Prison staff first aid, CPR
Insufficient official training for Operational Support Grades (OSGs), poor monitoring of first aid training logs, and lack of prison-specific unconsciousness recognition training.
126 items
7 sources
Source spread
Where this theme appears
Prison staff first aid, CPR has been flagged across 7 independent accountability sources:
54 PFD reports
1 committee rec
21 PPO recs
3 IOPC recs
39 IMB recs
4 Article 2 learning points
4 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.
PFD Reports (54) — showing 50 strongest matches
Jordan Buckton
Concerns: Prison staff lacked awareness of a prisoner's self-harm history due to information sharing failures. Additionally, there was inadequate follow-up after prescribing anti-depressants and a mental health course was discontinued due to staff shortages.
Overdue
Reggie John
Concerns: Poor communication and lack of written records between prisons compromised a high-risk prisoner's care. Failures included inadequate review processes and a nurse not accessing or updating crucial risk documents.
Response (Worcestershire Health Care NHS): The trust reiterated expectations regarding ACCT documents for prisoners arriving at HMP Hewell, and reviewed Prison Service Instruction 64/2011 to identify and address areas of non-compliance.
Response (HM Prison and Probation Service): HMP Bristol introduced a system to contact receiving establishments about prisoners on open ACCTs, and HMP Hewell issued a notice reminding staff to report information indicating a change in a …
Overdue
Ryan Clark
Concerns: Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR training.
Response (HM Prison and Probation Service): HMP and YOI Wetherby implemented a revised personal officer scheme in October 2013 to ensure greater continuity in the allocation of staff to young people, including a 'relief' arrangement and …
Response (Leeds City Council): Leeds City Council has agreed on a procedure between Children's Social Work Service and Youth Offending Service to share all relevant information about a young person going into custody with …
Responded
Abdullahi Sharif Abokar
Concerns: Mental health staff failed to assess suicide risk due to misconceptions, and resuscitation efforts were critically compromised by inadequate airway management, unactivated oxygen, and staff abandoning the patient.
Response (Camden & Islington NHS Trust): The Trust implemented a "Rapid Improvement Plan" for Coral ward, including mandatory training in suicide risk assessment and in-hospital life support, simulation exercises every 6 months, revised resuscitation scene management, …
Responded
William Anderson
Concerns: Prison staff lacked effective vigilance over inmate gatherings involving drugs/alcohol, were insufficiently trained in breathalyser use, and failed to adequately record inmate behaviour or promptly call emergency services.
Overdue
Darren Wright
Concerns: Emergency response was hindered by a staff nurse's inability to locate the incident and a lack of recent CPR training among prison officers due to resource limitations.
Response (Serco): Serco states that they were the healthcare provider at HMP Norwich at the time of the death but no longer provide any services there and thus cannot implement the recommendations. …
Response (Virgin Care Services Limited): Virgin Care, the current healthcare provider at HMP Norwich, has instituted changes to its procedures, including a local induction process and checklist, and guidance for resuscitation in a joint protocol …
Response (Ministry of Justice): HMP Norwich acknowledges the coroner's concerns regarding CPR training, outlines the current legislation and risk assessment process for first aid needs, and states that there is no requirement to provide …
Responded
Keith Murphy
Concerns: Prison staff lack basic first aid, CPR, and defibrillator training, and healthcare provision is unavailable outside limited hours, leaving prisoners vulnerable to medical emergencies.
Response (HM Prison and Probation Service): NOMS states that first aid training is being implemented at HMP Coldingley, with custodial managers trained and monthly closedown sessions used for wider staff training. They also state that a …
Overdue
Luke Myers
Concerns: HMP Liverpool miscalculated the deceased's sentence, which was a likely factor in his death. Additionally, prison discipline staff lacked current first aid training, raising concerns for lone working officers.
Response (Ministry of Justice): HMP Liverpool has reviewed sentence calculations and found no other miscalculated sentences. First aid training is being provided to all Custodial Managers who carry out orderly officer duties, and Operational …
Responded
Eitvydas Zdanys
Concerns: Police officers responding to a road traffic incident lacked basic life support training, rendering them unable to assess or resuscitate a seriously injured motorcyclist.
Response (E Zdanys): The officers involved will shortly receive training on when and how to administer CPR, and all officers will be reminded during their annual refresher training of when it is necessary …
Responded
Derrick Rose-Fowler
Concerns: A prison officer lacked first aid training, potentially delaying CPR, and the bullying policy was ineffective for prisoners unwilling to name names. Critical concerns about the deceased's mental health and self-harm history were not escalated to a MASH meeting.
Overdue
Benjamin Brown
Concerns: Concerns identified inadequate auditing of 15-minute observations and clozapine management, alongside insufficient staff training for patient resuscitation.
Overdue
Michelle Barnes
Concerns: Prison officers failed to initiate an ACCT process for a highly distressed prisoner, opting for a vague "offer support" note without a clear action plan, despite significant emotional risk.
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.
Response (Care UK): Care UK has changed the reception screening template to include mandatory PER review, seeks consent for GP records during screening, and reinforced Code Red/Blue training with staff and displayed posters. …
Overdue
Antony Abbott
Concerns: Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), posing a risk in emergency situations.
Overdue
Ondrej Suha
Concerns: Prison officers lacked specific training for night shifts and basic resuscitation, hindering their ability to respond effectively to emergencies.
Overdue
Mark Doyle
Concerns: Significant failings in ACCT case reviews, inadequate healthcare information sharing, and a lack of clear criteria for prisoner transfer decisions were identified. There is also no mandatory first aid training for existing prison officers.
Response (Care UK): Care UK has reflected on the inquest and reviewed healthcare processes, embedding Local Operating Procedures (LOPs) with senior management audits, to ensure relevant risks and triggers are identified and shared …
Overdue
Christopher Talbot
Concerns: An untrained supervising officer relied solely on shadowing, a senior officer lacked a breathing guard for resuscitation, and staff were not informed of previous unnatural death causes, reducing vigilance.
Overdue
Donald Martin
Concerns: A nurse lacked essential knowledge regarding appropriate CPR on flat surfaces and how to deflate patient mattresses during emergencies, posing a risk to patient safety.
Response (Royal College of Nursing): The RCN provides a reflective piece from Ms. Banjoko, detailing CPR processes and awareness of mattress deflation importance, and notes she has remediated her practice, completed basic life support training, …
Overdue
Nicola Lawrence
Concerns: A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, jeopardizing emergency response.
Response (HM Prison Probation Service): HM Prison & Probation Service acknowledges concerns about CPR training at HMP New Hall. They state that the governor has reviewed staff training and considers the current number of trained …
Responded
Daniel Stokes
Concerns: Prison healthcare staff possessed diazepam but were not trained or authorised to administer it, potentially hindering response to drug abuse incidents.
Overdue
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.
Response (GS4): G4S states that HMP Birmingham is currently being managed by HMPPS and decisions regarding actions/equipment are not within their remit, but they agree with the need for CCTV and airport-style …
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.
Response (HM Prison and Probabtion Service): HMPPS piloted a revised version of ACCT and will roll out a new version nationally in early 2020, and two on-site first aid trainers will deliver first aid training to …
Overdue
Darren McGuin
Concerns: A significant gap in mandatory basic life support training for prison officers employed during a specific period leads to delayed CPR, with no retrospective training efforts to rectify this.
Overdue
Robert Ginn
Concerns: Inadequate resuscitation efforts by prison nurses included failure to continuously check breathing for 11 minutes and insufficient oxygenation, alongside conflicting assessments of the patient's body temperature.
Response (Care UK): Care UK expresses condolences and addresses the coroner's concerns regarding first aid quality at HMP Pentonville. They discuss training, national changes to resuscitation procedures, and staff safety, but ultimately do …
Overdue
Daniel Akam
Concerns: ACCT observations were missed and recorded as completed, officers did not appear to know their obligations and responsibilities, and there was inadequate ACCT training for officers.
Overdue
Mark Mallinson
Concerns: Life-saving suicide intervention training, developed for new police recruits, is not being provided to all front-line staff, leaving many officers untrained in critical situations.
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
John Tucker
Concerns: There are concerns about the inadequate nature and extent of basic life support and first aid training provided to Gwent police staff, despite their regular contact with unwell or injured individuals.
Overdue
Kevin Lovatt
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
Peggy Copeman
Concerns: Patient transport staff failed to recognise a patient's respiratory distress, delayed calling emergency services, and performed ineffective CPR due to patient positioning. Only one staff member was CPR trained, violating policy.
Response (Premier Rescue Ambulance Service Ltd): Premier Rescue Ambulance Service Ltd. has trained all staff, including drivers, in CPR, with one member of staff now authorized to train others internally. The company has also implemented a …
Responded
Kesia Waller
Concerns: Residential housing staff for vulnerable young people lacked adequate training and tools to respond to self-harm emergencies. Key policies were ineffectively communicated, failing to ensure staff understanding and practical application.
Response (A2Dominion): The organisation has revamped first aid training to include suicide, self-harm and overdose, is providing ligature cutting kits in every office by the end of July 2021 and has implemented …
Responded
Trevor Smith
Concerns: Critical mental health information from MARAC was not accurately recorded or cascaded to police, leading to officers being unaware of the deceased's EMD status. There was also confusion and a lack of coordination during CPR efforts.
Response (College of Policing): The NPCC First Aid Forum will formally raise the issue of establishing a first aid (CPR) coordinator at its next meeting. The College of Policing will send out a national …
Response (West Midlands Police): West Midlands Police have updated team briefing sheets to include reference to the CPR coordinator role and updated the Medical Plan to include direction regarding the coordination of care. All …
Responded
Robert Ellery
Concerns: The prison control room delayed relaying critical information to the ambulance service, and a lack of direct communication between emergency operators and prison first responders hindered resuscitation efforts.
Response (HMP Cardiff): HMP Cardiff has devised a Local Operating Protocol and will pilot a mobile phone carried by officers to enable direct communication with the Welsh Ambulance Service.
Responded
Khadija Ahmed
Concerns: School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during a child's cardiac arrest.
Response (Swiss Cottage School): Swiss Cottage School has organised Basic Life Support with CPR training for 70 members of staff, timetabled to every class across the school, delivered on 12th and 14th January 2022.
Responded
Martin Brown
Concerns: Prison staff lacked training for medical emergencies and the ERIC system. There was poor liaison between healthcare and ambulance services, and communication between emergency responders and the control room was inadequate.
Response (Spectrum at HMP Lancaster Farms): Spectrum has developed an Emergency Response in Custody (ERIC) presentation and has been delivering training sessions to prison staff since January 2022. They have also implemented a system using a …
Response (HM Prison and Probation Service): The prison has distributed ERIC cards to all staff and commenced additional ERIC training delivered by the Head of Healthcare, with new staff receiving this training as part of their …
Responded
Lewis Johnson
Concerns: HMP Wealstun lacks night-time healthcare staff, and prison officers are inadequately trained in CPR and defibrillator use for self-harm incidents, compounded by a missing policy directive for immediate resuscitation.
Response (HM Prison Probation Service): HMPPS will update a training video for staff on emergency response, ligature use, and CPR (available Spring 2023). HMP Wealstun will resume FAW and EFAW training from April 2023, prioritizing …
Overdue
Nathan Forrester
Concerns: Prison officers lack training to safely remove and provide CPR to prisoners on top bunks. Nationally, nurses in detention settings may also have inadequate CPR training and insufficient emergency airway equipment.
Response (NHS England): NHS England commissions healthcare in prisons and ensures equivalence of care. They state that shortcomings in training have been addressed locally and all nurses in Oxleas NHS Trust are trained …
Response (HM Prison and Probation Service): All new prison officers receive first aid training covering moving individuals for CPR, and manual handling training has been updated to a digital format. eLearning is available to all staff.
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.
Response (NHS England): NHS England developed a training programme for Adult Safeguarding in Secure and Detained Settings in conjunction with HMPPS and HEE. The response also mentions a Ministry of Justice NPS toolkit.
Response (HM Prison Probation Service): HMPPS will review and develop the key work model to improve safety and reduce reoffending, including making it more flexible. HMP Guys Marsh introduced an assurance check for weekly case …
Response (HM Prison Probation Service): The response refers to the Director General's letter which outlines the actions being taken at HMP Guys Marsh, such as introducing a Buddy scheme, writing local guidance, introducing an assurance …
Responded
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.
Response (HM Prison and Probation Service): The First Aid Policy Framework is being re-issued with instructions on face shield use, requiring all first aid kits to contain them and for them to be monitored. Face shields …
Responded
Amarjit Singh
Concerns: There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance for prisoners on how to respond to a cellmate having a fit.
Response (HM Prison and Probation Service): HMPPS issued emergency response guides and pocket cards to all prisons. Training for prison staff in how to deal with fits is scheduled to be given at HMP Pentonville in …
Response (Practice Plus Group): Practice Plus Group has changed procedures to ensure cell sharing risk assessments are completed effectively, including long term conditions monitoring, and provide the HMP Pentonville prison team with a list …
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.
Response (Sodexo): Sodexo states that the MOJ have confirmed that all managers, including the Senior Leadership Team, are to undergo the national ACCT training as a matter of urgency, this will include …
Response (HM Prison and Probation Service): HMPPS issued guidance and a standard template for Early Learning Reviews (ELRs) in 2021, held a workshop with Group Safety Leads (GSLs) in July 2022, and another in April 2024 …
Responded
Liam Turner
Concerns: It is not mandatory for prison officers to maintain up-to-date basic first aid and CPR training, leaving a significant proportion of staff without current life-saving skills.
Response (HM Prison and Probation Service): HMPPS re-issued the First Aid Policy Framework in August 2023, highlighting training requirements and the need for risk assessments to determine adequate numbers of trained staff. HMP Manchester issued guidance …
Responded
Samuel Curless
Concerns: Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary first aid refresher training for life-preservation.
Response (College of Policing): The College of Policing updated the First Aid Learning Programme (FALP) in 2020, increasing recommended training time for both refresher and initial training for public-facing officers, now including basic life …
Response (Greater Manchester Police): Response is a placeholder document.
Responded
Paul Day
Concerns: Prison CPR guidance, particularly the inclusion of rigor mortis as an exclusion, is inappropriate for untrained staff in non-24-hour healthcare facilities, risking missed opportunities for life-saving resuscitation.
Response (HM Prison and Probation Service): HM Prison and Probation Service acknowledges concerns about CPR guidance and will review and revise the guidance regarding rigor mortis as a sign of death, following advice from the Resuscitation …
Responded
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.
Response (HM Prison and Probation Service): HMP Nottingham has increased SASH/ACCT awareness training for staff and introduced a 'trigger' database for sharing pertinent risk information. ACCT books are no longer removed from the wing during quality …
Responded
Stephen Sleaford
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
Daniel Beckford
Concerns: Prison officer first aid training lacked clarity on using rescue breaths during resuscitation, conflicting with current Resuscitation Council UK guidance.
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
Nathan Shepherd
Concerns: The Probation Service lacked policy and training for barricading incidents, approved premises had easily movable furniture and ligature points, agency staff CPR training was unchecked, and critical information sharing between prison and probation was ineffective.
Response (HM Prison and Probation Service): HMPPS has finalised Barricade Guidance, which will be issued to all approved premises staff on 1st August 2025, with staff required to acknowledge receipt by the end of September 2025. …
Responded
Nicholas Gedge
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
PPO Death in Custody Recommendations (21)
The Governor and Head of Healthcare of HMP Sudbury
The Governor and Head of Healthcare should review the provision of first aid training, the deployment of first aid trained officers and, in particular, ensure staff know how and when to deliver cardiopulmonary resuscitation and are confident in using a …
The Governor
The Governor should ensure that staff start CPR without delay when a prisoner has no pulse and stops breathing.
The Governor
The Governor should ensure that operational staff have up-to-date training to administer basic first aid.
The Governor
The Governor should ensure that staff are aware of their responsibilities during medical emergencies and that staff who discover the emergency should call the appropriate medical emergency code immediately.
The Governor
The Governor should ensure that all staff are aware of the importance of starting cardiopulmonary resuscitation at the earliest opportunity and that staff first on the scene of an emergency provide basic life support until qualified health professionals arrive.
The Director of HMP Parc
The Director will wish to remind staff about the need to commence CPR with as little delay as possible.
The Head of Healthcare
The Head of Healthcare should ensure that staff are competent to carry out cardiopulmonary resuscitation in line with national guidance and arrange for additional training as required.
The Approved Premises Manager
ensure that newly appointed staff receive first aid and CPR training before they start work in the AP;
The Governor
The Governor should ensure that staff are aware of their responsibilities during medical emergencies including that: staff who discover the emergency should call the appropriate medical emergency code immediately and start CPR if the prisoner is not breathing; and control …
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that staff efficiently communicate the nature of a medical emergency using the appropriate code.
The Governor
The Governor should ensure that all prison staff are made aware of, and understand their responsibilities during medical emergencies, including that staff: • understand and use the appropriate emergency code when they discover a medical emergency; and • enter cells …
The Governor
The Governor should ensure that all staff are made aware of and understand their role and responsibilities during medical emergencies, including that they should radio a code blue emergency if they are concerned a prisoner is not breathing and that …
The Governor
The Governor should ensure that all staff understand their responsibilities during a medical emergency, and in particular that: officers fully understand the expectation that preservation of life must take precedence when considering entering a locked cell whether at night or …
The Governor
The Governor should ensure that staff call a medical emergency code as soon as possible if a prisoner appears to be hanging.
The Governor
The Governor should conduct regular emergency response drills to allow staff to practice response requirements, including when to commence CPR.
The Governor
The Governor should ensure that all staff use the medical emergency codes as set out in PSI 03/2013.
The Manager of Elm Bank Approved Premises
The Manager of Elm Bank Approved Premises should ensure that all staff understand their responsibilities during medical emergencies, including that: Staff act promptly in a life-threatening situation. First aid is commenced immediately on discovery of a resident who is unconscious …
The Governor
The Governor should ensure that when staff call a medical emergency code, they provide relevant information about the prisoner’s condition to control room staff so that they can inform the Ambulance Service.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff understand their role in an emergency response, including recognising and managing seizures or loss of consciousness in line with current clinical guidelines, and recording actions taken. A local protocol, in …
The Head of Healthcare
The Head of Healthcare should ensure that there is always a registered nurse or a GP present during a medical emergency. Guidance on the role of GPs and senior managers during an emergency should be developed, detailing guidance on leadership, …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff are fully aware of and understand their responsibilities in a medical emergency, including the use of an emergency response code if a prisoner has chest pains and documenting incidents.
IOPC Learning Recommendations (3)
Recommendation - College of Policing and National Police Chiefs' Council, August 2019
Officers attended an incident where a young male was found hanging. They did not detect signs of life and did not administer CPR. Responding officers receive ‘Emergency First Aider at Work’ (EFAW) (Module 2) training, in line with the College …
Recommendations - Metropolitan Police Service, November 2018
The IOPC recommends that the MPS may want to consider reviewing and updating the concern for safety Standard Operating Procedure (SOP) to include under the 'first contact' heading 'request London Ambulance Service’ and also 'request if anyone present is medically …
Recommendations - Metropolitan Police Service, November 2018
The IOPC recommends that the MPS may want to consider reviewing and updating the sudden death Standard Operating Procedure (SOP) to include under the 'first contact' heading 'request if anyone present is medically trained to initiate first aid / CPR.’ …
IMB Recommendations (39)
Heathrow Immigration Removal Centre (2020)
The investment made in the Safer Community Team and the associated working practices should be continued, ensuring that good practice in violence reduction, anti-bullying and the development of a community in which everyone is respected is at the core of the Centre and practiced by all members of the community (See 4.4.12). The Board would support the Centre Manager in …
Governor / Director
Exeter (2021)
As a matter of some urgency support Governors to reduce the backlog in staff training and particularly C&R basic, refresher and advanced training.
HMPPS
Exeter (2022)
Address the backlog in staff training and particularly control and restraint (C&R), basic, refresher and advanced training.
HMPPS
Durham (2023)
How will you ensure there are sufficient trained ‘Listeners’ in, and distributed across, the prison, and that they are given access to prisoners requesting support? (4.2.13)
Governor / Director
Standford Hill (2025)
We believe that prison officers should wherever possible be on the wings for greater visibility, and to manage risk rather than in the wing office.
Governor / Director
Berwyn (2022)
The Board is concerned at the lack of sufficient staff, which is the biggest destabilising factor in the prison. We hope to see increased funding to help recruit and retain frontline operational staff.
Other
Channings Wood (2023)
As one manager told the Board in 2021, ‘You can’t achieve OMiC if you can’t achieve key work’. Last year, HM Inspectorate of Prisons stated: ‘The absence of a functioning key worker scheme exacerbated the problems that prisoners told us they faced in getting things done.’ For several reasons (and even under the delivery to priority groups only model) key …
Governor / Director
Bronzefield (2023)
What plans does the prison have to increase the allocation of key workers to prisoners and the number of prisoner/key worker meetings?
Governor / Director
Preston (2024)
The Board recommends reviewing the refresher training and mentoring with regard to pro-social modelling, de-escalation and neurodiversity awareness.
HMPPS
East Sutton Park (2025)
Could the Governor investigate making greater use of the incentives scheme, including warnings or other sanctions, to more quickly and effectively respond to instances of challenging behaviour or situations where behaviour falls short of the standards expected by the prison?
Governor / Director
Foston Hall (2020)
The need for further improvement in the use of body worn cameras during violent incidents (see paragraph 4.5.3).
Governor / Director
Foston Hall (2020)
The rise in the use of force (see paragraph 4.5.1).
Governor / Director
Foston Hall (2020)
The high rate of violent incidents – in particular, the level of assaults on staff (see paragraph 4.3.2).
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
Whitemoor (2021)
Will the Governor the Governor please ensure that the key worker scheme which has the potential to make a very positive contribution to staff/prisoner relations is resourced appropriately and supported from the top down to do the job it was created to do?
Governor / Director
Stoke Heath (2021)
The Board urges the Governor to give priority to his plans to re-introduce a full key worker programme as soon as restrictions allow. The Board believes that this will be a critical tool for the successful transition to a normal regime.
Governor / Director
Durham (2021)
Use of force is disproportionate in the age groups 18–21 and 22–29. Other than actively pursuing the young adult strategy, what else can be done to address the behaviour of this demographic (4.4.9)?
Governor / Director
Wayland (2022)
The Board recommends that prison officer training is reviewed to include deeper and more extensive training on key work and staff/prisoner relationships.
HMPPS
Guys Marsh (2022)
The cornerstone of offender management in custody (OMIC) is the importance of the key worker and prisoner relationship. Current staffing levels simply do not allow for the effective delivery of OMIC. leading to pressures elsewhere in the system. How can the Prison Service ensure the successful delivery of OMIC?
HMPPS
Belmarsh (2022)
Will the prison ensure adequate time is ring-fenced for key worker duties to ensure the compliance rate for key worker sessions meets the required level (see section 5.3 Staff-prisoner relationships, key workers)?
Governor / Director
Whatton (2023)
Will the Governor ensure that key working remains a priority and the correct level of engagement with prisoners is maintained?
Governor / Director
Eastwood Park (2024)
Implement measures to reduce the number of use of force incidents, which have doubled in the reporting year.
HMPPS
Peterborough (2025)
In November 2024, the men’s prison was re-roled to hold more than 80% remand prisoners, taking them from the Luton and Bedford catchment. What steps is the Prison Service taking to ensure that the prison is resourced in a timely fashion to deal with this significantly changed role that HMP Peterborough has been required to take on?
HMPPS
Whitemoor (2020)
Will the minister re-examine the dispersal system under which Whitemoor holds genuinely high-risk and dangerous men alongside those who could be held in less restrictive conditions, where they would be less vulnerable to pressures, could benefit from a wider range of opportunities to progress, and perhaps be located closer to their families?
Ministry of Justice
Cardiff (2020)
We applaud the establishment in its efforts to maintain key worker sessions during the restricted regime but would ask that consideration be given to whether the cross-deployment of key workers affected the incidence of self-harm (see paragraph 5.3.1).
Governor / Director
Brixton (2020)
as prisons return to a more normal regime, it is made a priority and funding is made available to provide all men in resettlement prisons with an activity that will reduce their risk of reoffending on release.
HMPPS
Werrington (2022)
How will you improve relationships between officers and young people so that they are sustained and meaningful?
Governor / Director
Oakwood (2022)
The Board asks that the Director reviews communication in relation to access to education and courses available. The Board also asks that consideration is given for prisoners who share a cell to be given access to a space to undertake coursework.
Governor / Director
Lincoln (2023)
There are ongoing issues with kit collection and distribution. Can sufficient kit items be provided for those arriving in reception, to cover until the first change on the wing? Can an effective system be put in place to ensure the laundry that is sent out from the wings matches that which is returned in both condition and numbers?
Governor / Director
Lewes (2023)
Will the Governor ensure that there are working washing machines and dryers on all wings to enable men to change their clothes regularly, and that men arriving into reception always receive two sets of kit?
Governor / Director
Thameside (2024)
The Board would welcome more robust accountability of processes that continue to affect prisoners’ lives on a day-to-day basis, such as property and the incentives scheme process, as this plays a significant part in reducing prisoner perception of unfairness, causing frustration and sometimes leading to acts of violence or self-harm.
Governor / Director
Leicester (2024)
Can the Governor develop a revised scheme that is deliverable within the resources available, which is predictable and routine and targets those most in need of attention and support?
Governor / Director
Durham (2024)
How will you ensure that prisoners are offered the minimum kit they are entitled to?
Governor / Director
Usk and Prescoed (2025)
HMPPS should implement specific plans and allocate resources to address the changed profile of prisoners at HMP Prescoed, who now have insufficient time for ROTL, and ensure an expanded offering of purposeful activities.
HMPPS
Lowdham Grange (2023)
The Board feels that the amendments to the Parole Board rules, which came into force in July 2022, are denying opportunities for prisoners who are seeking transfer to open conditions or moving towards release. The Board would like to see the opinions and recommendations of prison and probation staff being given due consideration when such decisions are made.
Ministry of Justice
Lowdham Grange (2023)
The Board believes there should be a renewed focus and energy on reviewing the sentences of indeterminate sentenced (IPP) prisoners, as this recommendation from the Justice Select Committee was not accepted.
Ministry of Justice
Forest Bank (2023)
What further support can be given to assist the prison in managing the onward movement of prisoners who intentionally disrupt transfers and are not accepted on the normal transport of the receiving establishment?
HMPPS
Isis (2024)
What alternative methods are there for bringing urgent but not emergency issues to the attention of officers?
Governor / Director
Isis (2024)
How will the Minister allocate the necessary resources for this age group in HMP/YOI Isis?
Ministry of Justice
Article 2 Learning Points (4)
— LP 6
I recommend that NOMS checks whether provision and deployment of first aid staff and equipment at Ranby are now at an acceptable level.
NOMS
— LP 2
We ask the Governor of Chelmsford and HMPPS what arrangements are in place to ensure that all prison staff who may be first on scene in a medical emergency are adequately trained to provide immediate care.
The Governor
Accepted
— LP 15
We recommend that HMPPS and HMCTS review and report on their progress in implementing the recommendations on Court Custody made by the Inspectorate in 2015. We recommend specifically that: Automated external defibrillators should be provided in all courthouses, accessible to the custody and court staff, who should be instructed in …
HMPPS and HMCTS
Accepted
— LP 6
We recommend that consideration should be given to locating defibrillators accessible to court custody staff and ensuring that all staff are competent to recognise the circumstances when they should be used and to use them. (It may be practicable to provide defibrillators in conjunction with the courts – see Recommendation …
HMPPS
Accepted
LGO / SPSO Decisions (4)
201203731 — Scottish Prison Service
Mr C, who is a prisoner, was placed on report for refusing to work. He was found guilty of this charge at a disciplinary hearing but complained that the adjudicator would not listen to him and denied him the right to present evidence in his defence. He also said the …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jul 2013
201303515 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison did not follow procedures when they downgraded him from less secure conditions to more secure. He also complained about the prison’s handling of his complaint. Prisons are entitled to decide to downgrade a prisoner when evidence is available to suggest …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2014
201507573 — Scottish Prison Service
Mr C said his complaints about swearing and the use of insulting language by prison staff had not been properly investigated. We found that the steps taken to investigate and respond to the complaints Mr C made were reasonable in the circumstances. There was a lack of evidence to corroborate …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Feb 2017
201105247 — Scottish Prison Service
Mr C, who is a prisoner, was reported for possessing a mobile telephone. He pled guilty at his disciplinary hearing and the adjudicator imposed a punishment. Following this, Mr C submitted a disciplinary appeal form. He said he was appealing on the grounds that he felt protocol was not fully …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Aug 2012