Recipient

Exeter Prison

First report 24 Jul 2015•Latest report 19 Sep 2023

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: 4
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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

19 Sep2023
Exeter and Greater Devon
Concerns raised4
1. Inconsistent conducting of ACCT observations
2. Excessive prison officer working hours
3. Different staff interpretations of ACCT observation timing requirements
1. Failure to accurately record ACCT observation times
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Stewart Stanley · 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

Stewart Stanley was remanded in custody at HMP Exeter and was found hanging in his cell on 12 July 2020 after the level of his observation had been reduced. He was taken to hospital and died on 14 July 2020. The concerns included inconsistent approaches to conducting and recording ACCT observations, differing interpretations of observation requirements, inaccurate recording of observation times, and evidence of excessive staff working hours. The inquest jury concluded that his death was probably caused or contributed to by failures to follow processes, including excluding the staff best qualified to assess his risk from the decision to remove him from constant watch.

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 Exeter Prison; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent conducting of ACCT observations
Wider context from the report
“(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording observations on prisoners subject to the Prison Service suicide and self-harm prevention procedures (known as ACCT). (2) The evidence also revealed that some Officers had a different interpretation of the requirements of set out in PSI 64/2011 in respect of the timing of observations. (3) The evidence also revealed that precise times of such observations were not routinely being recorded accurately. (4) During the evidence it became apparent that a prison officer worked 23 hours out of 24, he was asked if this was normal and he replied, “yes, to make the regime work.” ”
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 Exeter Prison; that does not assign responsibility.
PFD Monitor interpretation
Excessive prison officer working hours
Wider context from the report
“(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording observations on prisoners subject to the Prison Service suicide and self-harm prevention procedures (known as ACCT). (2) The evidence also revealed that some Officers had a different interpretation of the requirements of set out in PSI 64/2011 in respect of the timing of observations. (3) The evidence also revealed that precise times of such observations were not routinely being recorded accurately. (4) During the evidence it became apparent that a prison officer worked 23 hours out of 24, he was asked if this was normal and he replied, “yes, to make the regime work.” ”
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 Exeter Prison; that does not assign responsibility.
PFD Monitor interpretation
Different staff interpretations of ACCT observation timing requirements
Wider context from the report
“(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording observations on prisoners subject to the Prison Service suicide and self-harm prevention procedures (known as ACCT). (2) The evidence also revealed that some Officers had a different interpretation of the requirements of set out in PSI 64/2011 in respect of the timing of observations. (3) The evidence also revealed that precise times of such observations were not routinely being recorded accurately. (4) During the evidence it became apparent that a prison officer worked 23 hours out of 24, he was asked if this was normal and he replied, “yes, to make the regime work.” ”
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 Exeter Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to accurately record ACCT observation times
Wider context from the report
“(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording observations on prisoners subject to the Prison Service suicide and self-harm prevention procedures (known as ACCT). (2) The evidence also revealed that some Officers had a different interpretation of the requirements of set out in PSI 64/2011 in respect of the timing of observations. (3) The evidence also revealed that precise times of such observations were not routinely being recorded accurately. (4) During the evidence it became apparent that a prison officer worked 23 hours out of 24, he was asked if this was normal and he replied, “yes, to make the regime work.” ”
Open source report
28 Jul2021
Exeter and Greater Devon
Concerns raised1
1. Failure to preserve key evidence
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Carl Lee Walters · 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

Carl Lee Walters died suddenly and unexpectedly in his prison cell from a ruptured splenic pseudoaneurysm, with the evidence unable to establish whether it was naturally occurring or trauma related. CCTV footage had not been preserved and only limited cell bell records were kept, meaning key evidence was unavailable and the inquest could not be as full as it otherwise would have been.

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 Exeter Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to preserve key evidence
Wider context from the report
“The failure to preserve key evidence meant that the inquest could not be as full as it would otherwise have been. If key evidence is not preserved there is an ongoing risk that dangerous conditions or circumstances go undiscovered raising the prospect that appropriate steps to avoid a similar tragedy are overlooked. ”
Open source report
8 Sep2015
Exeter and Greater Devon
Concerns raised3
1. Lack of formal guidance or training for compassionate release decision-making
2. Lack of formal guidance or training for assessing the requirement for restraints
3. Resource constraints in end-of-life care provision
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Ian Paul Emsley · 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

Ian Paul Emsley, who had terminal metastatic renal cancer, died on 1 February 2015 in the palliative care wing at HMP Exeter after becoming unconscious and stopping breathing. The report identified that care at HMP YOI Portland was subject to resource constraints, meaning transfer to HMP Exeter could have occurred sooner, and found a potential for delays in transfer or compassionate release because of a lack of formal guidance or training on restraints and risk assessment.

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 Exeter Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of formal guidance or training for compassionate release decision-making
Wider context from the report
“The Clinical Reviewer found that overall it might be helpful for healthcare staff to be given formal guidance or training to assist them in making decisions regarding the assessment of the requirement of restraints and the assessment and decision making of release on compassionate grounds at Multi-Disciplinary Team Meetings involving prison (security) staff and healthcare staff. With lack of formal guidance/or training on the subject healthcare staff were uncomfortable with making decisions on a prisoners risk of re-offending or escape. As a consequence there is a potential for delay in effecting transfer and/or compassionate release for prisoners who are terminally ill, which could also impact on the family. ”
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 Exeter Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of formal guidance or training for assessing the requirement for restraints
Wider context from the report
“The Clinical Reviewer found that overall it might be helpful for healthcare staff to be given formal guidance or training to assist them in making decisions regarding the assessment of the requirement of restraints and the assessment and decision making of release on compassionate grounds at Multi-Disciplinary Team Meetings involving prison (security) staff and healthcare staff. With lack of formal guidance/or training on the subject healthcare staff were uncomfortable with making decisions on a prisoners risk of re-offending or escape. As a consequence there is a potential for delay in effecting transfer and/or compassionate release for prisoners who are terminally ill, which could also impact on the family. ”
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 Exeter Prison; that does not assign responsibility.
PFD Monitor interpretation
Resource constraints in end-of-life care provision
Wider context from the report
“During the Inquest into Mr Emsley’s death from Natural Causes in the palliative care wing at HMP Exeter, the care at HMP Exeter was highly proactive in the last 9 weeks of his life. The care given, in HMP YOI Portland was less so and subject to a number of resource based constraints in end of life care provision. The result being that transfer to HMP Exeter could have been much sooner. ”
Open source report
24 Jul2015
Exeter and Greater Devon
Concerns raised2
1. Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme
2. Deficient information sharing about custodial and welfare checks
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Carl David Roy 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

Carl David Roy SMITH was found unconscious and without signs of life in his cell at HMP Exeter on 22 November 2012, after being held on remand and receiving medication for seizures and detoxification. His death was concluded to be drug-related, involving methadone toxicity and illicitly obtained methadone. The report identified insufficient custodial and welfare checks and deficient information sharing about those checks for a prisoner on an ACCT and Methadone Stabilisation Programme.

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 Exeter Prison; that does not assign responsibility.
PFD Monitor interpretation
Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme
Wider context from the report
“The quality of custodial and welfare checks were insufficient for a prisoner on an ACCT and Methadone Stabilisation Programme and information sharing in relation to the checks made, appeared to be deficient. ”
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 Exeter Prison; that does not assign responsibility.
PFD Monitor interpretation
Deficient information sharing about custodial and welfare checks
Wider context from the report
“The quality of custodial and welfare checks were insufficient for a prisoner on an ACCT and Methadone Stabilisation Programme and information sharing in relation to the checks made, appeared to be deficient. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised4

Inconsistent conducting of ACCT observations

Excessive prison officer working hours

Different staff interpretations of ACCT observation timing requirements

Failure to accurately record ACCT observation times

Concerns raised1

Failure to preserve key evidence

Concerns raised3

Lack of formal guidance or training for compassionate release decision-making

Lack of formal guidance or training for assessing the requirement for restraints

Resource constraints in end-of-life care provision

Concerns raised2

Insufficient custodial and welfare checks for prisoners on an ACCT and Methadone Stabilisation Programme

Deficient information sharing about custodial and welfare checks