HM Prison and Probation Service
Central Government
Action Taken
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 since. In 2024, they introduced a quality assurance process for roll checks and the Standards Coaching Team provided support to staff over the summer. (AI summary)
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Dear Mr Rogers, Thank you for your Regulation 28 report of 1 October 2024, addressed to the Governor of HMP Wandsworth, following the inquest into the death of Brandon Johnson on 12 September 2019. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as the Director General of Operations. I know that you will share a copy of this response with Mr Johnson’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You have expressed concern about the robustness of the procedures and processes for checking on the welfare of prisoners within their cells and how the prison ensures that these checks have been undertaken. In respect of staff checks on prisoners, it may be helpful for me to first clarify the types of checks that staff are required to conduct on prisoners. Roll checks are undertaken as a fundamental security check to ensure that all prisoners are present in each area of the prison at particular times of the day. While the primary purpose of these checks is to ensure all prisoners are accounted for, staff are required to take any necessary action if there are any immediate concerns for a prisoner’s welfare. Welfare checks are undertaken by staff during or shortly after unlock so they can assure themselves of the wellbeing of prisoners. This can include verbal or physical acknowledgements, movement in a cell or in bed, or any other indication that a person is alive and there are no obvious issues of concern. Further, as part of the Assessment, Care in Custody and Teamwork (ACCT) process, observations are carried out on those who are considered to be at risk of self-harm or suicide to ensure these individuals are safe. Observations are carried out at irregular intervals and in the least obtrusive manner, particularly at night given the importance of sleep for wellbeing.
All prisons are required to have a local policy which sets out what staff are required to do during checks in order to ensure the above requirements are met. Local instructions and policies will supersede initial training as they set out the expectations of that establishment. I fully recognise the importance of checks being carried out as they should be. HMPPS would expect staff to take swift action if they have any concerns about an individual’s welfare no matter what type of check is being conducted. All staff receive training on the completion of roll checks before they commence their employment, and continued support is provided to staff by their managers to ensure they continue to employ good practice. Staff who are identified as needing additional support with roll check completion will be allocated additional training and development. HMP Wandsworth’s Local Security Strategy (LSS) provides clear guidance to staff about the manner and processes of roll check completion. The prison is presently reviewing the LSS and will consult the roll check policy as part of this review to ensure that there is continued focus on the importance of staff completing roll checks correctly. This prison issued a notice to all staff in March 2021 to remind them of the importance of having clear sight of a prisoner and obtaining signs of life during a roll check. Further communication and reminders have been published since. In 2024 the prison introduced a quality assurance process for roll checks where managers were present during their completion to ensure they were being done effectively. In addition, further support for staff with understanding the importance of roll checks and assisting staff in their effective completion was provided by the Standards Coaching Team, who were deployed to HMP Wandsworth over the summer of 2024. The completion of roll checks is discussed with staff in daily briefings at HMP Wandsworth. Staff are reminded to challenge prisoners who obscure their observation panels and prevent roll checks being completed effectively. They are also briefed on the process for calling for staff support if they are struggling to obtain a sufficient response during a roll check on a prisoner. I hope the measures outlined above provide you with reassurance that learning and appropriate action has been taken from the circumstances of Mr Johnson’s death.
All prisons are required to have a local policy which sets out what staff are required to do during checks in order to ensure the above requirements are met. Local instructions and policies will supersede initial training as they set out the expectations of that establishment. I fully recognise the importance of checks being carried out as they should be. HMPPS would expect staff to take swift action if they have any concerns about an individual’s welfare no matter what type of check is being conducted. All staff receive training on the completion of roll checks before they commence their employment, and continued support is provided to staff by their managers to ensure they continue to employ good practice. Staff who are identified as needing additional support with roll check completion will be allocated additional training and development. HMP Wandsworth’s Local Security Strategy (LSS) provides clear guidance to staff about the manner and processes of roll check completion. The prison is presently reviewing the LSS and will consult the roll check policy as part of this review to ensure that there is continued focus on the importance of staff completing roll checks correctly. This prison issued a notice to all staff in March 2021 to remind them of the importance of having clear sight of a prisoner and obtaining signs of life during a roll check. Further communication and reminders have been published since. In 2024 the prison introduced a quality assurance process for roll checks where managers were present during their completion to ensure they were being done effectively. In addition, further support for staff with understanding the importance of roll checks and assisting staff in their effective completion was provided by the Standards Coaching Team, who were deployed to HMP Wandsworth over the summer of 2024. The completion of roll checks is discussed with staff in daily briefings at HMP Wandsworth. Staff are reminded to challenge prisoners who obscure their observation panels and prevent roll checks being completed effectively. They are also briefed on the process for calling for staff support if they are struggling to obtain a sufficient response during a roll check on a prisoner. I hope the measures outlined above provide you with reassurance that learning and appropriate action has been taken from the circumstances of Mr Johnson’s death.