PFD report

Connor Arthur Steven Hout · Prevention of Future Deaths report

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Issued 30 Nov 2021•West Yorkshire Eastern

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to obtain a response from all prisoners during welfare checks
    Part of recurring concern: Inadequate supervision and monitoring of prisoners
  2. Lack of clearly understood systems for assuring prisoner wellbeing during or shortly after unlock
    Part of recurring concern: Inadequate supervision and monitoring of prisoners
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Issue a Governor’s Order requiring staff to obtain verbal responses from prisoners who are or appear awake during roll checks and unlocking procedures.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 30 November 2021.
  2. Action

    Circulate a Notice to Staff reminding staff to assure themselves of prisoners’ wellbeing during or shortly after unlock.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 30 November 2021.
  3. Action

    Discuss the concerns with staff who gave evidence at the inquest to reinforce unlock procedures, responsibilities and welfare escalation.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 30 November 2021.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to obtain a response from all prisoners during welfare checks

Wider context from the report

“The evidence revealed prison officers are not obtaining, nor did the prison systems require them to obtain, a response from all prisoners during welfare checks. More specifically, during the morning unlock they are not required to, and therefore do not necessarily seek to, obtain a response or otherwise engage with prisoners. In particular, no response is required, and therefore not sought, from prisoners who appear to be asleep in bed, notwithstanding the requirements of PSI 75/2011 (Residential Services). The PSI sets out the fact that residential prison staff play a key role in spotting any signs of distress and will often be the first to pick up information or signs, and should accordingly engage with prisoners in such a way that facilitates the identification of any concerns or distress. Further, paragraph 2.3 of the PSI, namely, “Output No. 3 Prisoners are supported and their daily needs are met” states that prisons are required to have, “clearly understood systems in place for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock”. In the absence of such systems prisoners in distress, or otherwise a cause for concern, may be missed. ”

Is this part of a recurring concern?

Yes — Inadequate supervision and monitoring of prisoners.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of clearly understood systems for assuring prisoner wellbeing during or shortly after unlock

Wider context from the report

“The evidence revealed prison officers are not obtaining, nor did the prison systems require them to obtain, a response from all prisoners during welfare checks. More specifically, during the morning unlock they are not required to, and therefore do not necessarily seek to, obtain a response or otherwise engage with prisoners. In particular, no response is required, and therefore not sought, from prisoners who appear to be asleep in bed, notwithstanding the requirements of PSI 75/2011 (Residential Services). The PSI sets out the fact that residential prison staff play a key role in spotting any signs of distress and will often be the first to pick up information or signs, and should accordingly engage with prisoners in such a way that facilitates the identification of any concerns or distress. Further, paragraph 2.3 of the PSI, namely, “Output No. 3 Prisoners are supported and their daily needs are met” states that prisons are required to have, “clearly understood systems in place for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock”. In the absence of such systems prisoners in distress, or otherwise a cause for concern, may be missed. ”

Is this part of a recurring concern?

Yes — Inadequate supervision and monitoring of prisoners.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Issue a Governor’s Order requiring staff to obtain verbal responses from prisoners who are or appear awake during roll checks and unlocking procedures.

Verbatim wording from the response

“In January 2020, and in response to the PPO’s investigation, HMP Wakefield issued a Governor’s Order that set out in expectation that staff should obtain a verbal response from all prisoners who are or appear to be awake when conducting roll checks and unlocking procedures, to avoid waking sleeping prisoners overnight or early in the morning, while ensuring that potential concerns are identified.”

Source location

2021-0405-Response-from-HMPPS_Published
Page 1 · response
Published 30 November 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Circulate a Notice to Staff reminding staff to assure themselves of prisoners’ wellbeing during or shortly after unlock.

Verbatim wording from the response

“Further, and in response to your concerns, the Governor of HMP Wakefield has now circulated a Notice to Staff reminding staff that they should assure themselves of the wellbeing of prisoners during or shortly after unlock. Additionally, your concerns will be discussed with the staff who gave evidence at the inquest to ensure they fully understand the process and their responsibilities during unlock, and know how to take action should they have any concerns about an individual’s welfare.”

Source location

2021-0405-Response-from-HMPPS_Published
Page 2 · response
Published 30 November 2021

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Discuss the concerns with staff who gave evidence at the inquest to reinforce unlock procedures, responsibilities and welfare escalation.

Verbatim wording from the response

“Further, and in response to your concerns, the Governor of HMP Wakefield has now circulated a Notice to Staff reminding staff that they should assure themselves of the wellbeing of prisoners during or shortly after unlock. Additionally, your concerns will be discussed with the staff who gave evidence at the inquest to ensure they fully understand the process and their responsibilities during unlock, and know how to take action should they have any concerns about an individual’s welfare.”

Source location

2021-0405-Response-from-HMPPS_Published
Page 2 · response
Published 30 November 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026