Prison nightly roll checks
Lack of robust auditing for nightly roll checks in prisons, leading to instances where checks are not conducted as recorded.
35 items
4 sources
Source spread
Where this theme appears
Prison nightly roll checks has been flagged across 4 independent accountability sources:
4 PFD reports
12 PPO recs
18 IMB recs
1 Scottish FAI
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.
PFD Reports (4)
Edwin O’Donnell
Concerns: Prison health reception screening failed due to lack of access to critical mental wellbeing documents and significant delays in follow-up screening. Additionally, probation staff lacked adequate ACCT training.
Response (HM Prison Probation Service): The Senior Officer in reception now provides a copy of the Person Escort Record (PER) to healthcare staff and reception staff have been made aware of this process. The individual …
Responded
Jason O’Rourke
Concerns: HMP Belmarsh's immediate needs form inadequately assesses self-harm risk for new prisoners without existing care plans. The nightly roll check system lacks robust auditing, risking missed checks and compromising prisoner safety.
Response (HM Prison and Probation Service): HMP Belmarsh has updated its 'immediate needs' form for new prisoners to provide clearer guidance to staff on actions to take regarding suicide/self-harm risks, including communication with healthcare and documentation. …
Responded
Giuseppe Tabone and Andrew Evans
Concerns: Prison staff failed to perform mandatory roll checks, with falsified records and confusion over requirements, creating a risk of undetected prisoner medical emergencies.
Response (HM Prison and Probation Service): HMP Lewes investigated and disciplined staff who failed to carry out roll checks, and has planned further 'bite size' training sessions on roll checks with support from the standards coaching …
Responded
Brandon Johnson
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
PPO Death in Custody Recommendations (12)
The Governor
The Governor should ensure that all staff understand the importance of conducting roll checks and welfare checks at the prescribed times and record the time the roll check was completed in the daily diary, in line with the Local Security …
The Governor
The Governor should ensure that staff understand the importance of conducting roll checks as required.
The Director at Parc
The Director at Parc should ensure that Parc’s instructions to staff about roll checks are consistent.
The Governor
The Governor should ensure that all staff understand of the importance of conducting roll checks at the prescribed times and record the time the roll check is completed in the daily diary, in line with the Local Security Strategy.
The Governor
The Governor should ensure that staff completing roll checks satisfy themselves that prisoners are alive and well.
The Director at Parc
The Director at Parc should ensure that when a cell door is unlocked, staff satisfy themselves of the wellbeing of the prisoner and that there are no immediate issues that need attention.
The Director of HMP Lowdham Grange
The Director should outline to the Ombudsman their plan going forward to randomly sample the accuracy of recorded checks until they are satisfied there is not a systemic issue with false entries.
The Governor
The Governor should ensure that when staff have concerns about a prisoner’s wellbeing during a roll check, they obtain a response from them to check they are alive and well.
The Governor
The Governor should ensure that staff carry out roll checks at the required times and only sign for them if they have completed them themselves.
The Director at HMP Lowdham Grange
The Director at HMP Lowdham Grange should ensure that staff understand they should complete a welfare check at unlock and consider randomised checks of CCTV footage to ensure they are being done.
The Governor of HMP Birmingham
The Governor should introduce a robust quality assurance process to ensure that staff conduct routine roll checks and welfare checks in line with local and national guidelines.
The Governor
The Governor should review the guidance on roll checks and covered observation panels.
IMB Recommendations (18)
Send (2020)
Regular incorrect roll checks have continued to disrupt the regime (7.1).
Governor / Director
Buckley Hall (2020)
Reduce the number of inaccurate roll checks and their disruption to the regime (see paragraph 5.1.14)
Governor / Director
Buckley Hall (2022)
Improve the accuracy of the daily roll checks.
Governor / Director
Bronzefield (2024)
Roll count has frequently been late, which has had a negative impact on the regime and security. How will the prison ensure that roll count returns to being accurate and timely? (4.6)
Governor / Director
Ranby (2025)
Could the Governor explain how the prison management is intending to rectify the situation (reconciliation of the roll) which is still not robust enough?
Governor / Director
Bure (2025)
Will the Governor address the numerous late roll calls sometimes having to have three recounts? This affects activities and healthcare appointments due to prisoners having to return to their cells. In addition, will the Governor explain why clashes between education and other purposeful activity have not improved since the matter was raised last year?
Governor / Director
Bronzefield (2025)
How will the prison ensure that roll counts return to being accurate and timely, given RRC roll counts continue to be frequently late, which has had a negative impact on the regime and security (6.4, 7)?
Governor / Director
Rochester (2020)
Roll Count Difficulties: The change in procedure has been difficult to implement at Rochester with its open estate. Obviously the whereabouts of prisoners must be known, but prior to lockdown this was causing unnecessary stress and disruption to many parts of the prison. As lockdown restrictions relax, can this situation be addressed so that the disruption experienced in January and …
Governor / Director
Rochester (2020)
The Board strongly recommends more effective control is required over cell checks on all wings.
Governor / Director
Pentonville (2023)
Will you undertake a comprehensive overhaul of property systems at Pentonville to ensure that they work effectively to enable prisoners to receive their property in a timely manner (and to avoid the unnecessary waste of staff time)?
Governor / Director
Pentonville (2023)
The new Prisoners’ Property Framework seems to have had no noticeable positive impact on the transfer of property between prisons. Will HMPPS commit to a meaningful, evidence-based review of the Framework?
HMPPS
Parc (2023)
There is a need to monitor and ensure that the Prisoners’ Property Policy Framework is followed and monitored to ensure that prisoners’ property is always transferred with them.
HMPPS
Onley (2023)
What action can be taken to ensure there is improvement in the management and processing of property and that it is issued to prisoners in a timely manner?
Governor / Director
Onley (2023)
How will you ensure that the situation regarding the loss or delay of prisoner property is improved, given it remains a problem and a main area of complaint despite the introduction of the Prisoners’ Property Framework?
HMPPS
Moorland (2025)
How and when will the Prison Service reduce the amount of property lost during transfers?
HMPPS
Lindholme (2025)
The Board asks that further measures be taken to reduce the loss of property during cell movements within the prison.
Governor / Director
Styal (2025)
What additional supervision is being provided at weekends and at night times to ensure safety and security, including Bollinwood House, which is outside the prison perimeter?
Governor / Director
Morton Hall (2022)
tightening up and/or amending the processes for roll reconciliation so that prisoners can take part in planned activities on time (see paragraph 6.5.4).
Governor / Director