Prison emergency cell entry
Unclear guidance for prison officers on emergency cell entry procedures, compromising prisoner welfare in critical situations.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
85match
Ian Deavall
Emergency cell bells at HMP Forest Bank can be readily deactivated by other prisoners, meaning the detection of medical emergencies is dependent on chance rather than robust systems, which poses a risk of future deaths.
Matched on
terms: cell, emergency, prison
PFD report
77match
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, prison
PFD report
73match
Luke Pearce
Staff did not receive timely training and guidance on how and when to enter a cell during a medical emergency, nor on the appropriate use of Code Blue and Code Red communications.
Matched on
terms: cell, emergency
PFD report
73match
Nicholas Gedge
A delay of over 8 minutes occurred before CPR was commenced, indicating a lack of shared understanding among staff regarding the urgency of CPR. There were also unclear protocols defining the respective roles of detention and medical staff during a cell medical emergency.
Matched on
terms: cell, emergency
PPO recommendation
69match
The Governor of HMP Whatton
The Governor should ensure that all prison staff are made aware that where there is an immediate threat to life, they can enter a cell at night without seeking permission from the Night Orderly Officer if it is safe to do so.
Matched on
terms: cell, prison
PPO recommendation
67match
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that: night staff enter cells as quickly as possible in a life-threatening situation; and night staff use the appropriate medical emergency response code, by radio where possible, to effectively communicate the nature of the emergency.
Matched on
terms: cell, emergency, prison
PFD report
65match
Kevin Lovatt
The coroner identified a lack of clear guidance and training for prison staff on the safe use of force when dealing with resistant prisoners who have items in their mouths, which could compromise their breathing.
Matched on
terms: prison
PFD report
65match
John Eyre
The coroner identified a lack of a clear escalation route when prison healthcare staff challenged hospital patient discharges, and no national guidance on returning prisoners to custody if healthcare concerns were unaddressed by consultants.
Matched on
terms: prison
PPO recommendation
60match
The Prison Group Director for the Women’s Estate
The Prison Group Director for the Women’s Estate should satisfy herself that staff at Eastwood Park understand their responsibilities during medical emergencies, including the use of emergency codes, and should write to the Ombudsman when she has done this.
Matched on
terms: emergency, prison
PPO recommendation
60match
The Governor of HMP Erlestoke
The Governor should ensure that, subject to a risk assessment, staff enter cells as quickly as possible if there is reason to consider that a prisoner may be at risk.
Matched on
terms: cell, prison
PFD report
57match
Sam Molyneux
The coroner noted that not all old prison wings have anti-barricade doors, which can delay staff access during emergencies. Concerns were also raised that Mr Molyneux was not on an ACCT plan despite expressing threats of self-harm.
Matched on
terms: prison
PPO recommendation
55match
The Director
The Director should ensure that when a cell door is unlocked, staff satisfy themselves of the safety of the prisoner by obtaining a response in line with local instructions.
Matched on
terms: cell, prison
Committee recommendation
55match
#19 - Unclear implementation details of the earned progression scheme raise serious concerns.
The Sentencing Bill 2024–25 aims to move towards an ‘earned progression scheme’, where eligible prisoners could be released earlier. However, as the Bill is currently drafted, it is unclear as to how this scheme will work in practice, especially as to whether as the Independent Sentencing Review set out, it is contingent on whether they have engaged constructively...
Matched on
terms: cell, prison
IMB recommendation
47match
Isis (2024)
With regard to ECBs, how is the prison monitoring whether the guidance in the Prison Officers’ Guide 2023 is being followed?
Matched on
terms: prison
IMB recommendation
46match
Buckley Hall (2021)
Ensure that all prisoners have ready access to a cell courtesy key (5.1.13)
Matched on
terms: cell, prison
PFD report
45match
Trystan Bryant
The coroner identified that ambulance doors cannot be locked when stationary, which may affect police containment of individuals escorted under Section 136 of the Mental Health Act.
Matched on
classifier match
IMB recommendation
44match
Doncaster (2024)
The Board has identified, on a significant number of occasions, cell bells not being answered. Whilst we welcome the continued scrutiny of cell bell data and attempts by the management team to improve answering times, this issue remains a grave concern for the Board.
Matched on
terms: cell
Article 2 learning point
44match
AC — HMP Brixton - LP N
We endorse the recommendation made by the Brixton internal investigation that, in the event of an incident of barricade or potential suicidal behaviour, contingency plans are managed by the Duty Governor. We would, however, add the proviso that this should not delay a response in an emergency.
Matched on
terms: emergency
LGO / SPSO decision
43match
201302308 - Scottish Prison Service
Mr C, who is a prisoner, complained that the Scottish Prison Service (SPS) unreasonably prevented him from accessing prison activities, because they had imposed special security measures on him. We found that, under The Prisons and Young Offenders (Scotland) Rules 2011, the SPS have the right to impose such measures. The records showed that they had explained the...
Matched on
terms: prison
IMB recommendation
39match
Lancaster Farms (2021)
To confirm that processes previously agreed with the Board, such as that the Board will be notified immediately following the deployment of PAVA or the use of the special cell, remain in force (paragraph 5.2.5).
Matched on
terms: cell
IMB recommendation
39match
Grendon (2022)
Reporting on response times to cell bells (4.2.4).
Matched on
terms: cell
IMB recommendation
39match
Lancaster Farms (2023)
To ensure that processes previously agreed with the Board, such as that the Board will be notified immediately following the deployment of PAVA, deaths in custody or the use of the special cell, are implemented. And that the Board receives responses to issues it raises in its weekly reports.
Matched on
terms: cell
Article 2 learning point
39match
AC — HMP Brixton - LP Q
The daily cell fabric check should include the inspection of the securing bolts on the anti-barricade lock plates.
Matched on
terms: cell
PPO recommendation
39match
The Governor of HMP Long Lartin
if a prisoner’s condition and mobility deteriorate so that restraints are no longer appropriate in line with the Graham judgment, escort staff should ask for restraints to be removed;
Matched on
terms: prison
IMB recommendation
35match
Leyhill (2020)
In view of the present unsatisfactory level of night-time staffing (see paragraph 7.13), will the Prison Service ensure that a thorough review is carried out, bearing in mind both present conditions and any future plans for the prison, to ensure that all on-call staff are close enough to provide a fast and effective response in acute circumstances.
Matched on
terms: prison
Article 2 learning point
35match
PL — HMP Stocken - LP 5
We invite the Governor to examine whether the 12 minutes from arrival at the prison to attending a patient on K wing is unavoidable or whether the process of accessing the wings in emergencies can be made more efficient.
Matched on
terms: prison
LGO / SPSO decision
35match
201507547 - Scottish Prison Service
Miss C complained about escorting services provided on behalf of the Scottish Prison Service on two occasions. Miss C said that on the first occasion, escort staff physically and verbally abused her and on the second occasion, staff undertook a lengthy diversion when taking her to a medical facility for assessment. Miss C also complained that her complaints...
Matched on
terms: prison
PPO recommendation
34match
The Governor and Head of Healthcare (HMP Full Sutton)
The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that authorising managers show that they have taken this information into account when assessing a prisoner’s current level of risk.
Matched on
terms: prison
Article 2 learning point
32match
AC — HMP Brixton - LP P
Consideration should be given to placing ‘Impact Screwdrivers’ into each wing office to facilitate the removal of seized and damaged bolts on anti-barricade lock plates.
Matched on
classifier match
Article 2 learning point
27match
AC — HMP Brixton - LP O
HMP Brixton should review the availability of a locksmith in the evenings and at weekends.
Matched on
classifier match
IMB recommendation
26match
Grendon (2021)
Restrictions due to Covid-19 and project work notwithstanding, the Board looks forward to: monitoring cell bell response times (see 4.2.9)
Matched on
terms: cell