Exeter Prison

Justice · Prison or young offender institution

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First report 24 Jul 2015•Latest report 19 Sep 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
4

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

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.

  1. Exeter and Greater Devon

    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

  2. Exeter and Greater Devon

    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

  3. Exeter and Greater Devon

    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

  4. Exeter and Greater Devon

    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
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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