Prison Overcrowding & Staff Vacancies
136 items
2 sources
Prison overcrowding combined with high staff vacancies severely undermining the ability of prisons to deliver rehabilitation and ensure safety.
Cross-Source Insight
Prison Overcrowding & Staff Vacancies has been flagged across 2 independent accountability sources:
1 inquiry rec
135 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
PFD Reports (135) — showing 100 most recent
Mujahid Adam
Concerns: Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used for vulnerable prisoners, allowed access to ligature material which was missed during daily checks.
Pending
Rajwinder Singh
Concerns: HMP Wandsworth lacks mandatory ACCT refresher training for prison officers and equivalent training for agency healthcare staff, and offers no training in risk formulation.
Pending
Gareth Chumber-Kelly
Concerns: Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature deaths.
Pending
Josh Tarrant (3)
Concerns: Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Pending
Josh Tarrant (2)
Concerns: Healthcare and prison staff lacked training to identify Acute Behavioural Disturbance (ABD), risking physiological collapse and death for individuals subjected to prolonged restraint.
Pending
Paul Thompson
Concerns: HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing with Probation Services.
Pending
Emmett Morrison
Concerns: HMP Long Lartin suffered from a continued influx of illicit drugs. There were also systemic failures in the ACCT process, with no support actions recorded for a prisoner with a history of self-harm.
Pending
Ryan Harding Prevention of future deaths report
Concerns: Inadequate prison infrastructure allows illicit materials to enter. Scheduled welfare checks were also frequently delayed or missed due to staffing shortages.
Pending
Nigel Feckey
Concerns: The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among vulnerable inmates, posing a risk of future deaths where still implemented.
Pending
Sundeep Ghuman
Concerns: Systemic misunderstanding of the CSRA policy for prisoners posing racist risks led to incorrect 'standard risk' categorization instead of 'high risk,' reflecting a significant training and operational failure.
Response: HMP Belmarsh has withdrawn its S1 system and both Belmarsh and HMP High Down are now fully compliant with national CSRA policy. Naloxone is now available across residential units with …
Overdue
Oliver Mulangala
Concerns: The pervasive availability of illicit drugs, particularly new psychoactive substances, and mobile phones in HMP High Down leads to widespread misuse, coercion, and severe safety concerns.
Response: HMPPS is investing over £40m in physical security measures across 34 prisons in 2025/2026, including anti-drone technology, and all adult male closed prisons are equipped with X-ray body scanners. They …
Overdue
Stuart Berry
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: HMPPS has developed interim upskilling sessions on self-harm and suicide risks for prison officers, and the Safety Support Skills training module is under national review. Four ligature-resistant cells were completed …
Response: HCRG is strengthening interfaces, retraining reception nurses, and has introduced a dedicated Early Days in Custody (EDiC) Nurse role to lead an action plan for improving care standards. They have …
Overdue
Diana Grant
Concerns: Critically ill mental health patients needing secure admission, especially if dangerous, face unavoidable prolonged detention in prison due to restricted unit capacity, where their needs cannot be fully met, posing a risk of death.
Response: NHS England has established Single Points of Contact (SPoCs) across all 15 Secure Provider Collaboratives to streamline mental health bed admissions from prisons, and these SPoCs are implementing robust referral …
Overdue
Derrion Adams
Concerns: Contraband and novel psychoactive substances continue to enter the prison, posing a risk to life and burdening staff during unpredictable "spikes" in incidents. Current staffing levels may be insufficient to manage these challenges.
Response: HM Prison and Probation Service has implemented Incentivised Substance Free Living Units in 85 prisons, embedded Drug Strategy Leads, and introduced the Adult Health, Care and Wellbeing Core Capabilities Framework. …
Responded
Scott Berry
Concerns: Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews or rehabilitative programs, increasing suicide risk.
Response: HM Prison and Probation Service has implemented multiple changes to policy and practice for IPP prisoners, including revisions to release on temporary licence and offender management processes. They have updated …
Responded
Richard Hunt
Concerns: Deliberate tampering with prison fire alarm systems, disabling their buzzers, led to undetected fires, a systemic issue worsened by the absence of central oversight for wing office fault reporting.
Overdue
Angela Thompson
Concerns: A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, creates risks for continuity of care.
Response: HM Prison and Probation Service highlights the establishment of Regional Health & Justice Teams and regular multidisciplinary meetings to improve integrated health services and support transitions. It also notes the …
Response: HMPPS has established Regional Health & Justice Teams and a central Deaths Under Supervision Team to improve integrated health services and liaison for prison leavers. Learning from this case will …
Responded
Steven Hart
Concerns: Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not being carried out to standard, contributing to the death.
Overdue
Martin Collins
Concerns: The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify risk triggers and prevent suicide.
Response: HM Prison and Probation Service confirms initial discussions are underway with BT to explore the technical feasibility of implementing automated monitoring of prisoner call volumes, with this work to be …
Overdue
Brian Burrows
Concerns: Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells and ACCT checks, risking inadequate responses.
Overdue
Patryk Gladysz
Concerns: Systemic failures include inadequate staffing affecting mental health assessments and key worker schemes, poor communication between prison and healthcare staff, and insufficient training on risks for foreign nationals and first aid.
Overdue
George Emmett
Concerns: An HMPPS staff member lacked familiarity with emergency medical response policies, potentially compromising timely, life-saving actions for prisoners in critical health situations.
Overdue
Anthony Binfield, David Richards and Rolandas Karbauskas
Concerns: Inadequate recruitment, retention, and training of prison and healthcare staff led to severe understaffing, restricted services, and fundamental failures in prisoner welfare, supervision, and basic safety protocols.
Responded
William Bissett
Concerns: Severe systemic failures in release planning for a vulnerable, elderly prisoner, including delayed engagement, inadequate accommodation arrangements, and insufficient emotional support, resulted in a tragic outcome.
Responded
Paul Gobell
Concerns: There is no policy for welfare checks when initial interviews are missed, and changes in cell sharing risk are not promptly communicated to prisoners. Furthermore, probation staff failed to report critical disclosures, resulting in an uninformed suitability assessment.
Responded
Jonathon Lawlor
Concerns: Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.
Responded
Wayne Bayley
Concerns: National replication of healthcare improvements, especially understanding sickle cell crisis risks and prisoner care, has not occurred across all UK prisons, posing a risk that lessons learned are not widely applied.
Responded
Mark Beresford
Concerns: Unreasonable prison risk assessments led to a premature ACCT closure and incorrect observation levels without required consultation. A senior officer provided incorrect and misleading evidence, raising concerns about policy adherence and accountability.
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.
Responded
Sean Davies
Concerns: Inadequate risk formulation for IPP prisoners and failures by prison officers to conduct welfare checks according to guidance. Furthermore, some operational support staff lacked proper training or adhered to it.
Overdue
Kevin McDonnell
Concerns: Prison staff failed to conduct meaningful ACCT observations and share critical risk information for at-risk prisoners. Furthermore, there was a failure to secure and retain accurate documentary evidence following a death in custody.
Responded
Matthew Braben
Concerns: Inadequate recognition of childbirth as a mental health risk factor, poor ACCT process and staff training, and prolonged cell confinement due to gym instructor shortages significantly harmed prisoner mental health.
Overdue
Yuri Hatton
Concerns: Many prison OSGs lacked official training, first aid training records were insufficient, and crucial prison-specific training for recognising unconsciousness had not been implemented.
Overdue
Daniel Beckford
Concerns: Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.
Overdue
Christine McDonald
Concerns: Failure to use emergency response codes left first responders unprepared for critical situations, compounded by training difficulties in simulating unexpected emergency scenarios.
Overdue
Luke Pearce
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.
Overdue
Mohammed Azizi
Concerns: Prison documentation was unreliable, with evidence of forged signatures, retrospective entry of notes, and incomplete disclosure of crucial documents, hindering external investigations.
Responded
Marlin Burrows
Concerns: The prison's welfare sheet was inadequate for monitoring prisoner health, lacking clarity and guidance. Entries were not shared with medical staff, and there was no joint prison/healthcare oversight.
Responded
Darren Docherty
Concerns: Prisoners released without accommodation are unable to access crucial GP and community mental health services, creating significant risks to their health and safety.
Overdue
Scott Rider
Concerns: The indefinite nature of IPP sentences traps prisoners, leading to feelings of hopelessness and challenging behaviours, raising concerns about inhumane treatment and future deaths if not reviewed.
Responded
Alan Davies
Concerns: Critical failures included poor communication between healthcare and prison, inadequate discharge planning, lack of staff escort during transfer, and insufficient prison resources or policies for complex patient needs. Staff were also fatigued and felt unable to raise concerns.
Responded
Abdullah Popalzai
Concerns: Acutely psychotic prisoners requiring transfer for treatment are left untreated and at risk due to a shortage of timely psychiatric hospital bed availability.
Responded
Kane Boyce
Concerns: Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.
Responded
Stephen Coster
Concerns: Inadequate prison healthcare assessment, observation, and care planning, coupled with poor communication and prison staff's lack of understanding of emergency transfer protocols, led to significant delays.
Responded
Wyndham Thomas
Concerns: The absence of in-cell ligature point risk assessments, ligature point maps, and mandatory "Safer Cells" in prisons creates critical missed opportunities to prevent self-harm by ligation.
Responded
Samuel Jones
Concerns: Prison and healthcare record systems failed to flag critical "trigger dates" for vulnerable prisoners. Staffing shortages prevented thorough record review, and system limitations meant crucial information was frequently overlooked.
Responded
Stewart Stanley
Concerns: Inconsistent and inaccurately recorded observations for suicide prevention, coupled with staff misinterpretation of guidelines and excessive working hours, posed significant risks in state custody.
Responded
Kristopher Tilbury
Concerns: HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on a 'Wellbeing Wing' and multiple subsequent drug-related deaths.
Overdue
Haik Nikolyan
Concerns: HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, impacting daily operations, training, incident response, and the management of vulnerable prisoners.
Responded
Christopher Smith
Concerns: Serious neglect in prison healthcare included unsafe cell door observations, failure to use the NEWS2 system, inadequate GP visits, and poor leadership resulting in a lack of a safe care plan.
Responded
Liam Bentley
Concerns: Critically low and predicted further reductions in prison staff complements compromised the safety of the deceased and pose an ongoing risk due to staff shortages.
Responded
Stephen Beadman
Concerns: A maximum-security prison with many prisoners having significant mental health issues has inadequate consultant psychiatrist resources, falling short of "equivalence of care" and risking insufficient specialist support for long-term inmates.
Overdue
Anthony Smith
Concerns: The absence of protective mouth masks for resuscitation in prison exposes resuscitators to the risk of blood-borne viruses and could deter life-saving rescue breaths.
Responded
Jason Williams
Concerns: Lack of national guidance for vulnerable prisoners and widespread failure to deliver the keyworker program, coupled with poor prison staff record-keeping due to insufficient refresher training, compromised care.
Responded
John Henderson
Concerns: There was no clear process for sharing critical medical information about prisoners with chronic conditions with frontline staff, leaving officers unaware of potential medical emergencies and appropriate responses.
Overdue
Floyd Carruthers
Concerns: Prison staff lacked adequate training on implementing safeguarding policies for self-neglect, and existing escalation routes focused on violence/self-harm, creating a gap in addressing non-violent injurious activity.
Overdue
Michael Smith
Concerns: Insufficient staffing levels in the prison's segregation unit prevented critical medical and mental health assessments for a vulnerable prisoner. A delay in emergency response due to staffing shortages also put his life at risk.
Responded
Carl Langdell
Concerns: A patient with chronic suicide risk was observed deteriorating after refusing medication. There is a systemic concern regarding items prisoners can possess in their cells overnight, and a national proposal is underway to remove identified risks.
Overdue
Robert Evans
Concerns: HMP Swansea has a repeated history of self-inflicted deaths soon after arrival. Critical witness accounts were not immediately captured after a death, hindering investigations and preventing lessons from being learned.
Responded
Khalid Abiaz
Concerns: A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.
Responded
Idris Habib
Concerns: Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' actions.
Responded
Kyle Nel
Concerns: The prison failed to adequately respond to family concerns, lacked structured record-keeping for prisoner welfare, and had known security flaws with fences enabling drug transfers between units.
Responded
Saul Thomas
Concerns: A third of prison staff lack up-to-date ACCT training, and critical psychiatric assessment information was not consistently included in handovers between prisons, posing a risk of future deaths.
Responded
Caden Stewart
Concerns: Prison staff were unaware of relevant policies, and there was a critical lack of communication among officers regarding a prisoner's unwell status and need for healthcare, leading to missed checks and handovers.
Responded
Colin Blackburn
Concerns: Prison staff demonstrated numerous failings in managing the ACCT process, including missed reviews, incomplete care plans, and insufficient observations, exacerbated by high demands and inadequate training, leading to significant risks of suicide/self-harm.
Overdue
Wayne Boughen
Concerns: HMP Leeds lacks certified anti-ligature cells, failing national standards, which allowed an inmate to use a jumper for self-harm in an ordinary cell.
Responded
Richard Ormond
Concerns: A 9-minute delay in upgrading an ambulance response occurred because prison staff initially failed to provide critical information about the patient's condition to emergency services, highlighting a gap in following emergency protocols.
Responded
Alvin Black
Concerns: Poor hygiene in non-clinical prison healthcare areas creates infection risks. A systemic failure allowed a senior house officer to miss a critical post-surgery VTE risk assessment, indicating a broader protocol adherence issue.
Overdue
Imre Thomas
Concerns: Cancelled hospital appointments put vulnerable prisoners at risk, highlighting a need to investigate organizing special prison clinics for hospital consultants.
Overdue
Brett Marrs
Concerns: Prison officers lacked essential first-aid and resuscitation training, and welfare checks during cell unlocks were routinely neglected despite clear instructions, indicating systemic safety failures.
Overdue
Tomasz Nowasad
Concerns: There was an over-reliance on prisoners' self-declarations regarding self-harm risk, and insufficient consideration of all risk factors or the "big picture" during ACCT reviews and discharge. Risk assessment rationales were also not consistently documented.
Responded
Daniel Akam
Concerns: Systemic failures involved prison officers failing to conduct and falsely recording ACCT observations for vulnerable prisoners. Inadequate ACCT training meant officers lacked understanding of their crucial responsibilities.
Overdue
Gareth Warburton
Concerns: Important letters from a clinician regarding a prisoner's prescription error and medication were neither acknowledged by the Governor nor passed to the prison healthcare team, posing a risk to prisoner welfare.
Overdue
Luke Jones
Concerns: Concerns exist regarding the continuing accessibility and use of novel psychoactive substances (NPS) within HMP Berwyn, posing significant health risks and a high probability of future deaths.
Overdue
Trevor Oakley
Overdue
Shaun Dewey
Concerns: The elevated risk of self-harm and suicide among remand prisoners is not adequately highlighted in staff training, care practices, or national guidance documents like ACCT.
Responded
Harold Uzomechina
Concerns: Detainees on the substance misuse unit received differential and inadequate care at night, lacking dedicated prison officers and equivalent attention compared to those on formal ACCTs.
Overdue
Cherylee Shennan
Concerns: Insufficient inter-agency communication and a lack of mandatory information sharing protocols for MAPPA Level 1 offenders with domestic abuse histories persist, despite known risks and previous reviews.
Overdue
Darren Cumberbatch
Concerns: Probation hostel staff lacked crucial training and awareness regarding Acute Behavioural Disturbance (ABD), a medical emergency, leading to missed opportunities for early recognition, de-escalation, and appropriate management.
Responded
Marcus McGuire
Concerns: HMP Birmingham failed to consistently assign single case managers for ACCT plans, leading to deficiencies in care and follow-up. Concerns exist that management is not accurately reporting the extent of improvements.
Overdue
Michael Folley
Concerns: The outdated Person Escort Record (PER) system limits access to crucial past self-harm risk data. Gaps in staff training and inconsistent transfer procedures for risk information pose significant safety concerns.
Overdue
Ryan Trimmer
Concerns: The ACCT process at HMP Lewes was ineffective due to inadequate reviews, and many prison staff, who act as first responders, lack up-to-date first aid training.
Responded
Daniel Davey
Concerns: Healthcare staff's non-routine attendance at ACCT reviews in prison highlighted a gap in collaborative care, requiring closer integration between prison and healthcare services.
Responded
Ricardo Holgate
Concerns: Inadequate management of illicit substance misuse in prison requires further steps, including implementing CCTV on all wings and airport-style scanners at entry points.
Overdue
Kirsty Walker
Concerns: Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended timeframes, are caused by a severe shortage of available beds.
Responded
John Mayhew
Concerns: Clarification, redrafting, and improved guidance are needed for the PSI64/2011 section on first case reviews of ACCT assessments to ensure consistent and effective application across all prisons.
Overdue
Bradley Brown
Concerns: Late prisoner transfers, particularly on weekends, are unsafe due to unavailable mental health assessments and limited access to healthcare records, heightening risk for vulnerable individuals.
Overdue
Paul James
Concerns: A prisoner with a serious self-harm history was permitted access to razor blades in a single cell, reflecting inadequate risk assessment and safety protocols for vulnerable individuals.
Responded
Anthony Paine
Concerns: The provided text is a placeholder, stating that a brief summary of matters of concern will follow, but no specific concerns are detailed.
Responded
Emily Hartley
Concerns: Prisons are unsuitable environments for individuals with severe mental health issues due to the lack of secure, therapeutic treatment facilities. This systemic failure, highlighted repeatedly over a decade, risks future deaths.
Overdue
John Chapman
Concerns: A critical lack of formal procedures for sharing prisoner self-harm and welfare alerts between prison reception staff and healthcare nurses during medical screenings created a risk of significant alerts being missed.
Responded
John O’Meara
Concerns: Prison officers inconsistently followed Code Blue/Red procedures, delaying emergency response and Naloxone administration due to inadequate training. There's also an insufficient number of passive drug detection dogs to control Novel Psychoactive Substances.
Responded
Stephen Shaylor
Concerns: Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night welfare checks. Intermittent observations are insufficient to detect self-harm, requiring continuous monitoring.
Overdue
Robert Richards
Concerns: HMP Wandsworth suffered from pervasive bullying due to inadequate staff, poor communication, insufficient training, and inappropriate cell allocation. Critical issues also included inadequate medical training and supply restocking.
Overdue
Vilhelmas Borkertas
Concerns: A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting profiles.
Overdue
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.
Responded
Arthur Morley
Concerns: The report indicated concerns but did not provide specific details on what matters gave rise to them, making it impossible to identify key safety issues.
Overdue
Mark Lilliott
Concerns: Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the wing, could critically impede swift responses in future emergencies.
Overdue
Andrew Machin
Concerns: Limited support was provided to a prison employee during a prolonged disciplinary process, and no internal investigation was conducted into the dismissal circumstances following his death.
Overdue
Tedros Kahssay
Concerns: Inadequate information transfer to prison healthcare, flawed nurse reception screening lacking objective analysis, and emergency response staff having insufficient understanding of medical emergency protocols.
Overdue