HM Prison & Probation Service

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First report 29 Jun 2026•Latest report 29 Jun 2026

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
1

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 HM Prison & Probation Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Lancashire and Blackburn with Darwen

    AI-generated summary

    Johnpaul Digweed · 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

    Johnpaul Digweed died by suicide by hanging in his cell at HMP Garth between 17:06 on 12 April 2024 and 11:31 on 13 April 2024. The concerns included failures to open an ACCT process after incidents of self-harm, inadequate assurance about staff training and information-sharing, and welfare observations not being carried out in accordance with prison procedures, including when observation panels were obscured.

    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 HM Prison & Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Welfare-check instructions failing to require visual checks of prisoners

    Wider context from the report

    “2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not aware of the instructions which were issued by email. As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff. In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths ”
    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 HM Prison & Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure critical welfare-check instructions are received and understood by affected staff

    Wider context from the report

    “2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not aware of the instructions which were issued by email. As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff. In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths ”
    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 HM Prison & Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure removal of coverings from cell-door observation panels

    Wider context from the report

    “2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not aware of the instructions which were issued by email. As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff. In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths ”
    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 HM Prison & Probation Service; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain and monitor staff competence in opening an ACCT where required

    Wider context from the report

    “1. Evidence was heard that despite several staff being aware of incidents of self-harm involving a prisoner at HMP Garth an Assessment, Care in Custody Teamwork process (ACCT) was not opened. Whilst evidence was provided that staff are trained as part of their induction program and that training materials is available to staff, no assurance could be given that there was any ongoing mandatory refresher training or any system in place to monitor understanding that every member of staff is responsible for opening an ACCT where required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths ”
    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