4 Apr 2017 ARTHUR ALBERT MORLEY · Prevention of Future Deaths report Buckinghamshire
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Concerns raised 9 Lack of review of proactive healthcare staff involvement in RTU decisions View source Delays in securing sanitation-room doors at night View source Unreduced accessibility of sanitation-room ligature points View source Lack of audit of wing and night staff inspection duties View source Delays in reviewing, amending and publishing revised LOPs View source Lack of review of wing log handover procedures View source Lack of specific audit of wing ligature points View source Failure to complete cold debriefs and interim incident reports View source Failure to ensure staff understanding and implementation of operational protocols View source See 6 more concerns
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AI-generated summary
ARTHUR ALBERT MORLEY · 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
Arthur Albert Morley was a prisoner serving an indeterminate sentence at HMP Grendon when he was found hanging from a pipe in a sanitation area shortly after being told he would be returned to his previous prison. The report raised concerns about accessible ligature points, inadequate sanitation-room security and inspection arrangements, delays in reviewing procedures and incident learning, and insufficient communication and healthcare involvement in return-to-unit decisions.
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 Grendon Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of review of proactive healthcare staff involvement in RTU decisions
Wider context from the report “(7) There has been no review of whether healthcare staff (who have access to a prisoners medical notes and past mental health history) should be involved proactively in RTU decisions .
” 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 Grendon Prison; that does not assign responsibility.
PFD Monitor interpretation Delays in securing sanitation-room doors at night
Wider context from the report “(2) The Local Operating Procedure LOP49 requires locking off of shower facilities at night such that prisoners would only have access to toilet facilities. Locking shower facilities could reduce access to possible ligature points. There is some work being undertaken to address the issues that many sanitation room doors cannot be locked but there appears to be no specific timescale or urgency to the implementation of this proposal .
” 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 Grendon Prison; that does not assign responsibility.
PFD Monitor interpretation Unreduced accessibility of sanitation-room ligature points
Wider context from the report “(1) The death occurred in December 2015. Since then there does not appear to have been a specific audit of possible ligature points on the wings, particularly pipework in the sanitation rooms, which remain accessible at night to prisoners but are out of view of wing staff . There are no current proposals to undertake works to reduce accessibility of ligature points such as open pipes .
” 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 Grendon Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of audit of wing and night staff inspection duties
Wider context from the report “(5) There has been no specific audit of wing and night staff duties to include wing room and sanitation area inspections during lock up . Mr Morley appears to have made use of a chair in the sanitation room, but no witnesses could be certain as to how the chair had got there and from where it had come.
” 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 Grendon Prison; that does not assign responsibility.
PFD Monitor interpretation Delays in reviewing, amending and publishing revised LOPs
Wider context from the report “(4) The need to review and amend Local Operating Procedures LOP48 (Communications Room) and LOP49 (Access to Ablutions) has emerged through the investigation and a number of key measures have been introduced, however the need for staff to be able to access, understand and implement revised written protocols remains and there was no particular timescale indicated within which these changes might be made and new LOPs published . Mr Morley’s death enabled the identification of shortcomings in knowledge and implementation of existing LOP procedures. There is a concern that staff uncertainty about operational protocols will continue until new LOPs are in place and staff are appropriately trained.
” 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 Grendon Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of review of wing log handover procedures
Wider context from the report “(6) There has been no specific review of verbal and written wing log handover procedures between day and night wing staff with a view to better highlighting and acknowledging key events (such as an RTU decision) relevant to a prisoner on that particular wing .
” 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 Grendon Prison; that does not assign responsibility.
PFD Monitor interpretation Lack of specific audit of wing ligature points
Wider context from the report “(1) The death occurred in December 2015. Since then there does not appear to have been a specific audit of possible ligature points on the wings, particularly pipework in the sanitation rooms , which remain accessible at night to prisoners but are out of view of wing staff. There are no current proposals to undertake works to reduce accessibility of ligature points such as open pipes.
” 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 Grendon Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to complete cold debriefs and interim incident reports
Wider context from the report “(3) Whilst there was a hot debrief conducted very shortly after Mr Morley’s death, there was no cold debrief and no Serious Incident Report . There is due to be a post-inquest debrief but as issues have emerged during the PFD investigation and the Coroner’s investigation and inquest, the lack of debriefing and interim incident reports delays the implementation of any necessary learning arising as a result of this incident.
” 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 Grendon Prison; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff understanding and implementation of operational protocols
Wider context from the report “(4) The need to review and amend Local Operating Procedures LOP48 (Communications Room) and LOP49 (Access to Ablutions) has emerged through the investigation and a number of key measures have been introduced, however the need for staff to be able to access, understand and implement revised written protocols remains and there was no particular timescale indicated within which these changes might be made and new LOPs published. Mr Morley’s death enabled the identification of shortcomings in knowledge and implementation of existing LOP procedures. There is a concern that staff uncertainty about operational protocols will continue until new LOPs are in place and staff are appropriately trained .
” 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