Recipient

Swansea Prison

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First report 30 May 2014•Latest report 20 Oct 2022

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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

  1. Swansea and Neath Port Talbot

    AI-generated summary

    Robert Lee Evans · 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

    Robert Lee Evans, a prisoner at HMP Swansea, was found deceased in his cell in the early hours of 14 January 2018 after tying a ligature around his neck, shortly after arriving at the prison and while undergoing alcohol detoxification. The concerns included inadequate assessment and monitoring of his suicide and self-harm risk, failures relating to prescribed antidepressant and detoxification medication, and failures to promptly capture evidence from prison staff witnesses after his death.

    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 Swansea Prison; that does not assign responsibility.

    PFD Monitor interpretation

    High risk of self-inflicted death during prisoners' early days in custody

    Wider context from the report

    “████████ I am aware that Her Majesty's Chief Inspector of Prisons 2018 inspection report in respect of HMP Swansea stated that. “there have been four self-inflicted deaths since the previous inspection, all within a week of arrival. This replicated findings at our previous inspection of Swansea” [S5]. The most current report of Her Majesty's Chief Inspector of Prisons dated 2020 states, “There had been two self-inflicted deaths since the last inspection, the most recent in December 2019. Both had occurred soon after the prisoners arrived at the prison” [1.23]. I have heard evidence that it is well known by prison staff and recognised in national Ministry of Justice policy and in HMP Swansea Prison Policy that the very early days are a particularly high-risk time for prisoners particularly those on remand or recalled on licence. This is supported by the findings of the above inspection report. ████████ I heard that there is a safer cell on the induction unit and in that cell the whole window unit has been replaced with plastic material that can be slid to allow prisoners to get air from the outside into the cell. I heard evidence that prisoners are not on the induction unit for a significant period but that prisoners in the induction unit are in a vulnerable time in custody as they have just arrived in prison. ”
    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 Swansea Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to promptly capture and consider evidence relevant to deaths in custody

    Wider context from the report

    “I heard evidence from the two prison officers who appear in the HMP Swansea CCTV as mentioned above. On the evidence I have seen these witnesses were the last members of prison staff Lee spoke to before his death. At all stages into the investigation into Lee’s death (prisons and probations ombudsman and coronial) these witnesses have stated that they are unable to assist with what Lee was saying to them before his death. I am concerned that immediately following Lee’s death and the following day that these highly material witnesses (who were on duty) were not spoken to, did not attend a hot or cold debrief and were not asked to make a first account of events when matters were fresh in their minds. These witnesses did become known to the PPO. As a result, my investigation into Lee’s death has been significantly hampered. I am therefore concerned that lessons may not have been fully learnt from the circumstances of Lee’s death. I am concerned that if evidence relevant to a death in custody is not immediately captured and considered a situation may be created where evidence is lost which prevents general lessons from being learnt from a death in custody and that this creates a risk that other deaths will occur. ”
    Open source report

  2. Swansea and Neath Port Talbot

    AI-generated summary

    Khalid Abiaz · 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

    Khalid Abiaz, a prisoner at HMP Swansea, died in the early hours of 13 September 2016 after being found suspended by a ligature. The report identified concerns that an ACCT was not opened despite suicide warning markers and relevant historical information, and that prison and bank nursing staff may not have received sufficiently frequent or up-to-date ACCT training.

    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 Swansea Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of regular access to ACCT training for bank nurses

    Wider context from the report

    “2. I heard evidence from the nurse who saw Khalid on reception. This person is an experienced mental health nurse who is now a charge nurse on bank. The nurse told me that he still does at times work through the bank as a mental health nurse in HMP Swansea. At the time of Khalid’s death the Nurse was the mental health nurse working on reception and he completed the first reception health screen for Khalid and he did not open an ACCT. It was unclear what documents the nurse had seen on reception for Khalid but he did not ask prison staff if he could see any documents. The Nurse gave evidence that even if he had known that there was a suicide warning marker on Khalid’s prison escort record this would not have been enough combined with what Khalid said to him to open an ACCT, he relies on Khalid’s presentation. Khalid had been assessed by a consultant psychiatrist as a significant risk to himself a matter of weeks before he was seen by the Nurse in reception. HMP Swansea prison staff and the Nurse were not aware of this information but even if the Nurse had known this information his evidence was that this would not necessarily have been enough for him to open an ACCT, he would consider presentation. The revised ACCT version 6 and accompanying policy guidance set out above makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. The answers of the Nurse raise a concern around the level and adequacy of the training on ACCT. The Nurse stated that he has reflected on his practice but that he still places emphasis on what the prisoner says and how they present when considering whether to open an ACCT. I heard evidence that bank nurses were supervised in the prison but that training on ACCT remained the responsibility of HMP Swansea. I am concerned that bank nurse may not receive access to ACCT training including at the required regularity and I am concerned that unless this happens there remains a risk of similar deaths occurring in the future in HMP Swansea ”
    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 Swansea Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to apply ACCT opening criteria to information indicating current self-harm or suicide risk

    Wider context from the report

    “2. I heard evidence from the nurse who saw Khalid on reception. This person is an experienced mental health nurse who is now a charge nurse on bank. The nurse told me that he still does at times work through the bank as a mental health nurse in HMP Swansea. At the time of Khalid’s death the Nurse was the mental health nurse working on reception and he completed the first reception health screen for Khalid and he did not open an ACCT. It was unclear what documents the nurse had seen on reception for Khalid but he did not ask prison staff if he could see any documents. The Nurse gave evidence that even if he had known that there was a suicide warning marker on Khalid’s prison escort record this would not have been enough combined with what Khalid said to him to open an ACCT, he relies on Khalid’s presentation. Khalid had been assessed by a consultant psychiatrist as a significant risk to himself a matter of weeks before he was seen by the Nurse in reception. HMP Swansea prison staff and the Nurse were not aware of this information but even if the Nurse had known this information his evidence was that this would not necessarily have been enough for him to open an ACCT, he would consider presentation. The revised ACCT version 6 and accompanying policy guidance set out above makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. The answers of the Nurse raise a concern around the level and adequacy of the training on ACCT. The Nurse stated that he has reflected on his practice but that he still places emphasis on what the prisoner says and how they present when considering whether to open an ACCT. I heard evidence that bank nurses were supervised in the prison but that training on ACCT remained the responsibility of HMP Swansea. I am concerned that bank nurse may not receive access to ACCT training including at the required regularity and I am concerned that unless this happens there remains a risk of similar deaths occurring in the future in HMP Swansea ”
    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 Swansea Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate frequency and currency of ACCT training for prison officers

    Wider context from the report

    “1. I heard evidence that following a review in 2015 changes to the ACCT document and process were piloted in 10 establishments in 2019 and this included HMP Swansea. As a result a revised ACCT version 6 and accompanying policy guidance was issued. This revised guidance makes clear that an ACCT must be opened by any member of staff who receives information that indicates a prisoner may be currently at risk of self-harm or suicide and that this information may come from a prison escort. However, this requirement is not new. It was clear in my view from the HMP Swansea Suicide and Prevention Policy that was in place at the time of Khalid’s death that a warning marker for suicide on a prison escort record (‘PER’) should result in the opening of an ACCT. The prison officer who saw Khalid first in reception gave evidence that he was an experienced prison officer with over 20 years-experience of working in prisons including 18 years at HMP Swansea. At the time when Khalid came into custody he was an ACCT assessor and remains in this role. He saw Khalid’s PER which stated that Khalid had recently made threats to kill himself and was alleging mental health issues and he saw the NOEMIS transfer report which contained reference to historic ACCTs that Khalid had been in custody and an act of cutting and ligaturing by Khalid 9 months before in December 2015. He did not open an ACCT but referred the nurse who also did not open an ACCT. In his evidence the Prison Officer stated that if a prisoner came into custody now in 2022 with a warning on his PER stating that he has recently made threats to kill himself then this would not be enough to trigger the opening of an ACCT. This view is inconsistent with the mandatory revised ACCT policy guidance that I have set out above. This indicates that the system for training on ACCT in HMP Swansea is inadequate. The Prison Officer could not recall whether his ACCT training was up to date. His training records show that he was ACCT trained in 2005, 2008, 2011 and 2014 and I am told there was training on the new ACCT document that is not recorded in the training records and a further up-skilling session with staff date not specified. I did hear that training was difficult during the Covid 19 pandemic in HMP Swansea, however, ACCT training is required to be carried out with much more frequency than the training provided to the officer on reception and staff should understand that warning markers that require an ACCT to be opened. I am concerned that unless prison officers are provided with frequent ACCT training which is kept up to date then there remains a risk of similar deaths occurring in the future in HMP Swansea. ”
    Open source report

  3. Swansea and Neath Port Talbot

    AI-generated summary

    Matthew Thomas Purser · 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

    Matthew Thomas Purser hanged himself in his cell at Swansea Prison on 13 June 2012, after being remanded there and placed on self-harm monitoring. The report identified concerns about inadequate ACCT training, insufficiently objective recording and review of trigger events and significant interactions, and unclear arrangements for obtaining community mental health records.

    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 Swansea Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear process for promptly obtaining community mental health records

    Wider context from the report

    “3. The prison appreciated that Mr. Purser was due to have a psychiatrist’s appointment in the community soon after coming into prison. Although he was booked into the primary care prison mental health service the means by which community health records were to be obtained was not clear. For an appropriate assessment to be made there is a need for an urgent contact with community mental health services to be made so that records are promptly obtained. ”
    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 Swansea Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure ACCT health-screening doctors are trained in required procedures

    Wider context from the report

    “1. The Doctor who saw Mr. Purser for the second health screen on the day after admission had not received ACCT training as required by PS 164/2011 and HMP Swansea Suicide Prevention Policy 2010 and was not aware of the requirement for him to be trained in the procedures. ”
    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 Swansea Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide sufficient ACCT trigger-event recording and assessment guidance for objective risk assessment

    Wider context from the report

    “2. The trigger event endorsed on the documentation requiring review of Mr. Purser under the ACCT was given as “loss of contact with partner/breakdown in relationship”. Mr. Purser’s apparent dependence on maintaining contact with his partner was correctly identified by the prison but the way in which the wording of the trigger was expressed left much to the subjective assessment of the officers about the state of his relationship with his partner. Because of the way in which the ACCT records were kept officers did not have enough information to make a realistic assessment and in their evidence some officers draw a distinction between Mr. Purser’s relationship going through a difficult time and it having broken down. If a trigger event is something which cannot be easily and objectively determined by an officer more detailed observations and recording will be required. If the only way in which a trigger can be expressed is in similar language to the trigger some indication needs to be given as to how the assessment is to be carried out and how clearly information must be shared by means of the records kept. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

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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