Vincent Oliver · Prevention of Future Deaths report

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Issued 9 Oct 2014•North Northumberland

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised2

  1. Failure to obtain a response from each prisoner during cell unlocking and roll checks
    Part of recurring concern: Inadequate supervision and monitoring of prisonersPart of recurring concern: Unreliable prison roll-check procedures
  2. Lack of requirement to record compliance with roll check procedures

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. National Offender Management Service (NOMS) Equality, Rights and Decency Group

    Introduce written recording of prisoners’ wellbeing checks throughout the day and amend wing diaries to document them.

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 each prisoner during cell unlocking and roll checks

Wider context from the report

“The prison officer unlocking Mr Oliver’s cell on 4th July 2013 at approximately 5.40 p.m. for the evening meal did not check on his physical well-being by getting a response from him, before moving on to the next cell. This led to Mr Oliver, who had died some time earlier and was affected by rigor mortis, being found by another prisoner when he entered Mr Oliver’s cell. There has been a number of other occasions at the prison when appropriate cell unlocking procedures have not been followed and the Prisons and Probation Ombudsman has made recommendations about this previously. I understand that a Prison Director’s Order has been issued requiring that on roll check Prison Officers must obtain a response from each prisoner to ensure their physical presence and well-being. My understanding of the procedures is that there is no current requirement for the Officer completing the roll check to record on the roll check report that he or she has complied with the requirements of the above Order. ”

Is this part of a recurring concern?

Yes — Inadequate supervision and monitoring of prisoners; Unreliable prison roll-check procedures.

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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 requirement to record compliance with roll check procedures

Wider context from the report

“The prison officer unlocking Mr Oliver’s cell on 4th July 2013 at approximately 5.40 p.m. for the evening meal did not check on his physical well-being by getting a response from him, before moving on to the next cell. This led to Mr Oliver, who had died some time earlier and was affected by rigor mortis, being found by another prisoner when he entered Mr Oliver’s cell. There has been a number of other occasions at the prison when appropriate cell unlocking procedures have not been followed and the Prisons and Probation Ombudsman has made recommendations about this previously. I understand that a Prison Director’s Order has been issued requiring that on roll check Prison Officers must obtain a response from each prisoner to ensure their physical presence and well-being. My understanding of the procedures is that there is no current requirement for the Officer completing the roll check to record on the roll check report that he or she has complied with the requirements of the above Order. ”

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

Introduce written recording of prisoners’ wellbeing checks throughout the day and amend wing diaries to document them.

Verbatim wording from the response

“In order to address this issue HMPS Northumberland have introduced a system for recording in writing that wellbeing checks of prisoners have taken place throughout the day. The wing diaries have been amended to reflect the change and the system was in place from Sunday 16th November 2014. I attach copies of the relevant Director’s Order and Notice to Prisoners.”

Source location

2014-0438-Response-by-NOMS
Page 1 · response
Published 9 October 2014

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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