Prison emergency cell entry

Unclear guidance for prison officers on emergency cell entry procedures, compromising prisoner welfare in critical situations.

39 items 6 sources
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Prison emergency cell entry has been flagged across 6 independent accountability sources:

8 PFD reports 1 committee rec 14 PPO recs 9 IMB recs 5 Article 2 learning points 2 LGO/SPSO decisions

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

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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.

Sam Molyneux
13 Sep 2017 · Liverpool & Wirral
Concerns: Old prison wings lacking anti-barricade doors delayed emergency access, and a prisoner with documented self-harm threats was not placed on an appropriate monitoring plan (ACCT).
Response (HM Prison Probation Service): HM Prison & Probation Service will revise the ACCT form and PSI 64/2011 Safer Custody policy to direct staff to consider emergency access, including the presence of an anti-barricade door, …
Responded
Trystan Bryant
19 Oct 2018 · Plymouth, Torbay and South Devon
Concerns: Stationary ambulance doors that cannot be locked pose a risk to police containment of individuals detained under the Mental Health Act, potentially allowing egress from the vehicle.
Response (National Police Chiefs' Council): The National Police Chiefs' Council issued a reminder to all Chief Constables to treat all ambulances as non-secure environments when detaining individuals under S136 of the Mental Health Act.
Overdue
Kevin Lovatt
15 Jan 2021 · Staffordshire South
Concerns: National training for prison staff lacks clear guidance on the safe use of force when prisoners have items in their mouths, posing a risk to breathing.
Response (NHS England): NHS England and NHS Improvement outline the commissioning of healthcare into prisons is done on a principle of equivalence. They state Advanced Life Support is not appropriate for healthcare professionals …
Overdue
Luke Pearce
16 May 2024 · Staffordshire and Stoke on Trent
Concerns: Staff lack timely training and guidance on appropriate cell entry during medical emergencies and correct use of Code Blue/Red communications, risking delayed or improper responses.
Response (HM Prison and Probation Service): A new national video on medical emergency procedures, including entering cells and using emergency codes, was launched in January 2024 and made available to all HMPPS staff. The Governor of …
Overdue
Ian Deavall
09 Sep 2024 · Greater Manchester West
Concerns: A significant risk exists in HMP Forest Bank due to emergency cell bells being easily deactivated by other prisoners, potentially delaying critical medical responses.
Response (HM Prison and Probation Service): HMP Forest Bank has split the induction across two wings, housing vulnerable prisoners and non-vulnerable prisoners separately, eliminating the risk of cell call bells being cancelled by other prisoners. Plans …
Overdue
John Eyre
07 Oct 2024 · Mid Kent and Medway
Concerns: There's no clear escalation route for prison healthcare staff to challenge inappropriate prisoner discharges from acute care, nor national guidance for returning prisoners when healthcare concerns are unaddressed by consultants.
Response (Department of Health and Social Care): Medway Maritime Hospital is working with system partners to co-create a written document setting out the process for effective and safe discharges of prisoners and has implemented twice-daily board rounds …
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
Nicholas Gedge
11 Mar 2025 · West Yorkshire East
Concerns: A significant delay in commencing CPR occurred due to a lack of shared understanding of its urgency and an uncoordinated response among detention officers and a nurse. No clear protocols define emergency roles.
Response (Leeds Community Healthcare NHS Trust): Leeds Community Healthcare NHS Trust outlines actions taken, including a working group to review the Death in Custody procedure, reflective conversations with staff, and inclusion of 'coordination of response' in …
Response (West Yorkshire Police): West Yorkshire Police clarifies the roles and training of Detention Officers in medical emergencies, emphasizing their responsibility to provide basic life support until a Healthcare Professional arrives and to follow …
Responded
The Governor of HMP Whatton
The Governor should ensure that all prison staff are made aware that where there is an immediate threat to life, they can enter a cell at night without seeking permission from the Night Orderly Officer if it is safe to …
The Governor
The Governor should ensure that staff understand that where there is an immediate threat to life, they can enter a cell alone at night where it is safe to do so.
The Governor
The Governor should ensure staff are aware that where there is a threat to life, they may enter a cell alone at night if they feel safe to do so.
The Governor of HMP Erlestoke
The Governor should ensure that, subject to a risk assessment, staff enter cells as quickly as possible if there is reason to consider that a prisoner may be at risk.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that staff enter cells as quickly as possible in life threatening situations.
The Director
The Director should ensure that staff understand that they can enter cells at night in medical emergencies without the permission of the night orderly officer in line with PSI 24/2011.
The Governor
The Governor should ensure that subject to a dynamic risk assessment, staff enter a cell as quickly as possible, where there is a risk to life or concerns about a prisoner’s welfare.
The Director
The Director should ensure that when a cell door is unlocked, staff satisfy themselves of the safety of the prisoner by obtaining a response in line with local instructions.
The Governor
The Governor should ensure that all prison staff understand their responsibilities during a medical emergency, including that staff use an emergency code promptly to communicate the nature of an emergency.
The Prison Group Director for the Women’s Estate
The Prison Group Director for the Women’s Estate should satisfy herself that staff at Eastwood Park understand their responsibilities during medical emergencies, including the use of emergency codes, and should write to the Ombudsman when she has done this.
The Governor
The Governor should ensure that all staff understand their responsibilities during medical emergencies, including calling an immediate emergency code when there is a threat to life, in line with PSI 03/2013.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that: night staff enter cells as quickly as possible in a life-threatening situation; and night staff use the appropriate medical …
The Governor of HMP Long Lartin
if a prisoner’s condition and mobility deteriorate so that restraints are no longer appropriate in line with the Graham judgment, escort staff should ask for restraints to be removed;
The Governor and Head of Healthcare (HMP Full Sutton)
The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that authorising managers show that they have taken this information into …
Doncaster (2024)
The Board has identified, on a significant number of occasions, cell bells not being answered. Whilst we welcome the continued scrutiny of cell bell data and attempts by the management team to improve answering times, this issue remains a grave concern for the Board.
Governor / Director
Lancaster Farms (2021)
To confirm that processes previously agreed with the Board, such as that the Board will be notified immediately following the deployment of PAVA or the use of the special cell, remain in force (paragraph 5.2.5).
Governor / Director
Grendon (2022)
Reporting on response times to cell bells (4.2.4).
Governor / Director
Lancaster Farms (2023)
To ensure that processes previously agreed with the Board, such as that the Board will be notified immediately following the deployment of PAVA, deaths in custody or the use of the special cell, are implemented. And that the Board receives responses to issues it raises in its weekly reports.
Governor / Director
Isis (2024)
With regard to ECBs, how is the prison monitoring whether the guidance in the Prison Officers’ Guide 2023 is being followed?
Governor / Director
Leyhill (2020)
In view of the present unsatisfactory level of night-time staffing (see paragraph 7.13), will the Prison Service ensure that a thorough review is carried out, bearing in mind both present conditions and any future plans for the prison, to ensure that all on-call staff are close enough to provide a fast and effective response in acute circumstances.
HMPPS
Isis (2024)
Who is responsible for attending when an ECB is rung over the lunch period or during morning briefings – times when our investigation shows that the time taken to answer is very long?
Governor / Director
Buckley Hall (2021)
Ensure that all prisoners have ready access to a cell courtesy key (5.1.13)
Governor / Director
Grendon (2021)
Restrictions due to Covid-19 and project work notwithstanding, the Board looks forward to: monitoring cell bell response times (see 4.2.9)
Governor / Director
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