PFD report

Wesley Dennis Rowlands · Prevention of Future Deaths report

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Issued 5 Oct 2020•Lancashire and Blackburn with Darwen

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
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. Failure to remove redundant television brackets constituting ligature points
    Part of recurring concern: Failure to control ligature risks in inpatient and custodial environments
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

    Alert Prison Group Directors and Governors to identify unused brackets and arrange their prompt removal.

    Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 27 November 2020.
  2. Action

    Review all HMP Garth cells and remove unused television brackets presenting ligature points.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2020.
  3. Action

    Review equivalent accommodation and reported self-harm incidents across other prisons to identify and remove unused ligature-point brackets.

    Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2020.

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 remove redundant television brackets constituting ligature points

Wider context from the report

“A number of cells at HMP Garth, including the deceased’s cell, have television brackets built into the structure of the cell walls. Although the brackets are now redundant, they remain in place and constitute a gross and obvious ligature point and will continue to do so until removed. ”

Is this part of a recurring concern?

Yes — Failure to control ligature risks in inpatient and custodial environments.

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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

Alert Prison Group Directors and Governors to identify unused brackets and arrange their prompt removal.

Verbatim wording from the response

“Please be assured that this is an issue that we take very seriously, and arrangements have already been made by our Prison Maintenance Group to review all cells at HMP Garth and to remove the brackets. This work was delayed by the restrictions that we implemented in response to the pandemic, but I can confirm that it will be completed by February 2021. We are seeking also to address any similar risks in other prisons by reviewing all accommodation of the same type, and looking back at reported self-harm incidents, so that we can identify and remove any other unused brackets that offer ligature points. We will also alert Prison Group Directors and Governors to the concerns that you have reported, so that they are aware of the importance of identifying unused brackets and taking prompt action to remove them.”

Source location

2020-0195-Response-from-HMP-Garth_Redacted.pdf
Page 1 · response
Published 27 November 2020

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

Review all HMP Garth cells and remove unused television brackets presenting ligature points.

Verbatim wording from the response

“During the inquest, evidence was given that a number of cells at HMP Garth have television brackets, which are no longer in use, built into the structure of the cells walls, and you have expressed concern that unless removed they will continue to present a potential ligature point.”

Source location

2020-0195-Response-from-HMP-Garth_Redacted.pdf
Page 1 · response
Published 27 November 2020

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

Review equivalent accommodation and reported self-harm incidents across other prisons to identify and remove unused ligature-point brackets.

Verbatim wording from the response

“Please be assured that this is an issue that we take very seriously, and arrangements have already been made by our Prison Maintenance Group to review all cells at HMP Garth and to remove the brackets. This work was delayed by the restrictions that we implemented in response to the pandemic, but I can confirm that it will be completed by February 2021. We are seeking also to address any similar risks in other prisons by reviewing all accommodation of the same type, and looking back at reported self-harm incidents, so that we can identify and remove any other unused brackets that offer ligature points. We will also alert Prison Group Directors and Governors to the concerns that you have reported, so that they are aware of the importance of identifying unused brackets and taking prompt action to remove them.”

Source location

2020-0195-Response-from-HMP-Garth_Redacted.pdf
Page 1 · response
Published 27 November 2020

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.3

  1. 1

    Use safer-cell design standards that design out ligature points and incorporate measures to minimise self-harm in new prisons.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.
  2. 2

    Design cells to reduce blind spots so staff can check and confirm prisoners’ wellbeing more effectively.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.
  3. 3

    Provide observation cells in each houseblock and Care & Separation Unit for prisoners at immediate risk of self-harm.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 27 November 2020.

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

Use safer-cell design standards that design out ligature points and incorporate measures to minimise self-harm in new prisons.

Verbatim wording from the response

“Your concerns will inform our decisions relating to future prison capacity and our approach on new prison builds, including house block expansion designs. Our new prison design, which is being used for HMP Five Wells, the new prison at Glen Parva and four other new prisons, includes cells that will be finished to a ‘safer cell’ standard, meaning that ligature points have been designed out as far as possible and other design and construction”

Source location

2020-0195-Response-from-HMP-Garth_Redacted.pdf
Page 1 · response
Published 27 November 2020

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

Design cells to reduce blind spots so staff can check and confirm prisoners’ wellbeing more effectively.

Verbatim wording from the response

“measures have been taken to minimise the instances of self-harm. A number of observation cells have also been placed in each of the houseblocks and Care & Separation Units (CASU) so that prisoners who have been identified as at immediate risk of self-harm can be monitored and managed appropriately. These cells will be used alongside the support provided to a prisoner from staff, healthcare providers and other partners. In addition, cells have been designed to reduce ‘blind spots’, enabling staff to check and confirm the wellbeing of prisoners more effectively.”

Source location

2020-0195-Response-from-HMP-Garth_Redacted.pdf
Page 2 · response
Published 27 November 2020

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 observation cells in each houseblock and Care & Separation Unit for prisoners at immediate risk of self-harm.

Verbatim wording from the response

“measures have been taken to minimise the instances of self-harm. A number of observation cells have also been placed in each of the houseblocks and Care & Separation Units (CASU) so that prisoners who have been identified as at immediate risk of self-harm can be monitored and managed appropriately. These cells will be used alongside the support provided to a prisoner from staff, healthcare providers and other partners. In addition, cells have been designed to reduce ‘blind spots’, enabling staff to check and confirm the wellbeing of prisoners more effectively.”

Source location

2020-0195-Response-from-HMP-Garth_Redacted.pdf
Page 2 · response
Published 27 November 2020

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