Ranby Prison

Justice · Prison or young offender institution

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First report 16 Mar 2016•Latest report 25 Oct 2024

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
2

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
7

Across all linked responses

Stated actions
15

Described in responses

Concerns and recipient responses

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

  1. Nottinghamshire

    AI-generated summary

    Mark Stephen Beresford · 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

    Mark Stephen Beresford died at Bassetlaw District General Hospital on 7 July 2023 after applying a ligature while detained at HMP Ranby, having been discovered unresponsive and resuscitated. The jury found that he was suffering significant mental ill health and identified failings in the assessment and management of his mental health and self-harm risk, ACCT observations, completion of an action plan, response to his cell bell, and staffing. The report also raises concerns about prison leadership’s understanding and assessment of risk and its lack of candour and reflection during the inquest.

    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to act with due reflection and candour during inquests

    Wider context from the report

    “I heard evidence that the prison authorities have already taken important steps, which I am satisfied address many of the concerns arising from Mark’s death. I am concerned however, that despite very strong evidence to the contrary, they maintained the risk assessments conducted on 2 and 3 July were reasonable in all the circumstances. The supervising officer involved in the decision to close Mark’s ACCT on the morning of 3 July 2023, gave evidence that there was no likelihood Mark would commit further ACCTs of self-harm. While the inexperienced officer who later reopened the ACCT set Mark’s observations at one no more than two hours apart, relying in part on the fact that is what they had been set at when the ACCT had been reopened the previous day. However, there had since been two significant risk incidents and the officer did not consult a supervising officer as required by PSI 64/2011. It is difficult to understand the prison’s position that these assessments were reasonable in all the circumstances. Furthermore, on two occasions, the Head of Operations gave evidence that was incorrect and liable to mislead the jury and/or the coroner. He gave evidence confirming the requirement for a person raising a concern under the ACCT process to consult with a supervising officer in respect of observation levels. He then added: “I firmly believe that the supervising officers who gave evidence earlier this week, whether they recall it or not, would naturally have had that conversation, out of being inquisitive, that would be my own personal view point but in terms of the prison stance, that’s what the policy says.” When it was pointed out to him that that was not supported by either of the witnesses involved – who were both very clear that there had been no consultation - he apologised and suggested he had misunderstood. I am troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken. The second occasion concerned the issue of cell bell cover on the day of the event that caused Mark’s death. Mark was housed on HB3 North. The Head of Operations gave evidence that it is normal for both HB3 North and HB3 South to have a single officer detailed to deal with cell bells over the lunch period. The officer on duty on 3 July was however very clear in his evidence that he was detailed to cover HB3S only. Every other prison witness asked about this agreed that there should be an officer covering each side of HB3 over lunch. Curious and concerned as to how a member of the prison’s leadership team could have made such an error, I later recalled and asked the Head of Operations for an explanation. He could provide none. Although, he did later apologise for his difficulty answering other questions asked of him, explaining that he does not usually work in safer custody. 1. That, notwithstanding steps since taken to improve work around ACCT processes and risk assessments, there remains an issue with understanding and assessing risk, which extends up to the leadership team at HMP Ranby. 2. That there was a failure by the prison authorities to act with due reflection and candour during the inquest which, if unaddressed, will impede their ability to fully learn the lessons from deaths in custody. ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to understand and assess risk in ACCT processes and risk assessments

    Wider context from the report

    “I heard evidence that the prison authorities have already taken important steps, which I am satisfied address many of the concerns arising from Mark’s death. I am concerned however, that despite very strong evidence to the contrary, they maintained the risk assessments conducted on 2 and 3 July were reasonable in all the circumstances. The supervising officer involved in the decision to close Mark’s ACCT on the morning of 3 July 2023, gave evidence that there was no likelihood Mark would commit further ACCTs of self-harm. While the inexperienced officer who later reopened the ACCT set Mark’s observations at one no more than two hours apart, relying in part on the fact that is what they had been set at when the ACCT had been reopened the previous day. However, there had since been two significant risk incidents and the officer did not consult a supervising officer as required by PSI 64/2011. It is difficult to understand the prison’s position that these assessments were reasonable in all the circumstances. Furthermore, on two occasions, the Head of Operations gave evidence that was incorrect and liable to mislead the jury and/or the coroner. He gave evidence confirming the requirement for a person raising a concern under the ACCT process to consult with a supervising officer in respect of observation levels. He then added: “I firmly believe that the supervising officers who gave evidence earlier this week, whether they recall it or not, would naturally have had that conversation, out of being inquisitive, that would be my own personal view point but in terms of the prison stance, that’s what the policy says.” When it was pointed out to him that that was not supported by either of the witnesses involved – who were both very clear that there had been no consultation - he apologised and suggested he had misunderstood. I am troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken. The second occasion concerned the issue of cell bell cover on the day of the event that caused Mark’s death. Mark was housed on HB3 North. The Head of Operations gave evidence that it is normal for both HB3 North and HB3 South to have a single officer detailed to deal with cell bells over the lunch period. The officer on duty on 3 July was however very clear in his evidence that he was detailed to cover HB3S only. Every other prison witness asked about this agreed that there should be an officer covering each side of HB3 over lunch. Curious and concerned as to how a member of the prison’s leadership team could have made such an error, I later recalled and asked the Head of Operations for an explanation. He could provide none. Although, he did later apologise for his difficulty answering other questions asked of him, explaining that he does not usually work in safer custody. 1. That, notwithstanding steps since taken to improve work around ACCT processes and risk assessments, there remains an issue with understanding and assessing risk, which extends up to the leadership team at HMP Ranby. 2. That there was a failure by the prison authorities to act with due reflection and candour during the inquest which, if unaddressed, will impede their ability to fully learn the lessons from deaths in custody. ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consult a supervising officer on ACCT observation levels

    Wider context from the report

    “I heard evidence that the prison authorities have already taken important steps, which I am satisfied address many of the concerns arising from Mark’s death. I am concerned however, that despite very strong evidence to the contrary, they maintained the risk assessments conducted on 2 and 3 July were reasonable in all the circumstances. The supervising officer involved in the decision to close Mark’s ACCT on the morning of 3 July 2023, gave evidence that there was no likelihood Mark would commit further ACCTs of self-harm. While the inexperienced officer who later reopened the ACCT set Mark’s observations at one no more than two hours apart, relying in part on the fact that is what they had been set at when the ACCT had been reopened the previous day. However, there had since been two significant risk incidents and the officer did not consult a supervising officer as required by PSI 64/2011. It is difficult to understand the prison’s position that these assessments were reasonable in all the circumstances. Furthermore, on two occasions, the Head of Operations gave evidence that was incorrect and liable to mislead the jury and/or the coroner. He gave evidence confirming the requirement for a person raising a concern under the ACCT process to consult with a supervising officer in respect of observation levels. He then added: “I firmly believe that the supervising officers who gave evidence earlier this week, whether they recall it or not, would naturally have had that conversation, out of being inquisitive, that would be my own personal view point but in terms of the prison stance, that’s what the policy says.” When it was pointed out to him that that was not supported by either of the witnesses involved – who were both very clear that there had been no consultation - he apologised and suggested he had misunderstood. I am troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken. The second occasion concerned the issue of cell bell cover on the day of the event that caused Mark’s death. Mark was housed on HB3 North. The Head of Operations gave evidence that it is normal for both HB3 North and HB3 South to have a single officer detailed to deal with cell bells over the lunch period. The officer on duty on 3 July was however very clear in his evidence that he was detailed to cover HB3S only. Every other prison witness asked about this agreed that there should be an officer covering each side of HB3 over lunch. Curious and concerned as to how a member of the prison’s leadership team could have made such an error, I later recalled and asked the Head of Operations for an explanation. He could provide none. Although, he did later apologise for his difficulty answering other questions asked of him, explaining that he does not usually work in safer custody. 1. That, notwithstanding steps since taken to improve work around ACCT processes and risk assessments, there remains an issue with understanding and assessing risk, which extends up to the leadership team at HMP Ranby. 2. That there was a failure by the prison authorities to act with due reflection and candour during the inquest which, if unaddressed, will impede their ability to fully learn the lessons from deaths in custody. ”
    Open source report

  2. Nottinghamshire

    AI-generated summary

    Steven James May · 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

    Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.

    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate First Aid training for prison staff

    Wider context from the report

    “(9) The inadequacy of First Aid training provided to prison staff in any event (namely, the administration of CPR by prison staff whilst the deceased was lying on a bed); ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Selective emergency First Aid training among prison staff

    Wider context from the report

    “(7) The selective training of prison staff in emergency First Aid (namely the first member of prison staff on the scene of the death was not trained in the administration of CPR and was ignorant of the location of and method of use of defibrillators); ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of mental health experience and/or training among reception nursing staff

    Wider context from the report

    “(2) The lack of experience and/or training of reception nursing staff in the field of mental health; ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process

    Wider context from the report

    “(5) The involvement in the ACCT process of prison staff possessing neither relevant training nor the appropriate rank; ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone

    Wider context from the report

    “(8) The hesitancy of the first member of prison staff on the scene to enter the deceased’s cell in apparent adherence to an instruction not to enter cells alone; ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure medical professional attendance at First Care Reviews

    Wider context from the report

    “(6) The failure of prison staff to ensure the attendance of a medical professional at the First Care Review; ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of reception nursing staff to consult historical medical notes during reception interviews

    Wider context from the report

    “(1) The failure of reception nursing staff, by reason of lack of training and/or instruction or lack of staff and/or time, to consult the deceased’s historical medical notes prior to or during the reception interview; ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Limited accessibility of health and/or mental health care during weekends and Bank Holidays

    Wider context from the report

    “(10) The accessibility of health and/or mental health care to inmates at weekends and during Bank Holidays. ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on verbal handovers rather than written records for prisoner information

    Wider context from the report

    “(4) Reliance by prison staff on verbal and/or oral handovers of information, rather than written records, regarding the deceased; ”
    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 Ranby Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to prepare sufficiently full ACCT assessment notes

    Wider context from the report

    “(3) The failure of prison staff when preparing the ACCT document to prepare as full a note as possible. For example, to follow the subject areas suggested in the narrative accompanying sections 1-8 of the Assessment Interview; ”
    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