PFD report

Brian Burrows (also known as Brian Smith) · Prevention of Future Deaths report

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Issued 9 Sep 2025•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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised1

  1. Lack of effective training and guidance for prison officers managing competing priority tasks
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.4

  1. Action

    Deploy Safety Floorwalkers to reinforce guidance and provide real-time support to landing staff and managers.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 17 September 2025.
  2. Action

    Strengthen local training through direct engagement with the Enable programme.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 September 2025.
  3. Action

    Conduct the Foundation Training Reform review of initial prison officer training.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 17 September 2025.

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 effective training and guidance for prison officers managing competing priority tasks

Wider context from the report

“(1) The inquest was told that no training is given to prison officers about decision making in dynamic situations where competing priority tasks needs to be completed namely what to do when faced by a number of emergency cell bells and a number of ACCT checks. (2) The inquest was told that briefings delivered by senior staff on the wing do not assist prison officers by providing guidance on how to complete tasks of competing priority. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Deploy Safety Floorwalkers to reinforce guidance and provide real-time support to landing staff and managers.

Verbatim wording from the response

“Additionally, the prison will introduce a new Supervising Officer (Wellbeing, Care and Coaching) role to provide enhanced support and coaching for staff. Safety Floorwalkers will work closely with landing staff and managers to reinforce guidance and offer real-time support.”

Source location

Response from HM Prison & Probation Service
Page 2 · response
Published 17 September 2025

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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

Strengthen local training through direct engagement with the Enable programme.

Verbatim wording from the response

“I would like to assure you that HMPPS is committed to strengthening the support and training it provides to prison officers, recognising that these are essential to improving staff retention. At the heart of this commitment is the ‘Enable’ programme, which is a psychologically and operationally informed workforce transformation initiative. ‘Enable’ is designed to reshape how HMPPS trains, develops, leads and supports prison staff, with the ultimate goal of creating safer, more supportive working environments where staff feel valued and empowered.”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 17 September 2025

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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

Conduct the Foundation Training Reform review of initial prison officer training.

Verbatim wording from the response

“A key part of this transformation is the Foundation Training Reform, a long-term review of the initial training offer for prison officers. The future model will focus on experiential learning delivered over a 12-month period, ensuring new officers are better supported from the outset of their careers. This extended and immersive approach is designed to build confidence, competence, and a stronger sense of belonging. It contains a focus on how staff would carry out a dynamic risk assessment in order to prioritise work.”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 17 September 2025

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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

Implement High Reliability Checklist Briefings across all prison wings.

Verbatim wording from the response

“The leadership team at HMP Leeds has engaged directly with the ‘Enable’ programme to strengthen their training locally and reinforce these principles. From October 2025, the prison will implement High Reliability Checklist Briefings across all wings. These structured, short meetings are designed to provide clear guidance on managing competing priorities, enhance confidence and capability in defensible decision-making and improve communication and”

Source location

Response from HM Prison & Probation Service
Page 1 · response
Published 17 September 2025

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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.2

  1. 1

    Conduct daily senior-management assessments of ACCT caseload manageability and resource allocation.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 September 2025.
  2. 2

    Introduce a Supervising Officer role focused on wellbeing, care and coaching for staff.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 17 September 2025.

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 daily senior-management assessments of ACCT caseload manageability and resource allocation.

Verbatim wording from the response

“Senior managers also meet daily to assess the manageability of Assessment, Care in Custody and Teamwork (ACCT) caseloads and resource allocation, enabling deployment of additional staff where necessary. These processes have been embedded for over 12 months and support early intervention when ACCT volumes or observation levels are elevated.”

Source location

Response from HM Prison & Probation Service
Page 2 · response
Published 17 September 2025

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

Introduce a Supervising Officer role focused on wellbeing, care and coaching for staff.

Verbatim wording from the response

“Additionally, the prison will introduce a new Supervising Officer (Wellbeing, Care and Coaching) role to provide enhanced support and coaching for staff. Safety Floorwalkers will work closely with landing staff and managers to reinforce guidance and offer real-time support.”

Source location

Response from HM Prison & Probation Service
Page 2 · response
Published 17 September 2025

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