PFD report

CHARLIE BRIAN TODD · Prevention of Future Deaths report

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Issued 21 Sep 2021•County Durham and Darlington

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.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
4

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 raised3

  1. Failure to complete SACU hourly prisoner checks consistently
    Part of recurring concern: Inadequate supervision and monitoring of prisoners
  2. Lack of day-to-day supervision and structured allocation of key SACU tasks
  3. Lack of real-time detection of incomplete SACU prisoner checks
    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

    Provide an additional officer and administration staff member to support SACU operations.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
  2. Action

    Oversee daily and weekly SACU management checks and report recurring issues to the Head of Residence for action.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 September 2021.
  3. Action

    Provide a “Know Your Job” sheet for staff temporarily assigned to SACU, setting out required duties.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 September 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    A real-time system for confirming checks cannot be implemented because the required resources would be significant and prohibitive.

    Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 complete SACU hourly prisoner checks consistently

Wider context from the report

“During the course of the inquest evidence was heard from a number of witnesses of the supervision and staffing arrangements within SACU. The overall position was that there was no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed, and officers, including officers not posted to the SACU, but covering for a shift, were required to allocate various tasks between themselves on an ad hoc basis. On the 2nd September 2019 the document setting out which hourly checks had been undertaken in the SACU was incomplete. No check on Mr Todd’s cell took place at 3pm that day. Evidence was heard that staffing levels can vary, with officers being occupied on tasks which meant hourly checks could not always be completed. Whilst there is auditing of the hourly checks retrospectively, there is no ‘real time’ system which would alert officers and their supervisors to checks being incomplete for a prisoner/s as the record of checks are paper based and held in the SACU, as well there is no constant supervising officer present or other system there to ensure compliance. ”

Is this part of a recurring concern?

Yes — Inadequate supervision and monitoring of 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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of day-to-day supervision and structured allocation of key SACU tasks

Wider context from the report

“During the course of the inquest evidence was heard from a number of witnesses of the supervision and staffing arrangements within SACU. The overall position was that there was no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed, and officers, including officers not posted to the SACU, but covering for a shift, were required to allocate various tasks between themselves on an ad hoc basis. On the 2nd September 2019 the document setting out which hourly checks had been undertaken in the SACU was incomplete. No check on Mr Todd’s cell took place at 3pm that day. Evidence was heard that staffing levels can vary, with officers being occupied on tasks which meant hourly checks could not always be completed. Whilst there is auditing of the hourly checks retrospectively, there is no ‘real time’ system which would alert officers and their supervisors to checks being incomplete for a prisoner/s as the record of checks are paper based and held in the SACU, as well there is no constant supervising officer present or other system there to ensure compliance. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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 real-time detection of incomplete SACU prisoner checks

Wider context from the report

“During the course of the inquest evidence was heard from a number of witnesses of the supervision and staffing arrangements within SACU. The overall position was that there was no supervising officer present on a day to day basis to ensure key tasks were always allocated or completed, and officers, including officers not posted to the SACU, but covering for a shift, were required to allocate various tasks between themselves on an ad hoc basis. On the 2nd September 2019 the document setting out which hourly checks had been undertaken in the SACU was incomplete. No check on Mr Todd’s cell took place at 3pm that day. Evidence was heard that staffing levels can vary, with officers being occupied on tasks which meant hourly checks could not always be completed. Whilst there is auditing of the hourly checks retrospectively, there is no ‘real time’ system which would alert officers and their supervisors to checks being incomplete for a prisoner/s as the record of checks are paper based and held in the SACU, as well there is no constant supervising officer present or other system there to ensure compliance. ”

Is this part of a recurring concern?

Yes — Inadequate supervision and monitoring of prisoners.

Open source report

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

Provide an additional officer and administration staff member to support SACU operations.

Verbatim wording from the response

“I am confident that the staffing levels and supervisory arrangements in place are sufficient to deliver all of the SACU’s regime, and allow for the required checks to take place. The staffing of the SACU is in line with national benchmarking standards, and indeed the Governor has provided an additional officer resource, as well as an administration staff member in order to support the work of the SACU. HMP Durham have a weekly Regime Management Plan meeting which forecasts staffing levels for the following week to ensure that the regime across the prison is delivered and consistent.”

Source location

2021-0318-Response-from-HMPPS_Published
Page 1 · response
Published 23 September 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

Oversee daily and weekly SACU management checks and report recurring issues to the Head of Residence for action.

Verbatim wording from the response

“Additionally, the SACU CM has been tasked with overseeing the daily and weekly management checks being carried out and will also provide an update to the Head of Residence, so that any reoccurring issues can be promptly addressed as appropriate with individual staff.”

Source location

2021-0318-Response-from-HMPPS_Published
Page 2 · response
Published 23 September 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

Provide a “Know Your Job” sheet for staff temporarily assigned to SACU, setting out required duties.

Verbatim wording from the response

“It is inevitable that at some points staff who are not normally based in the SACU will be required to work on the unit for a shift, and in order to support those staff in understanding the expectations of the unit a “Know Your Job” sheet will be provided to them, setting out the tasks they will be required to cover.”

Source location

2021-0318-Response-from-HMPPS_Published
Page 1 · response
Published 23 September 2021

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

A real-time system for confirming checks cannot be implemented because the required resources would be significant and prohibitive.

Verbatim wording from the response

“Given the number of checks that take place throughout the prison on a daily basis, implementing a ‘real-time’ system to ensure these have been done would require significant and prohibitive resource. I believe that the robust assurance processes already in place, together with the improvements made will ensure that prisoners located in the SACU at HMP Durham, can be safely managed.”

Source location

2021-0318-Response-from-HMPPS_Published
Page 2 · response
Published 23 September 2021

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Existing staffing, supervision and assurance arrangements are considered sufficient to deliver SACU regimes and required hourly checks safely.

Verbatim wording from the response

“I can assure you that there is clear management oversight of the SACU. The day-to-day running of the unit is directed by a dedicated Custodial Manager (CM), responsible for the allocation of tasks and performance management of the officers working there. The CM reports to, and is supported by, the Head of Residence and Safety (a Governor grade) who forms part of the Governor’s Senior Management Team. The running of the SACU is further subject to daily checks undertaken by the Orderly Officer and Duty Governor, and the Governor undertakes a weekly in-charge check.”

Source location

2021-0318-Response-from-HMPPS_Published
Page 1 · response
Published 23 September 2021

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Conduct the commissioned SACU pilot to improve paperwork and strengthen health support practices for segregated prisoners.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2021.

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

Conduct the commissioned SACU pilot to improve paperwork and strengthen health support practices for segregated prisoners.

Verbatim wording from the response

“A recently commissioned SACU pilot, considering operational processes within the SACU and the management of segregated prisoners, will provide the prison with an opportunity to improve paperwork and will also be used to look at the health support provided on the unit with feedback used to strengthen current practices.”

Source location

2021-0318-Response-from-HMPPS_Published
Page 2 · response
Published 23 September 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