paranoid schizophrenia and was on remand at HM Prison Bedford, was found hanging in his cell on 11 July 2016 and died two days later. Concerns included the arrangements for risk assessment and observation after an ACCT was opened, the accessibility of information about previous ACCTs in NOMIS, and the lack of Wing Transfer documentation containing relevant risk information.

    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. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inability to carry out risk assessments with mental health input during patrol state

    Wider context from the report

    “1. The ACCT was opened during patrol state. The first review was planned the following morning. Apart from 30 minute observations and the information on NOMIS (which was scant) there was no ability to carry out a risk assessment with mental health input. It seems to me that prisoners are especially vulnerable during this patrol state period and greater observations and/or other strategies should be undertaken until the first review can take place. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of Wing Transfer documentation conveying past ACCTs and risk factors

    Wider context from the report

    “3. The jury were also concerned that there appears to be no Wing Transfer documentation, which could have included information about past ACCTs and indeed past risk factors. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bedford Prison; that does not assign responsibility.

    PFD Monitor interpretation

    NOMIS failing to alert staff to past ACCTs from the initial screen

    Wider context from the report

    “2. The jury expressed concerns that the NOMIS layout were not helpful to staff in that the staff needed to drill down beyond the initial screen to be alerted to past ACCTs ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026