Wandsworth Prison

Justice · Prison or young offender institution

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First report 31 May 2017•Latest report 19 Feb 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: 6
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

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

19 Feb2026
Inner West London
Concerns raised3
1. Lack of training in the principles of risk formulation during ACCT induction
2. Lack of mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment
3. Lack of mandatory ACCT refresher training for prison officers
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Rajwinder Singh · 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

Rajwinder Singh was imprisoned after being sentenced at Southwark Crown Court and was identified as at risk of self-harm and suicide. He was transferred to St George’s Hospital after failures including unanswered cell bells and inadequate observations, and died there on 25th June 2026. The principal concerns included inadequate risk assessment and record keeping, failures in observations and handovers, and insufficient mandatory ACCT training for prison and agency healthcare staff.

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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of training in the principles of risk formulation during ACCT induction
Wider context from the report
“(3) When Prison Officers and/or Healthcare staff are given ACCT induction training at HMP Wandsworth, there is no training in the principles of risk formulation ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment
Wider context from the report
“(2) There are no mandatory procedures to ensure that, before they are deployed in the prison setting, Oxleas agency staff have the same mandatory ACCT training as that provided to permanent healthcare staff. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of mandatory ACCT refresher training for prison officers
Wider context from the report
“(1) There is no mandatory ACCT refresher training for prison officer at HMP Wandsworth; ”
Open source report
1 Oct2024
Inner West London
Concerns raised3
1. Failure to perform robust, timely checks that elicit reliable positive responses or obvious signs of life
2. Failure to record and verify positive responses from prisoner life checks
3. Failure to ensure staff know how and when to perform prisoner life checks and identify signs of life
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Brandon Valrick JOHNSON · 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

Brandon Valrick JOHNSON died of cardio-respiratory failure at his cell in HMP Wandsworth on 12 September 2019, aged 40. He was not discovered deceased until late afternoon despite several attendances at his cell. The report raised concerns about the robustness, timing, recording, oversight and staff training relating to checks intended to establish that prisoners were alive.

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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to perform robust, timely checks that elicit reliable positive responses or obvious signs of life
Wider context from the report
“I am concerned about the robustness of the procedures and processes for checking that prisoners are alive within their cells. My concern arises because I heard evidence that Brandon was not discovered as deceased until the late afternoon of 12ᵗʰ September 2019 despite a number of attendances at his cell by prison officers and other staff. Rigor mortis and pooling of the blood had been identified. I was told various checks had been undertaken since 0430. I was not confident, having heard and assessed the evidence as a whole that staff had sufficient time to properly check on inmates and obtain positive responses or note obvious signs of life. The checks that were made were for a matter of seconds, and I was not satisfied that the signs of life said to have been noted were sufficiently obvious or reliable to have given appropriate reassurance, or that signs of life were actually being looked for rather than as being incidental to other observations. I am concerned whether all appropriate measures are being taken to perform robust checks at appropriate times that elicit positive responses to indicate that a prisoner remains alive. In addition, I am concerned about how the prison satisfies itself that staff know how and when to perform these checks, what that consists of, and in relation to signs of life/positive response what those are meant to be and where that is set out in the training of staff. Further if checks are performed which elicit a positive life response how are those recorded, who checks this is being done, in what form and how often. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to record and verify positive responses from prisoner life checks
Wider context from the report
“I am concerned about the robustness of the procedures and processes for checking that prisoners are alive within their cells. My concern arises because I heard evidence that Brandon was not discovered as deceased until the late afternoon of 12ᵗʰ September 2019 despite a number of attendances at his cell by prison officers and other staff. Rigor mortis and pooling of the blood had been identified. I was told various checks had been undertaken since 0430. I was not confident, having heard and assessed the evidence as a whole that staff had sufficient time to properly check on inmates and obtain positive responses or note obvious signs of life. The checks that were made were for a matter of seconds, and I was not satisfied that the signs of life said to have been noted were sufficiently obvious or reliable to have given appropriate reassurance, or that signs of life were actually being looked for rather than as being incidental to other observations. I am concerned whether all appropriate measures are being taken to perform robust checks at appropriate times that elicit positive responses to indicate that a prisoner remains alive. In addition, I am concerned about how the prison satisfies itself that staff know how and when to perform these checks, what that consists of, and in relation to signs of life/positive response what those are meant to be and where that is set out in the training of staff. Further if checks are performed which elicit a positive life response how are those recorded, who checks this is being done, in what form and how often. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure staff know how and when to perform prisoner life checks and identify signs of life
Wider context from the report
“I am concerned about the robustness of the procedures and processes for checking that prisoners are alive within their cells. My concern arises because I heard evidence that Brandon was not discovered as deceased until the late afternoon of 12ᵗʰ September 2019 despite a number of attendances at his cell by prison officers and other staff. Rigor mortis and pooling of the blood had been identified. I was told various checks had been undertaken since 0430. I was not confident, having heard and assessed the evidence as a whole that staff had sufficient time to properly check on inmates and obtain positive responses or note obvious signs of life. The checks that were made were for a matter of seconds, and I was not satisfied that the signs of life said to have been noted were sufficiently obvious or reliable to have given appropriate reassurance, or that signs of life were actually being looked for rather than as being incidental to other observations. I am concerned whether all appropriate measures are being taken to perform robust checks at appropriate times that elicit positive responses to indicate that a prisoner remains alive. In addition, I am concerned about how the prison satisfies itself that staff know how and when to perform these checks, what that consists of, and in relation to signs of life/positive response what those are meant to be and where that is set out in the training of staff. Further if checks are performed which elicit a positive life response how are those recorded, who checks this is being done, in what form and how often. ”
Open source report
11 Jun2024
Inner West London
Concerns raised4
1. Failure of first aid training to be prison specific for recognising unconsciousness
2. Lack of official training for Operational Support Grades
3. Failure to centrally record and monitor first aid training
1. Failure to implement induction training on responding to suspected prisoner unconsciousness
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Yuri Hatton · 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

Yuri Hatton, who was detained at HMP Wandsworth, died in hospital on 9 November 2018 after being found unresponsive following a suspected opiate overdose and later showing features of brain stem death. The jury identified four failures that cumulatively possibly contributed to his death, including failures involving emergency response, clinical observations and communications. The report also raised concerns about limited OSG training, the frequency and monitoring of first aid training, and the lack of prison-specific training on recognising unconsciousness.

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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure of first aid training to be prison specific for recognising unconsciousness
Wider context from the report
“(3) Recognising unconsciousness. The First Aid training offered, whilst addressing unconsciousness, is not prison specific. A new induction package was said to be rolled out imminently which will include instructions about what a member of prison staff should do if they believe that a prisoner could be unconscious and will reiterate the instruction to call a code blue in such circumstances. This training has not yet been implemented. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of official training for Operational Support Grades
Wider context from the report
“(1) Operational Support Grade (OSG) training. Following the Inquest, I sought further evidence regarding several matters, including OSG training. A statement provided by HMP Wandsworth confirms that of 83 OGSs, only 5 had received HMPPS official training. This is against the background of OSG’s only being present on the wings at night, and therefore often the first to respond to any emergency. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to centrally record and monitor first aid training
Wider context from the report
“(2) The frequency and monitoring of first aid training. First Aid training is said to be refreshed locally annually. Training logs of some staff members involved in the Inquest did not show centrally all the training received, instead a local training log is said to be kept, but which were absent at the inquest or post-inquest. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to implement induction training on responding to suspected prisoner unconsciousness
Wider context from the report
“(3) Recognising unconsciousness. The First Aid training offered, whilst addressing unconsciousness, is not prison specific. A new induction package was said to be rolled out imminently which will include instructions about what a member of prison staff should do if they believe that a prisoner could be unconscious and will reiterate the instruction to call a code blue in such circumstances. This training has not yet been implemented. ”
Open source report
11 Jun2024
Inner West London
Concerns raised1
1. Lack of clarity in first aid training on the use of rescue breaths during resuscitation attempts
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Daniel Beckford · 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

Daniel Beckford was detained at HMP Wandsworth and was found hanging in his cell after taking an overdose of prescribed antibiotic medication. He was transferred to St George’s Hospital, where he was declared deceased. The report identified concerns about the provision and content of first aid training, including a lack of clarity about the use of rescue breaths during resuscitation attempts.

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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity in first aid training on the use of rescue breaths during resuscitation attempts
Wider context from the report
“(1) The provision and content of first aid training. The evidence of witnesses revealed an absence of clarity in the first aid training to prison officers on the use of rescue breaths during resuscitation attempts, as per current advice from the Resuscitation Council UK. ”
Open source report
20 Nov2017
Inner West London
Concerns raised15
1. Inadequate staff training for managing bullying
2. Inadequate communication between healthcare, psychological, psychiatric and prison staff
3. Inadequate medical staff training in resuscitation
1. Failure of the system for restocking used medical supplies
2. Inappropriate mixing of vulnerable prisoners with non-vulnerable prisoners in the vulnerable prisoners’ unit
3. Inadequate systems for managing bullying
4. Poor recognition of bullying risk
5. Inadequate security and intelligence systems for identifying and containing bullying and crime risks
6. Insufficient staffing for managing bullying
7. Regular passage of prisoners from other wings through the vulnerable prisoners’ unit
8. Poor communication between teams about bullying risks
9. Absence of a personal officer system providing prisoners with a named officer who knows them well
10. Failure to undertake risk assessments of prisoners before sentencing
11. Inappropriate cell allocation for vulnerable prisoners
12. Mixing of vulnerable prisoners with potential bullies
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Robert John Richards · 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 John Richards died by suicide after being found hanging by a sheet in his cell at HMP Wandsworth on 29 July 2014. The report identified concerns about bullying, extortion, inadequate risk management and communication, unsuitable cell allocation, staffing and training, and failings in resuscitation equipment and procedures.

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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Inadequate staff training for managing bullying
Wider context from the report
“1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty, poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Inadequate communication between healthcare, psychological, psychiatric and prison staff
Wider context from the report
“7. That the communications interface between the medical staff, those supplying psychological support and psychiatric services needs to be improved, as does the communication of these staff with prison officers, such that risks of self harm and bullying are appropriately communicated and acted upon. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Inadequate medical staff training in resuscitation
Wider context from the report
“5. That training of medical staff in relation to Resuscitation is inadequate. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure of the system for restocking used medical supplies
Wider context from the report
“6. That the system for ensuring restocking of medical supplies such as oxygen after they have been used needs to be reviewed. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Inappropriate mixing of vulnerable prisoners with non-vulnerable prisoners in the vulnerable prisoners’ unit
Wider context from the report
“2. The organisation of the vulnerable prisoners’ unit is such that those truly vulnerable are mixed with those prisoners placed there for reasons as drug debt from other wings, who are not vulnerable in other ways and then abuse prisoners such as Mr Richards. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Inadequate systems for managing bullying
Wider context from the report
“1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty, poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Poor recognition of bullying risk
Wider context from the report
“1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty, poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Inadequate security and intelligence systems for identifying and containing bullying and crime risks
Wider context from the report
“9. That security and intelligence systems are upgraded and overhauled such that risks of bullying and crime within the prison that feed into self-harm and suicide by prisoners are reduced and contained appropriately. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staffing for managing bullying
Wider context from the report
“1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty, poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Regular passage of prisoners from other wings through the vulnerable prisoners’ unit
Wider context from the report
“3. That prisoners from other wings pass through the VP unit on a regular basis and thus increase the chance of bullying to the vulnerable prisoners. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Poor communication between teams about bullying risks
Wider context from the report
“1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty, poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Absence of a personal officer system providing prisoners with a named officer who knows them well
Wider context from the report
“10. That the personal officer system be re-established, so that prisoners have a named officer who knows them well. Risks should then be communicated and managed more appropriately within HMP Wandsworth, such that self-harm and suicide of prisoners is reduced. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake risk assessments of prisoners before sentencing
Wider context from the report
“8. That there is a risk assessment undertaken of prisoners in the approach to sentencing so that any increase in risk may be appropriately managed. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Inappropriate cell allocation for vulnerable prisoners
Wider context from the report
“4. That the system for cell allocation is inappropriate such that a young and immature and vulnerable man such as Mr Richards was sharing a cell with a prisoner with convictions for predatory sexual behaviour with boys. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Mixing of vulnerable prisoners with potential bullies
Wider context from the report
“1. That bullying within HMP Wandsworth is not appropriately managed due to inadequate systems being in place, too few staff on duty, poor communication between teams, inadequate staff training, poor recognition of risk and the mixing of vulnerable prisoners with potential bullies. ”
Open source report
31 May2017
Inner West London
Concerns raised3
1. Failure to provide an effective pathway for family health information to reach relevant prison welfare teams
2. Ineffective control of contraband inflow into the prison
3. Failure to maintain comprehensive records of family health-information contacts
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Jonathan David Palmer · 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

Jonathan David Palmer was found suspended from a ligature in his cell at HMP Wandsworth on 19 November 2015 and was declared dead after resuscitation efforts were abandoned. The Inquest found the cause of death to be hanging. The substantive concerns included the lack of an effective system for families to provide and have health information disseminated within the prison, and apparently ineffective controls on contraband such as Spice.

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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide an effective pathway for family health information to reach relevant prison welfare teams
Wider context from the report
“1. There is no effective system by which the family of a prisoner can input information they deem relevant to a prisoner's health needs and be assured this will be disseminated to relevant teams within the prison, with appropriate records being maintained in order to be able to demonstrate this has been done. Families can be a source of valuable medical information, particularly, where GP records have not been obtained and the individual himself may not be a reliable source. It would be beneficial to have a clear, publicised conduit for a family to provide relevant medical information to a specified department. The Inquest was informed that a single point of contact has now been established, but it remains unclear whether comprehensive records of all contacts will be maintained, or whether this will result in the timely dissemination of information to those with a role in the prisoner's welfare, such as healthcare staff, RAPt or the chaplains. As the Personal Officer scheme appears to have been abandoned at HMP Wandsworth there is no alternative individual for a concerned family to approach. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Ineffective control of contraband inflow into the prison
Wider context from the report
“2. The steps taken to control the inflow of contraband material into the prison (such as the illicit drug known as Spice), appear ineffective. Insidious substances such as Spice can mimic the symptoms of psychotic illness and jeopardise life when unpredictable reactions occur to those using it. Spice is also likely to adversely affect discipline within the prison, create the potential for intra prisoner bullying (arising from drug debts) and stretch already depleted healthcare resources. In order to combat this menace, steps should be taken to identify the entry points in order that they can be more effectively controlled and those involved, deterred. ”
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 Wandsworth Prison; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain comprehensive records of family health-information contacts
Wider context from the report
“1. There is no effective system by which the family of a prisoner can input information they deem relevant to a prisoner's health needs and be assured this will be disseminated to relevant teams within the prison, with appropriate records being maintained in order to be able to demonstrate this has been done. Families can be a source of valuable medical information, particularly, where GP records have not been obtained and the individual himself may not be a reliable source. It would be beneficial to have a clear, publicised conduit for a family to provide relevant medical information to a specified department. The Inquest was informed that a single point of contact has now been established, but it remains unclear whether comprehensive records of all contacts will be maintained, or whether this will result in the timely dissemination of information to those with a role in the prisoner's welfare, such as healthcare staff, RAPt or the chaplains. As the Personal Officer scheme appears to have been abandoned at HMP Wandsworth there is no alternative individual for a concerned family to approach. ”
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 raised3

Lack of training in the principles of risk formulation during ACCT induction

Lack of mandatory procedures ensuring ACCT training equivalence for agency healthcare staff before deployment

Lack of mandatory ACCT refresher training for prison officers

Concerns raised3

Failure to perform robust, timely checks that elicit reliable positive responses or obvious signs of life

Failure to record and verify positive responses from prisoner life checks

Failure to ensure staff know how and when to perform prisoner life checks and identify signs of life

Concerns raised4

Failure of first aid training to be prison specific for recognising unconsciousness

Lack of official training for Operational Support Grades

Failure to centrally record and monitor first aid training

Failure to implement induction training on responding to suspected prisoner unconsciousness

Concerns raised1

Lack of clarity in first aid training on the use of rescue breaths during resuscitation attempts

Concerns raised15

Inadequate staff training for managing bullying

Inadequate communication between healthcare, psychological, psychiatric and prison staff

Inadequate medical staff training in resuscitation

Failure of the system for restocking used medical supplies

Inappropriate mixing of vulnerable prisoners with non-vulnerable prisoners in the vulnerable prisoners’ unit

Inadequate systems for managing bullying

Poor recognition of bullying risk

Inadequate security and intelligence systems for identifying and containing bullying and crime risks

Insufficient staffing for managing bullying

Regular passage of prisoners from other wings through the vulnerable prisoners’ unit

Poor communication between teams about bullying risks

Absence of a personal officer system providing prisoners with a named officer who knows them well

Failure to undertake risk assessments of prisoners before sentencing

Inappropriate cell allocation for vulnerable prisoners

Mixing of vulnerable prisoners with potential bullies

Concerns raised3

Failure to provide an effective pathway for family health information to reach relevant prison welfare teams

Ineffective control of contraband inflow into the prison

Failure to maintain comprehensive records of family health-information contacts