PFD report

Steven Lee RUDDICK · Prevention of Future Deaths report

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Issued 18 Nov 2025•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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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. Failure to prevent unobserved removal and relocation of prohibited items during toilet visits by detained persons on close observations
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.2

  1. Action

    Issue PECS suppliers a reflective direction and briefing on risk-based searching.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 21 November 2025.
  2. Action

    Review suppliers’ searching procedures and confirm their compliance with HMPPS policy and PECS requirements.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 21 November 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Existing HMPPS supervision policy is sufficient; routine direct observation is not required except for formally assessed acute safety risks.

    Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 prevent unobserved removal and relocation of prohibited items during toilet visits by detained persons on close observations

Wider context from the report

“It emerged during the evidence that there is a material difference between police procedures for managing a detained person on close observations and those of GeoAmey and, it is understood, HM Prison Service in relation to using the toilet in this case. In police custody, the detained person would be in standard cuffs and the officer would be present and observing directly during the toilet visit. In GeoAmey and Prison Service custody, in contrast, the detained person would be in a 1 metre closet chain and would be attached to the officer by means of a 1.5-2 metre chain and he/she would used the toilet without the officer observing directly. While this preserves the privacy and dignity of the detained person it can also, as in this scenario, potentially offer him/her the opportunity of removing prohibited items from the rectum without being observed and relocating them on his/her person. ████████ police and GeoAmey/HM Prison Service on this issue only emerged during the evidence of witnesses to the Inquest itself and it’s significance not predicted by either myself or any of the Interested Persons or their representatives before the Inquest. By that stage, MOJ had been stood down as an Interested Person (which was agreed across the board) since the Pre-Inquest Review in February 2025. Further, it was only established at the very end of the Inquest during submissions on Regulation 28 matters that the policy and procedures governing custody in the scenario here relevant is provided by PECS rather than by GeoAmey itself. Clearly, had either of these factors been different, then MOJ would have had a chance to contribute ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Issue PECS suppliers a reflective direction and briefing on risk-based searching.

Verbatim wording from the response

“PECS recognises the concerns raised in relation to searching following toilet visits. In response, suppliers searching standard operating procedures have been reviewed and confirmed as compliant with HMPPS policy and the PECS ‘Authority’ reflective direction and briefing around risk based searching to both PECS suppliers.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 21 November 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

Review suppliers’ searching procedures and confirm their compliance with HMPPS policy and PECS requirements.

Verbatim wording from the response

“PECS recognises the concerns raised in relation to searching following toilet visits. In response, suppliers searching standard operating procedures have been reviewed and confirmed as compliant with HMPPS policy and the PECS ‘Authority’ reflective direction and briefing around risk based searching to both PECS suppliers.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 21 November 2025

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 HMPPS supervision policy is sufficient; routine direct observation is not required except for formally assessed acute safety risks.

Verbatim wording from the response

“HMPPS policy is explicit that, unless a prisoner is subject to a formally risk-assessed regime of constant supervision due to active suicide and/or self-harm risk, prisoners would not be supervised within toilet facilities in such close proximity to staff as to permit direct observation.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 21 November 2025

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

Reviewed supplier procedures and prescribed fully clothed rub-down searches are compliant and considered sufficient despite unavoidable residual risks.

Verbatim wording from the response

“PECS recognises the concerns raised in relation to searching following toilet visits. In response, suppliers searching standard operating procedures have been reviewed and confirmed as compliant with HMPPS policy and the PECS ‘Authority’ reflective direction and briefing around risk based searching to both PECS suppliers.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 21 November 2025

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

The escort chain remains a proportionate and appropriate restraint control, with alternatives considered only in exceptional, formally assessed acute-risk cases.

Verbatim wording from the response

“The HMPPS Directorate of Security have been consulted and jointly considered the issues raised and advises that the continued use of the escort chain, rather than standard handcuffs, remains a proportionate and appropriate control measure for HMPPS external escorts.”

Source location

Response from HM Prison and Probation Service
Page 2 · response
Published 21 November 2025

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 positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Police custody practice falls outside HMPPS’s remit because it operates under a separate legal and policy framework.

    Stated by HM Prison and Probation ServiceOutside remitThe respondent said that this matter was outside its role or authority.

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

Police custody practice falls outside HMPPS’s remit because it operates under a separate legal and policy framework.

Verbatim wording from the response

“At the outset, it is important to clarify that HMPPS cannot offer a view or opinion on police custody practice, which operates under its own legal and policy framework. PECS suppliers are mandated to comply with HMPPS policy requirements, specifically those set out within the HMPPS External Escorts Framework, and do not exercise discretion to depart from those requirements.”

Source location

Response from HM Prison and Probation Service
Page 1 · response
Published 21 November 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