Prison cell observation panels

Prison culture and practice leading to obscured cell observation panels, staff delaying entry, and misinterpreting views.

94 items 7 sources
Source spread

Where this theme appears

Prison cell observation panels has been flagged across 7 independent accountability sources:

11 PFD reports 12 PPO recs 8 IOPC recs 2 IMB reports 50 IMB recs 4 Article 2 learning points 7 LGO/SPSO decisions

When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.

Browse by source

Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.

Damion Anthony Andre Martin
30 Oct 2013 · Liverpool
Concerns: Inadequate prison risk assessment failed to identify a key suicide risk factor, first responders lacked CPR refresher training, and cell observation was compromised by restricted views and missed checks.
Overdue
Michael Williams
11 Jul 2016 · Leicester City and Leicestershire South
Concerns: Prison staff missed mandated observations and used predictable intervals for checks. There was an inappropriate delay in responding after a cell observation panel was blocked, indicating a lack of clear training.
Response (HM Prison and Probation Service): HMP Leicester reminded staff about conducting observations at unpredictable times, management checks are in place, ACCT documents are quality assured, the contingency plan was revised, and staff were trained to …
Responded
Daniel Dunkley
02 May 2017 · Milton Keynes
Concerns: The report notes that three referrals were made for Mr Dunkley to undergo a full mental health assessment before his death.
Overdue
Raymond Knight
05 Apr 2019 · Essex
Concerns: Police station CCTV cameras do not cover individual holding cells, creating a critical gap in monitoring and photographic records of prisoners.
Overdue
Maureen Martin
26 Jun 2019 · Staffordshire South
Concerns: The Nurses' Station desk on the ward was improperly positioned, obstructing staff visibility, which contributed to a patient's fall.
Response (University Hospitals of Derby and Burton NHS Trust): The Trust removed the nursing station desk on Ward 5 and provided staff with a "desk on wheels" to improve visibility. A walkaround review has been undertaken of all of …
Responded
Serena Nicolle
22 Jun 2021 · Surrey
Concerns: The standard prison procedure of assessing breathing through a cell hatch by observing chest movement is unreliable, leading to erroneous assessments and a risk of future deaths.
Overdue
Saifur Rahman
26 May 2022 · Birmingham and Solihull
Concerns: Delayed emergency "code blue" calls, absence of a central cell history record, and inadequate visual risk assessments by mental health staff in the prison pose significant ongoing safety risks.
Response (BSMHFT): BSMHFT states that it had already updated the sampling of cells under the Ligature Risk Assessment to enable greater coverage of cells from year to year, and to generate an …
Response (HM Prison and Probation Service): HMPPS reports that HMP Birmingham has undertaken initiatives to maintain staff awareness of medical emergency procedures, including safety talks and signage. The Governor has reviewed the local medical emergency response …
Responded
Brandon Johnson
01 Oct 2024 · Inner West London
Concerns: Inadequate and unreliable procedures for checking prisoners' signs of life, with staff lacking sufficient time and clear training to perform robust, positive-response checks in cells.
Response (HM Prison and Probation Service): HMP Wandsworth issued a notice in March 2021 to remind staff to have clear sight of prisoners and obtain signs of life during roll checks and have published further communications …
Responded
Stephen Sleaford
14 Oct 2024 · Leicester City and South Leicestershire
Concerns: There's a severe lack of first aid and CPR training for prison officers, including new recruits, creating critical response gaps. Routinely obscured cell observation panels and unclear guidance on emergency cell entry further compromise prisoner safety.
Response (HMPPS received by CCO): HMPPS re-issued the First Aid Policy Framework in August 2023, re-issued a notice to staff in October 2024 reminding them of the importance of challenging prisoners who block their observation …
Overdue
Anthony Binfield
17 Dec 2025 · Nottingham City and Nottinghamshire
Concerns: A dangerous prison culture of delaying cell entry when observation panels are obscured, assuming privacy rather than self-harm risk, persists despite repeated policy reminders and staff unawareness.
Response (HM Prison and Probation Service): HMPPS has reinforced the importance of clear observation panels at HMP Lowdham Grange through staff briefings, Governor's orders, and video messages to prisoners. Prisoners blocking panels may face sanctions and …
Responded
Stuart Berry
01 Dec 2025 · Essex
Concerns: Multiple failures by mental health services and serious deficiencies in prison suicide risk assessment, including poor ACCT completion, inadequate observations, and accessible ligature points, contributed to the death.
Response (HM Prison Probation Service): HMPPS is reviewing national prison officer training, developing interim upskilling sessions on recognising risks and triggers, and considering upgrading Victorian-style windows to anti-ligature designs. They are concluding a project to …
Response (HCRG): HCRG is retraining reception nurses, introducing an Early Days in Custody (EDiC) Nurse role, improving identification and escalation of urgent mental health referrals, and reviewing the Mental Health Operational Standard …
Overdue
The Governor
The Governor should ensure that: prisoners who block their observation panels are challenged, blockages are removed, and frequent offenders receive appropriate disciplinary action or support; staff are aware of national guidance and understand their responsibilities when they find a cell …
The Governor
The Governor should ensure that: • Bedford Staff Community Notice 19/2020 is updated to provide guidance to staff about measures to take when checking on prisoners with damaged, broken or blocked observation panels; and • broken observation panels are replaced …
The Governor of HMP Liverpool
The Governor should ensure that staff are aware of and understand what is expected of them when they find a cell observation panel obscured.
The Governor of HMP Whatton
The Governor should ensure that a local protocol is developed and shared with staff to instruct them on what to do if they find a cell observation panel obscured.
The Director of HMP Lowdham Grange
The Director should evidence how the prison will monitor the challenging of blocked observation panels to ensure compliance with local processes.
The Governor
The Governor should ensure that staff understand local policy around covered observation panels, that prisoners are appropriately challenged, and blockages removed, and that there is not a culture in which prisoners routinely cover observation panels.
The Governor of HMP Erlestoke
The Governor should ensure that a local protocol is developed and shared with staff to instruct them on what to do if they find a cell observation panel obscured.
The Governor
The Governor should ensure that staff respond appropriately to blocked observation panels to ensure the security and safety of prisoners, and that managers support staff to enforce this.
The Governor
The Governor should ensure that staff follow the correct procedures when they find a prisoner has covered their cell observation panel.
The Governor
The Governor should ensure that the CCTV cameras on Houseblock 4 are reactivated or replaced as a matter of urgency.
The Governor
The Governor should evidence how the prison will monitor the challenging of blocked observation panels to ensure compliance with local processes.
The Governor
The Governor should review the guidance on roll checks and covered observation panels.
Man dies after becoming unwell in custody - Essex Police, November 2017
An investigation into the death of a man following his detention at Grays Police Station found that there was not full CCTV coverage of the holding cell in which he had been placed. This was because the CCTV camera in …
Man dies after becoming unwell in custody - Essex Police, November 2017
Our investigation into the death of a man following his detention at Grays Police Station found that there was not full CCTV coverage of the holding cell in which he had been placed. This was because the CCTV camera in …
Recommendations - Leicestershire Police and Mitie, October 2025
The IOPC recommends that Mitie should work with Leicestershire Police to review their initial custody training to ensure it aligns with national standards for police custody, including how to conduct cell checks and what should be done if a detainee …
Recommendations - Leicestershire Police and Mitie, October 2025
The IOPC recommends that Leicestershire Police should create guidance for custody staff to support them in implementing the College of Policing Authorised Professional Practice (APP) when conducting cell checks. The guidance should include the length of cell checks, actions to …
Recommendation - Greater Manchester Police, June 2022
The IOPC recommends that Greater Manchester Police should ensure custody cell doors are equipped with an opening hatch that allows officers to be able to hear and communicate with detainees without the requirement to open the cell door in order …
Recommendation - North Yorkshire Police, March 2021
​The IOPC recommends that North Yorkshire Police should: Until any work on re-positioning/re-configuring any CCTV facilities are completed North Yorkshire Police should put in place interim measures to mitigate the risks posed by CCTV blind spots in cells. This follows …
Man sustained a serious injury while in custody – Cleveland Police, August …
The IOPC recommends that Cleveland Police should review the working practices used in custody, specifically in relation to CCTV observations, to ensure that the principles set out in the Authorised Professional Practice (APP) are followed. This should include consideration of; …
Recommendations - Metropolitan Police Service, July 2021
The IOPC recommends that the Metropolitan Police Service (MPS) should review the custody handover practices to ensure there is adequate monitoring of occupied cells during handover periods. We would recommend that as part of this, it is also ensured that …
Gartree (2023)
Can the Governor give further assurance that staff will be adequality trained to ensure they challenge all and any prisoners who cover their observations panels? This has been raised in a number of PPO reports about Deaths in Custody.
Governor / Director
Woodhill (2025)
Will the Governor respond to the PPO report and impose a more stringent incentives scheme policy for prisoners who repeatedly block their cell door observation panels?
Governor / Director
Exeter (2020)
Will the Governor consider deploying dedicated staffing in the CSU to provide night cover and/or increase viewing access to CCTV in the CSU so that it can be viewed from the A2/3 wing offices? (See paragraph 5.2.2).
Governor / Director
Lancaster Farms (2021)
To ensure that work previously planned to introduce screening of toilets within double cells is completed as soon as possible (paragraph 5.1.2).
Governor / Director
Gartree (2024)
Please can the Governor give further assurance that staff will be adequately trained to ensure that they challenge any prisoner who covers their observations panels? This has been raised in a number of Prisons and Probation Ombudsman reports about deaths in custody.
Governor / Director
Rochester (2021)
The Board is still noting that cell clearance checks remain haphazard and many are not conducted properly, particularly when an individual is moved to the CSU from a double cell. Can this be addressed please?
Governor / Director
Feltham (2024)
When will the enhanced support unit be reopened on Feltham A?
HMPPS
Exeter (2024)
Will the return of the temporary CSU to A wing, following refurbishment, provide a suitable location for segregated prisoners and an appropriate and dedicated space for reviews and adjudications to take place?
HMPPS
Coldingley (2024)
Does the Minister agree that it is unacceptable in 2024 for prisoners to live without in-cell sanitation? The refurbishment in Coldingley will not be completed for at least three years so, for at least two years, some men will continue to rely on an antiquated and unreliable sanitation system. What can be done to ensure these prisoners can relieve and …
Ministry of Justice
Winchester (2020)
Despite the Board informing ministers for several years that the CSU in HMP/YOI Winchester is unfit for habitation, unsafe and prevents the humane treatment of prisoners, there is still no definite date or funding for the start of a promised replacement building (see sections 2, 3.1, 3.2, 3.5, 4.4, 5.2, 6.2, 6.3). When will this unacceptable and dangerous situation be …
Ministry of Justice
Lincoln (2020)
The Board is still concerned about the lack of closed-circuit television (CCTV) on E wing (see paragraph 4.8). When can we expect it to be installed?
HMPPS
Featherstone (2020)
Despite expenditure on a refurbishment programme, much of the residential accommodation, such as windows, heating and showers, is below the standard expected in the 21st century. While there has been some improvement in the operation of the maintenance contract, prison managers are often frustrated by the lack of progress, which is outside of their remit. How will the minister support …
Ministry of Justice
Drake Hall (2020)
The Board again draws attention to the condition of Richmond and Plymouth houses, which are not fit for purpose. Allowing prisoners to live in sub-standard accommodation is detrimental to their physical and mental wellbeing, and the provision of new accommodation is long overdue.
Ministry of Justice
Swaleside (2021)
The lack of in-cell telephony in the inpatients department (IPD) still needs to be addressed. (see sections 5.4 and 6.1)
HMPPS
Norwich (2021)
Are there plans for the replacement/refurbishment of the segregation unit to provide a unit with the scope to allow staff to 'focus on helping prisoners manage their behaviour and problems rather than simply on punishment' (PSO 1700, Introduction)?
HMPPS
Norwich (2021)
The Board requests that the prison service looks into the case of the prisoner referred to in section 5.2 (Segregation/Special Accommodation) as his treatment is inhumane and there are fears for his wellbeing. This does not in any way reflect upon the care for this prisoner given by HMP/YOI Norwich which continues to be fair, but on the individual specifics …
HMPPS
Lancaster Farms (2023)
To ensure that any work in regard to toilets in double cells is speedily addressed: broken screens, lack of toilet seats, etc.
Governor / Director
Durham (2023)
How will you ensure that cells are adequately furnished and that new receptions have access to bedding and clothing? (5.1.8 - 5.1.11)
Governor / Director
Dartmoor (2024)
Lockdown, due to the Covid pandemic, coincided with the elevated Radon gas levels being identified. During this period, 2020-2021, prisoners were frequently locked down for 23 hours a day. The risk to prisoners of prolonged exposure to Radon gas in cells with poor ventilation appears to have been ignored. Why was this not raised?
HMPPS
Erlestoke (2025)
What action can be taken to improve the quality and safety of the constant watch cell, given that the three proposed new house blocks are on hold?
HMPPS
Wormwood Scrubs (2020)
Can the Governor take whatever steps are necessary to ensure that prisoners on the Elizabeth Fry unit are not susceptible to other prisoners from E wing coming onto the unit?
Governor / Director
Maidstone (2020)
Implement the move of the segregation unit cells (see paragraph 6.1).
HMPPS
Maidstone (2020)
Deliver on the promise made in the reply to last year’s annual report, to move the segregation unit (see paragraph 6.1).
Other
Birmingham (2020)
Will the minister guarantee that, as advised, when the three Victorian wings, now closed, are refurbished they will be single-occupancy cells, to avoid the overcrowding of the past that contributed to uninhabitable living conditions, poor staff/prisoner relationships and an unsafe prison?
Ministry of Justice
Coldingley (2021)
Would the Prison Service please confirm that priority will be given in terms of resource allocation (such as effective CCTV) to keeping prisoners safe and free from bullying?
HMPPS
Preston (2022)
Cell conditions should be Improved and upgraded, including better toilet screening.
Governor / Director
Long Lartin (2022)
Will they give their assurance that due attention is being given to this issue? [cells on four wings lack running water and sanitation]
Other
Leeds (2022)
Yet again, the IMB must raise the issue of inappropriate accommodation for prisoners. Sharing small cells that were built for single occupancy is difficult at the best of times. Prisoners sharing a cell with someone they do not get on with or have different values or beliefs from is often a recipe for trouble and prisoners have little or no …
Ministry of Justice
Bedford (2022)
We hope that this year the segregation unit will finally be moved from its underground location.
Governor / Director
Rochester (2023)
As noted last year, there has been some improvement in cell clearance checks, but it still remains haphazard and many are not conducted properly, particularly when an individual is moved to the CSU. Can this be addressed? (See paragraph 5.8.c.)
Governor / Director
Brixton (2024)
HMP Brixton recently celebrated its bicentenary. Old buildings do not get better with age and without money spent on them; we have reported as much year after year. In 2012, we wrote ‘The neglect of capital works at Brixton, over many years, means that the prison buildings are not fit for purpose, and will not be, despite best efforts, for …
HMPPS
Berwyn (2024)
What will the Prison Service do to address the serious problem with paint peeling off the walls in cells, given that the refurbishment programme has been stopped due to the increase in the prison population and current measures are inadequate?
HMPPS
Preston (2025)
The Governor should outline intentions to improve cell clearance procedures.
Governor / Director
Erlestoke (2025)
What processes and checks will be put in place to ensure improvements are made to the poor state of the induction cells?
Governor / Director
Swinfen Hall (2020)
Concerns about hygiene include: • the practice of prisoners on most wings being required to eat meals in their cells, close to a toilet (see paragraph 5.1(b)). Is there a plan to improve this? • the risk of further infestation of rats on the site, which was dangerously extensive last year (see paragraph 5.1(c)]. What mitigation measures are in place?
Governor / Director
Cookham Wood (2020)
The CSU is old and has inadequate facilities. What will be done to improve these facilities, or to relocate the unit? In particular, boys in this unit (unlike all the other boys at Cookham Wood) do not have in-cell telephones to speak with their families. Will in-cell telephones be provided in the CSU, and if not, why not?
Governor / Director
Bure (2020)
Will the minister ensure that resources are made available for urgent work to the ventilation system in residences 1 to 6, to improve the air quality and increase the level of ventilation, especially taking into account that prisoners are presently locked up for up to 23 hours a day owing to COVID-19 and the expectation that this situation will continue …
Ministry of Justice
Wayland (2022)
The Board suggests wing management ensure that cell clearances are properly carried out in future.
Governor / Director
Isis (2022)
A solution to the broken windows in prisoners’ cells needs to be found and funded.
HMPPS
Foston Hall (2023)
There has been continued inadequacy of accommodation in the CSU and D wing. Will there be further funding to improve the quality and decency of these wings?
HMPPS
Buckley Hall (2023)
When will CCTV be installed in Healthcare?
Governor / Director
Chelmsford (2024)
The Board asks, again (as in our previous report), how does the Prison Service plan to eliminate overcrowding? A total of 69% of men in HMP Chelmsford share cells designed for single occupancy. This conflicts with the requirements of decency and respect and is in contravention of the United Nations standard minimum rules for the treatment of prisoners. The Board …
HMPPS
Bedford (2024)
Whilst there have been improvements in overall cleanliness, many of the cells remain in a very poor condition.
Governor / Director
Werrington (2025)
Given the risk of young people being assaulted by their peers, what measures will the Minister implement to safeguard those convicted of sexual offences, and does this include the provision of dedicated, separate accommodation?
Ministry of Justice
Swansea (2025)
Prisoners with significant mental health needs are being held for lengthy periods, often in segregated conditions, whilst waiting for specialist hospital care. Given that demand for inpatient care appears to exceed healthcare capacity, what specific actions will the Minister take to reduce delays, prevent the use of segregation for acutely unwell prisoners and ensure timely access to appropriate inpatient mental …
Other
Berwyn (2020)
The Board again highlights the issue of the lack of facilities, in terms of meeting rooms and interview rooms, in this newly built establishment. The 70% double room and 30% single room configuration is proving challenging to manage, given the requirements of CSRAs and the composition of this diverse population. The figure of 70% double rooms and 30% single rooms …
Ministry of Justice
Coldingley (2022)
managers must not give up searching for innovative and imaginative methods of increasing surveillance and improving everyone’s safety.
Governor / Director
Wealstun (2024)
As referenced in our last report, when is it planned to consider a complete refurbishment or replacement of the older wings (A and B wings)? It is increasingly apparent that this accommodation, built in the 1960s, needs significant remedial action for a number of reasons and is not a humane environment for prisoners.
HMPPS
Long Lartin (2024)
Lack of in-cell sanitation: prisoners on four wings continue to use the 'slopping out' process, which falls below modern standards of decency. When does the Government intend to provide all cells with running water and sanitation?
Ministry of Justice
Lindholme (2025)
The Board asks that the Governor considers implementing a deep-cleaning programme of the in-cell toilets.
Governor / Director
201303897 — Scottish Prison Service
Mr C, a prisoner, complained that staff at his prison carried out a personal search in a manner that was unreasonable in his particular circumstances. In looking at Mr C's complaint, our role was to examine whether the prison followed the correct procedure in carrying out the search. When we …
SPSO (Scottish Public Se… Prisons Upheld Apr 2014
201305611 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison did not address his concerns about the temperature in his residential hall. We made enquiries of the Scottish Prison Service (SPS), and found that complaints were received from prisoners about the temperature in the hall. Steps were taken to resolve …
SPSO (Scottish Public Se… Prisons Not Upheld Jul 2014
201103838 — Scottish Prison Service
Mr C, who is a prisoner, complained that at times the Scottish Prison Service (SPS) had required him to share a cell that was not of an adequate size to accommodate two prisoners. He had been sharing a cell that was intended as a single, but which has been fitted …
SPSO (Scottish Public Se… Prisons Not Upheld Jun 2012
201200636 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison refused to locate him next to his friend and also that they inappropriately located him next to individuals with whom he had had issues in the past. When the prison explained to us the reasons for their decisions, we were …
SPSO (Scottish Public Se… Prisons Not Upheld Oct 2012
201304806 — Scottish Prison Service
Mr C, who is a prisoner, complained that the built-in DVD player on his in-cell TV set did not work. He did not feel it was fair to pay the full TV service charge when his set was defective. However, the prison confirmed that Mr C was paying for access …
SPSO (Scottish Public Se… Prisons Partly Upheld Jun 2014
201404940 — Scottish Prison Service
Mr C complained that his prison unreasonably reversed their decision to allow him to move into a shared cell. We found that, as they acknowledged, the prison had made the wrong decision in allowing Mr C to move to a shared cell and, therefore, they were correcting their mistake when …
SPSO (Scottish Public Se… Prisons Not Upheld May 2015
201607622 — Scottish Prison Service
Ms C complained about a number of aspects of the Scottish Prison Service (SPS)' management of her. She complained that the SPS: held her in an unsuitable cell when she was on Act 2 Care (the suicide risk management policy) acted unreasonably in relation to an incident when she was …
SPSO (Scottish Public Se… Prisons Partly Upheld Feb 2019