Recipient

Garth Prison

First report 5 Oct 2020•Latest report 6 Nov 2025

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: 3
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 Garth Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

6 Nov2025
Lancashire and Blackburn with Darwen
Concerns raised4
1. Failure to carry out keyworker sessions as required
2. Lack of knowledge of the required frequency of keyworker sessions
3. Lack of ACCT training and awareness of ACCT responsibilities among prison officers
1. Failure to open an Assessment, Care in Custody Teamwork process after a serious incident of self-harm
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

Aaron Lee Taylor · 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

Aaron Lee Taylor was discovered in his prison cell on 28 August 2023, having died between the evening of 27 August and the morning of 28 August 2023. The inquest heard that he had taken steps intending to take his own life and identified multiple failures in measures to prevent self-harm and suicide, including inadequate assessments, documentation, policy compliance and mental health interventions.

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 Garth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to carry out keyworker sessions as required
Wider context from the report
“(2) Evidence was also heard that keyworker sessions were not being carried out as they should have been with a prisoner who had been identified as in need of support through the keyworker scheme. A prison officer with keyworker responsibilities gave evidence that they did not know how frequently keyworker sessions should 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 Garth Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of knowledge of the required frequency of keyworker sessions
Wider context from the report
“(2) Evidence was also heard that keyworker sessions were not being carried out as they should have been with a prisoner who had been identified as in need of support through the keyworker scheme. A prison officer with keyworker responsibilities gave evidence that they did not know how frequently keyworker sessions should 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 Garth Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of ACCT training and awareness of ACCT responsibilities among prison officers
Wider context from the report
“(1) Evidence was heard that despite several prison officers being aware of a serious incident of self-harm involving a prisoner with a history of self-harm, an Assessment, Care in Custody Teamwork process (ACCT) was not opened. No evidence was provided confirming all prison officers were ACCT trained and/or were all aware of their responsibilities in relation to ACCT ”
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 Garth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to open an Assessment, Care in Custody Teamwork process after a serious incident of self-harm
Wider context from the report
“(1) Evidence was heard that despite several prison officers being aware of a serious incident of self-harm involving a prisoner with a history of self-harm, an Assessment, Care in Custody Teamwork process (ACCT) was not opened. No evidence was provided confirming all prison officers were ACCT trained and/or were all aware of their responsibilities in relation to ACCT ”
Open source report
30 Apr2024
Liverpool and the Wirral
Concerns raised4
1. Lack of clarity about the welfare sheet’s purpose for monitoring prisoners whose health is of concern
2. Insufficient guidance for completing the welfare sheet
3. Failure of prison and healthcare services to jointly consider the welfare sheet’s nature and operation
1. Failure to communicate prison staff entries on the welfare sheet to attending medical staff
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

Marlin Burrows · 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

Marlin Burrows was found collapsed in his cell at HMP Garth on 15 August 2022 and died in the early hours of 16 August 2022 after being semi-conscious for nearly 15 hours. The inquest concluded that he died from multi-organ failure due to serotonin syndrome and drug toxicity, including amitriptyline toxicity. Concerns included unclear welfare-sheet purposes and guidance, poor communication of entries to medical staff, and insufficient joint consideration of the sheet by prison and healthcare services.

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 Garth Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity about the welfare sheet’s purpose for monitoring prisoners whose health is of concern
Wider context from the report
“(1) The existing welfare sheet lacks clarity as to its exact purpose in terms of monitoring a prisoner whose health is of concern. ”
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 Garth Prison; that does not assign responsibility.
PFD Monitor interpretation
Insufficient guidance for completing the welfare sheet
Wider context from the report
“(2) The sheet contains little guidance in relation to its completion. ”
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 Garth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure of prison and healthcare services to jointly consider the welfare sheet’s nature and operation
Wider context from the report
“(4) The nature and operation of the sheet appears not to have been the subject of joint consideration on behalf of both prison and healthcare ”
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 Garth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate prison staff entries on the welfare sheet to attending medical staff
Wider context from the report
“(3) Entries on the sheet made by prison staff appear not to be made known to attending medical staff ”
Open source report
5 Oct2020
Lancashire and Blackburn with Darwen
Concerns raised1
1. Failure to remove redundant television brackets constituting ligature points
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

Wesley Dennis Rowlands · 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

Wesley Dennis Rowlands died by suicide through ligature hanging in his cell at HMP Garth, using a fixed television bracket. The principal concern was that redundant television brackets remained installed in cells, including his, creating gross and obvious ligature points until removed.

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 Garth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to remove redundant television brackets constituting ligature points
Wider context from the report
“A number of cells at HMP Garth, including the deceased’s cell, have television brackets built into the structure of the cell walls. Although the brackets are now redundant, they remain in place and constitute a gross and obvious ligature point and will continue to do so until removed. ”
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

Failure to carry out keyworker sessions as required

Lack of knowledge of the required frequency of keyworker sessions

Lack of ACCT training and awareness of ACCT responsibilities among prison officers

Failure to open an Assessment, Care in Custody Teamwork process after a serious incident of self-harm

Concerns raised4

Lack of clarity about the welfare sheet’s purpose for monitoring prisoners whose health is of concern

Insufficient guidance for completing the welfare sheet

Failure of prison and healthcare services to jointly consider the welfare sheet’s nature and operation

Failure to communicate prison staff entries on the welfare sheet to attending medical staff

Concerns raised1

Failure to remove redundant television brackets constituting ligature points