Connor Hoult
PFD Report
All Responded
Ref: 2021-0405
All 1 response received
· Deadline: 26 Jan 2022
Coroner's Concerns (AI summary)
Prison officers are not required to obtain a response from all prisoners during welfare checks, especially those appearing asleep, risking missed signs of distress or concerns.
View full coroner's concerns
The evidence revealed prison officers are not obtaining, nor did the prison systems require them to obtain, a response from all prisoners during welfare checks. More specifically, during the morning unlock they are not required to, and therefore do not necessarily seek to, obtain a response or otherwise engage with prisoners. In particular, no response is required, and therefore not sought, from prisoners who appear to be asleep in bed, notwithstanding the requirements of PSI 75/2011 (Residential Services).
The PSI sets out the fact that residential prison staff play a key role in spotting any signs of distress and will often be the first to pick up information or signs, and should accordingly engage with prisoners in such a way that facilitates the identification of any concerns or distress.
Further, paragraph 2.3 of the PSI, namely, “Output No. 3 Prisoners are supported and their daily needs are met” states that prisons are required to have, “clearly understood systems in place for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock”.
In the absence of such systems prisoners in distress, or otherwise a cause for concern, may be missed.
The PSI sets out the fact that residential prison staff play a key role in spotting any signs of distress and will often be the first to pick up information or signs, and should accordingly engage with prisoners in such a way that facilitates the identification of any concerns or distress.
Further, paragraph 2.3 of the PSI, namely, “Output No. 3 Prisoners are supported and their daily needs are met” states that prisons are required to have, “clearly understood systems in place for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock”.
In the absence of such systems prisoners in distress, or otherwise a cause for concern, may be missed.
Responses
Action Taken
HMP Wakefield issued a Governor’s Order in January 2020 regarding verbal responses during roll checks and unlocking procedures. The Governor has now circulated a Notice to Staff reminding them to assure themselves of prisoners' wellbeing during unlock, and the concerns will be discussed with relevant staff. (AI summary)
HMP Wakefield issued a Governor’s Order in January 2020 regarding verbal responses during roll checks and unlocking procedures. The Governor has now circulated a Notice to Staff reminding them to assure themselves of prisoners' wellbeing during unlock, and the concerns will be discussed with relevant staff. (AI summary)
View full response
Dear Ms Wolstenholme,
Thank you for your Regulation 28 report of 30 November 2021, addressed to the Ministry of Justice and the Governor of HMP Wakefield, following the inquest into the death of Connor Hoult on the 10 June 2019. I am responding as Director General of Prisons.
I know that you will share a copy of this response with Mr Hoult’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You expressed concern about the conduct and quality of prisoner checks at HMP Wakefield. I will endeavour to address your points of concern, however it may be helpful for me to first clarify the types of checks that staff are required to conduct on prisoners.
Roll checks are undertaken to ensure that all prisoners are present. They involve staff counting the number of prisoners in each area of the prison at particular times of the day, and taking any necessary action if there are any immediate concerns for a prisoner’s welfare. Welfare checks are undertaken by staff during or shortly after unlock so they can assure themselves of the wellbeing of prisoners. This can include verbal or physical acknowledgements, movement in a cell or in bed, or any other indication that a person is alive.
Further, as part of the ACCT (Assessment, Care in Custody, Teamwork) process, welfare observations are carried out on those who are considered to be at risk of self-harm or suicide to ensure these individuals are safe. Observations will be carried out at irregular intervals and in the least obtrusive manner, particularly at night given the importance of sleep for wellbeing.
In January 2020, and in response to the PPO’s investigation, HMP Wakefield issued a Governor’s Order that set out the expectation that staff should obtain a verbal response from all prisoners who are or appear to be awake when conducting roll checks and unlocking procedures, to avoid waking sleeping prisoners overnight or early in the morning, while ensuring that potential concerns are identified.
Further, and in response to your concerns, the Governor of HMP Wakefield has now circulated a Notice to Staff reminding staff that they should assure themselves of the wellbeing of prisoners during or shortly after unlock. Additionally, your concerns will be discussed with the staff who gave evidence at the inquest to ensure they fully understand the process and their responsibilities during unlock, and know how to take action should they have any concerns about an individual’s welfare.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised
Thank you for your Regulation 28 report of 30 November 2021, addressed to the Ministry of Justice and the Governor of HMP Wakefield, following the inquest into the death of Connor Hoult on the 10 June 2019. I am responding as Director General of Prisons.
I know that you will share a copy of this response with Mr Hoult’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You expressed concern about the conduct and quality of prisoner checks at HMP Wakefield. I will endeavour to address your points of concern, however it may be helpful for me to first clarify the types of checks that staff are required to conduct on prisoners.
Roll checks are undertaken to ensure that all prisoners are present. They involve staff counting the number of prisoners in each area of the prison at particular times of the day, and taking any necessary action if there are any immediate concerns for a prisoner’s welfare. Welfare checks are undertaken by staff during or shortly after unlock so they can assure themselves of the wellbeing of prisoners. This can include verbal or physical acknowledgements, movement in a cell or in bed, or any other indication that a person is alive.
Further, as part of the ACCT (Assessment, Care in Custody, Teamwork) process, welfare observations are carried out on those who are considered to be at risk of self-harm or suicide to ensure these individuals are safe. Observations will be carried out at irregular intervals and in the least obtrusive manner, particularly at night given the importance of sleep for wellbeing.
In January 2020, and in response to the PPO’s investigation, HMP Wakefield issued a Governor’s Order that set out the expectation that staff should obtain a verbal response from all prisoners who are or appear to be awake when conducting roll checks and unlocking procedures, to avoid waking sleeping prisoners overnight or early in the morning, while ensuring that potential concerns are identified.
Further, and in response to your concerns, the Governor of HMP Wakefield has now circulated a Notice to Staff reminding staff that they should assure themselves of the wellbeing of prisoners during or shortly after unlock. Additionally, your concerns will be discussed with the staff who gave evidence at the inquest to ensure they fully understand the process and their responsibilities during unlock, and know how to take action should they have any concerns about an individual’s welfare.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised
Sent To
- HMP Wakefield and Minister of State for Prisons and Probation
Response Status
Linked responses
1 of 1
56-Day Deadline
26 Jan 2022
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 14th June 2019, an investigation was commenced into the death of Connor Arthur Steven Hoult, aged 24 years, who died on 10th June 2019. The investigation concluded at the end of the inquest on 28th October 2021. The medical cause of death was and the conclusion of the inquest was suicide.
Circumstances of the Death
On 10th June 2019 at approximately 6.30am a prison officer did a roll check, and in the very brief observation noted Connor appeared to be
, which was not unusual for Connor or other prisoners. It was assumed he was watching television.
Connor’s cell was unlocked for the morning at around 8am. The second officer’s interaction was no more than a fleeting glance of one to two seconds through the observation panel, where Connor appeared to him to be
At approximately 8.45am a different (third) officer relocked Connor’s cell for the morning session and thought he saw Connor appearing to watch television. Again, it was a glance of no more than one to two seconds through the observation panel.
At approximately 9.50am the second officer returned to Connor’s cell to seize some unauthorised footwear. As the officer entered the doorway of the cell he was able to see Connor was . Connor was in the same position as when this officer had observed him at 8am.
At the time Connor was found the level of rigor mortis and hypostasis revealed he had been deceased for a considerable number of hours. His eyes were noted to be closed by attending medics looking for, and confirming the absence of, signs of life.
, which was not unusual for Connor or other prisoners. It was assumed he was watching television.
Connor’s cell was unlocked for the morning at around 8am. The second officer’s interaction was no more than a fleeting glance of one to two seconds through the observation panel, where Connor appeared to him to be
At approximately 8.45am a different (third) officer relocked Connor’s cell for the morning session and thought he saw Connor appearing to watch television. Again, it was a glance of no more than one to two seconds through the observation panel.
At approximately 9.50am the second officer returned to Connor’s cell to seize some unauthorised footwear. As the officer entered the doorway of the cell he was able to see Connor was . Connor was in the same position as when this officer had observed him at 8am.
At the time Connor was found the level of rigor mortis and hypostasis revealed he had been deceased for a considerable number of hours. His eyes were noted to be closed by attending medics looking for, and confirming the absence of, signs of life.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.