Prison cell observation panels
Prison culture and practice leading to obscured cell observation panels, staff delaying entry, and misinterpreting views.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
99match
Anthony Binfield
The coroner raises concerns about prison staff failing to manage cell observation panels safely and in accordance with policy, noting a culture of delayed cell entry when panels are obscured. This practice, which risks lives, persists despite previous incidents and multiple staff notices.
Matched on
terms: cell, observation, panel, prison
PFD report
85match
Stephen Sleaford
The coroner raises concerns about a lack of first aid and CPR training for prison officers, including its omission from new officer foundation training programmes. Additionally, officers routinely permit cell observation panels to be obscured, and there is insufficient guidance on entering cells during emergencies.
Matched on
terms: cell, observation, panel, prison
PPO recommendation
85match
The Governor
The Governor should ensure that: prisoners who block their observation panels are challenged, blockages are removed, and frequent offenders receive appropriate disciplinary action or support; staff are aware of national guidance and understand their responsibilities when they find a cell observation panel obscured; they confirm with PPO that that a Safety Newsletter/handbook has been issued and the date...
Matched on
terms: cell, observation, panel, prison
PPO recommendation
85match
The Governor of HMP Liverpool
The Governor should ensure that staff are aware of and understand what is expected of them when they find a cell observation panel obscured.
Matched on
terms: cell, observation, panel
PPO recommendation
85match
The Governor of HMP Whatton
The Governor should ensure that a local protocol is developed and shared with staff to instruct them on what to do if they find a cell observation panel obscured.
Matched on
terms: cell, observation, panel
PPO recommendation
85match
The Governor of HMP Erlestoke
The Governor should ensure that a local protocol is developed and shared with staff to instruct them on what to do if they find a cell observation panel obscured.
Matched on
terms: cell, observation, panel
PFD report
81match
Damion Anthony Andre Martin
Concerns were raised regarding the prison's initial risk assessment missing a known suicidal risk factor, the lack of refresher training in basic life support for officers, and a restricted cell observation window. An officer also reportedly did not visit the cell during a roll check.
Matched on
terms: cell, observation, prison
PFD report
81match
Michael Williams
The coroner noted several missed observations and predictable 15-minute observation intervals for Mr Williams. There was also an inappropriate delay in opening his cell door, indicating a need for clear guidance and training for prison officers in such situations.
Matched on
terms: cell, observation, prison
IMB recommendation
81match
Gartree (2023)
Can the Governor give further assurance that staff will be adequality trained to ensure they challenge all and any prisoners who cover their observations panels? This has been raised in a number of PPO reports about Deaths in Custody.
Matched on
terms: observation, panel, prison
PPO recommendation
77match
The Director of HMP Lowdham Grange
The Director should evidence how the prison will monitor the challenging of blocked observation panels to ensure compliance with local processes.
Matched on
terms: observation, panel, prison
IMB recommendation
77match
Woodhill (2025)
Will the Governor respond to the PPO report and impose a more stringent incentives scheme policy for prisoners who repeatedly block their cell door observation panels?
Matched on
terms: cell, observation, panel, prison
IMB recommendation
76match
Gartree (2024)
Please can the Governor give further assurance that staff will be adequately trained to ensure that they challenge any prisoner who covers their observations panels? This has been raised in a number of Prisons and Probation Ombudsman reports about deaths in custody.
Matched on
terms: observation, panel, prison
PFD report
69match
Serena Nicolle
The coroner notes that observing a person's chest and abdomen through a cell door hatch, a standard prison procedure, may be an unreliable method for checking if they are breathing, creating a risk of future deaths.
Matched on
terms: cell, prison
IOPC learning recommendation
69match
Recommendations - Leicestershire Police and Mitie, October 2025
The IOPC recommends that Leicestershire Police should create guidance for custody staff to support them in implementing the College of Policing Authorised Professional Practice (APP) when conducting cell checks. The guidance should include the length of cell checks, actions to be taken and what should be observed, what to do if a detainee’s face is obscured (for example,...
Matched on
terms: cell
CJINI report
66match
A Review into the operation of Care and Supervision Units in the Northern Ireland Prison Service: A Follow-Up...
Matched on
terms: prison
IOPC learning recommendation
65match
Man dies after becoming unwell in custody - Essex Police, November 2017
Our investigation into the death of a man following his detention at Grays Police Station found that there was not full CCTV coverage of the holding cell in which he had been placed. This was because the CCTV camera in the holding area did not include, within its coverage, sight into the individual holding cells. This issue was...
Matched on
terms: cell, prison
LGO / SPSO decision
63match
201304806 - Scottish Prison Service
Mr C, who is a prisoner, complained that the built-in DVD player on his in-cell TV set did not work. He did not feel it was fair to pay the full TV service charge when his set was defective. However, the prison confirmed that Mr C was paying for access to TV channels, which he still had, and...
Matched on
terms: cell, prison
PFD report
61match
Brandon Johnson
The coroner noted inadequate robustness in prisoner welfare checks, citing insufficient time for staff, unreliable signs of life, and gaps in training on how to perform checks and record positive responses.
Matched on
terms: prison
PFD report
57match
Raymond Knight
The CCTV camera in the holding area at Grays Police Station did not extend into individual holding cells, meaning there was no visual record of detainees while inside them. The coroner identified a need for discrete camera coverage within cells to monitor detainees and potentially prevent future deaths.
Matched on
terms: cell
PFD report
57match
Saifur Rahman
The coroner identified gaps in emergency 'code blue' response, the absence of a central record for cell fabric history at HMP Birmingham, and a lack of formalised visual inspection of all healthcare cells by the mental health trust.
Matched on
terms: cell
LGO / SPSO decision
57match
201303897 - Scottish Prison Service
Mr C, a prisoner, complained that staff at his prison carried out a personal search in a manner that was unreasonable in his particular circumstances. In looking at Mr C's complaint, our role was to examine whether the prison followed the correct procedure in carrying out the search. When we looked at the search procedures we found that...
Matched on
terms: prison
IMB recommendation
56match
Coldingley (2024)
Does the Minister agree that it is unacceptable in 2024 for prisoners to live without in-cell sanitation? The refurbishment in Coldingley will not be completed for at least three years so, for at least two years, some men will continue to rely on an antiquated and unreliable sanitation system. What can be done to ensure these prisoners can...
Matched on
terms: cell, prison
LGO / SPSO decision
55match
201103838 - Scottish Prison Service
Mr C, who is a prisoner, complained that at times the Scottish Prison Service (SPS) had required him to share a cell that was not of an adequate size to accommodate two prisoners. He had been sharing a cell that was intended as a single, but which has been fitted with bunk beds. The prison told him that...
Matched on
terms: cell, prison
LGO / SPSO decision
55match
201404940 - Scottish Prison Service
Mr C complained that his prison unreasonably reversed their decision to allow him to move into a shared cell. We found that, as they acknowledged, the prison had made the wrong decision in allowing Mr C to move to a shared cell and, therefore, they were correcting their mistake when they returned him to a single cell. Therefore,...
Matched on
terms: cell, prison
PFD report
53match
Maureen Martin
The coroner noted the nurses' station desk on the ward was incorrectly positioned, potentially affecting staff visibility of patients. A review of desk positioning at Queens Hospital was requested to ensure optimal visibility is maintained.
Matched on
classifier match
IOPC learning recommendation
52match
Recommendation - Greater Manchester Police, June 2022
The IOPC recommends that Greater Manchester Police should ensure custody cell doors are equipped with an opening hatch that allows officers to be able to hear and communicate with detainees without the requirement to open the cell door in order to facilitate this. This follows an IOPC review of a Death and Serious Injury (DSI) local investigation by...
Matched on
terms: cell
IMB annual report
52match
Woodhill (2025)
HMP Woodhill faced ongoing challenges in safety, healthcare, and infrastructure during the reporting year, despite some positive developments like an improved induction unit and valued mental health services. High rates of assaults and self-harm, coupled with staffing inexperience and significant delays in mental health transfers, were prominent concerns. The Board also highlighted the deteriorating state of the prison's...
Matched on
terms: prison
LGO / SPSO decision
52match
201305611 - Scottish Prison Service
Mr C, who is a prisoner, complained that the prison did not address his concerns about the temperature in his residential hall. We made enquiries of the Scottish Prison Service (SPS), and found that complaints were received from prisoners about the temperature in the hall. Steps were taken to resolve this, including providing advice to prisoners on how...
Matched on
terms: prison
IOPC learning recommendation
52match
Recommendation - North Yorkshire Police, March 2021
The IOPC recommends that North Yorkshire Police should: - re-position/re-configure the CCTV cameras within the cells at Scarborough custody suite to ensure that there is comprehensive CCTV coverage of the interior of cells. In particular, any re-positioning/re-configuration of CCTV cameras should ensure there is an unrestricted view of the bed area within cells. - review the CCTV coverage...
Matched on
terms: cell
IMB recommendation
51match
Dartmoor (2024)
Lockdown, due to the Covid pandemic, coincided with the elevated Radon gas levels being identified. During this period, 2020-2021, prisoners were frequently locked down for 23 hours a day. The risk to prisoners of prolonged exposure to Radon gas in cells with poor ventilation appears to have been ignored. Why was this not raised?
Matched on
terms: cell, prison
LGO / SPSO decision
51match
201607622 - Scottish Prison Service
Ms C complained about a number of aspects of the Scottish Prison Service (SPS)' management of her. She complained that the SPS: held her in an unsuitable cell when she was on Act 2 Care (the suicide risk management policy) acted unreasonably in relation to an incident when she was attempting suicide unreasonably removed her from Act 2...
Matched on
terms: cell, prison
IMB recommendation
51match
Birmingham (2020)
Will the minister guarantee that, as advised, when the three Victorian wings, now closed, are refurbished they will be single-occupancy cells, to avoid the overcrowding of the past that contributed to uninhabitable living conditions, poor staff/prisoner relationships and an unsafe prison?
Matched on
terms: cell, prison
Article 2 learning point
51match
AB — HMP Bedford - LP H
We recommend that a more detailed policy is developed about the allocation of cells. For prisoners subject to ACCT monitoring, any cell moves should be agreed as part of the reviewing process, other than in an emergency when they should be reported to the Case Review.
Matched on
terms: cell, prison
IMB recommendation
48match
Lancaster Farms (2021)
To ensure that work previously planned to introduce screening of toilets within double cells is completed as soon as possible (paragraph 5.1.2).
Matched on
terms: cell
IMB recommendation
48match
Exeter (2024)
Will the return of the temporary CSU to A wing, following refurbishment, provide a suitable location for segregated prisoners and an appropriate and dedicated space for reviews and adjudications to take place?
Matched on
terms: prison
Article 2 learning point
48match
AB — HMP Bedford - LP D
Although there is now CCTV, staff should check prisoners in the holding room every ten minutes.
Matched on
terms: prison
IOPC learning recommendation
47match
Man sustained a serious injury while in custody – Cleveland Police, August 2019
The IOPC recommends that Cleveland Police should review the working practices used in custody, specifically in relation to CCTV observations, to ensure that the principles set out in the Authorised Professional Practice (APP) are followed. This should include consideration of; - the procedures in place to ensure custody staff carrying out CCTV observations are not engaged in other...
Matched on
terms: observation
IOPC learning recommendation
47match
Recommendations - Metropolitan Police Service, July 2021
The IOPC recommends that the Metropolitan Police Service (MPS) should review the custody handover practices to ensure there is adequate monitoring of occupied cells during handover periods. We would recommend that as part of this, it is also ensured that there is a process in place for officers/ staff monitoring cells to also be given the handover information.
Matched on
terms: cell
IMB recommendation
47match
Leeds (2022)
Yet again, the IMB must raise the issue of inappropriate accommodation for prisoners. Sharing small cells that were built for single occupancy is difficult at the best of times. Prisoners sharing a cell with someone they do not get on with or have different values or beliefs from is often a recipe for trouble and prisoners have little...
Matched on
terms: cell, prison
IMB recommendation
47match
Brixton (2024)
HMP Brixton recently celebrated its bicentenary. Old buildings do not get better with age and without money spent on them; we have reported as much year after year. In 2012, we wrote ‘The neglect of capital works at Brixton, over many years, means that the prison buildings are not fit for purpose, and will not be, despite best...
Matched on
terms: cell, prison
IMB recommendation
47match
Berwyn (2024)
What will the Prison Service do to address the serious problem with paint peeling off the walls in cells, given that the refurbishment programme has been stopped due to the increase in the prison population and current measures are inadequate?
Matched on
terms: cell, prison
Article 2 learning point
47match
SR — HMP Durham - LP 1
In order to reduce the risk of harm posed by prisoners to other prisoners’ Cell Sharing Risk Assessments should be better recorded and steps to mitigate risk of harm clearly stated. In addition, there should be a system for retrieval of the document upon request.
Matched on
terms: cell, prison
IMB annual report
46match
Durham (2025)
HMP Durham, a reception and resettlement prison, housed an average of 961 men against an operational capacity of 985 during the reporting year. The Board observed improvements in first-night healthcare screening and a reduction in self-harm incidents, alongside a significant increase in overall deaths in custody. Persistent overcrowding, inadequate regime delivery with prisoners spending 21.5 hours in cells,...
Matched on
terms: cell, prison
IMB recommendation
46match
Swinfen Hall (2020)
Concerns about hygiene include: • the practice of prisoners on most wings being required to eat meals in their cells, close to a toilet (see paragraph 5.1(b)). Is there a plan to improve this? • the risk of further infestation of rats on the site, which was dangerously extensive last year (see paragraph 5.1(c)]. What mitigation measures are...
Matched on
terms: cell, prison
PFD report
45match
Daniel Dunkley
The coroner noted that three referrals for mental health assessments for Mr Dunkley were not carried out before his death, and a scheduled assessment was not communicated to him or his unit.
Matched on
classifier match
PFD report
45match
Stuart Berry
The coroner noted recurrent failings at EPUT, previously identified in multiple PFD reports, concerning care planning, risk assessment, documentation, and internal communication. Actions taken to address these acknowledged issues have been inadequate.
Matched on
classifier match
IMB recommendation
44match
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).
Matched on
classifier match
Scottish FAI
44match
Kristoffer Batt
In my view, the light and buzzer system should be extended to these areas, and I so recommend. [305] Perhaps more importantly, however, I recommend that there be installed an extension of the assistance light system to the charge bar, in order that the Custody Sergeant on duty can readily see whether Custody Care Assistants are responding promptly...
Matched on
classifier match
IMB recommendation
44match
Rochester (2021)
The Board is still noting that cell clearance checks remain haphazard and many are not conducted properly, particularly when an individual is moved to the CSU from a double cell. Can this be addressed please?
Matched on
terms: cell
IMB recommendation
43match
Norwich (2021)
Are there plans for the replacement/refurbishment of the segregation unit to provide a unit with the scope to allow staff to 'focus on helping prisoners manage their behaviour and problems rather than simply on punishment' (PSO 1700, Introduction)?
Matched on
terms: prison