Prison emergency cell entry
Unclear guidance for prison officers on emergency cell entry procedures, compromising prisoner welfare in critical situations.
Source spread
Where this theme appears
This theme appears across 7 independent accountability sources, so the source mix matters as much as the headline total.
8 PFD reports
1 committee rec
14 PPO recs
9 IMB recs
5 Article 2 learning points
2 LGO/SPSO decisions
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.
Prevention of Future Deaths reports(8)
Sam Molyneux
Concerns: 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.
Response (HM Prison Probation Service): • The revised ACCT form and accompanying policy will direct staff to consider emergency access, including the presence of an anti-barricade door, when making decisions about the location of a … (AI summary)
Responded
Trystan Bryant
Concerns: 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.
Response (National Police Chiefs' Council): • The National Police Chiefs' Council wrote to all Chief Constables. • The letter requested Chief Constables to remind operational officers that ambulances should be treated as non-secure environments for … (AI summary)
Overdue
Kevin Lovatt
Concerns: 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.
Response (NHS England): • NHS England stated that the Service Specification for primary care in prisons requires healthcare providers to develop and implement protocols for responding to and managing emergencies. • NHS England … (AI summary)
Overdue
Luke Pearce
Concerns: 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.
Response (HM Prison and Probation Service): • A national video demonstrating emergency response procedures, including cell entry and medical emergency codes, was launched in January 2024 and delivered to all new officers. • The video is … (AI summary)
Overdue
Ian Deavall
Concerns: 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.
Response (HM Prison and Probation Service): • HMP Forest Bank has separated vulnerable and non-vulnerable prisoners on induction wings. • Future investment plans for the cell call system will be determined by competition and contract awards. (AI summary)
Overdue
John Eyre
Concerns: 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.
Response (Department of Health and Social Care): • The Department of Health and Social Care stated it would ask officials to consider amending hospital discharge guidance to make explicit the obligation to consider concerns raised by care … (AI summary)
Responded
Stephen Sleaford
Concerns: 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.
Response (HMPPS received by CCO): • HMPPS re-issued its First Aid Policy Framework in August 2023 and confirmed Emergency First Aid is a mandatory part of foundation training for new officers. • HMP Gartree issued … (AI summary)
Responded
Nicholas Gedge
Concerns: 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.
Response (Leeds Community Healthcare NHS Trust): • The Trust expanded life support training for staff to include medical emergency/CPR scenarios and will further expand this to include simulation exercises in custody suites with detention officers. • … (AI summary)
Response (West Yorkshire Police): • West Yorkshire Police stated that Detention Officers receive regular training on their defined role in medical emergencies, including basic life support and taking direction from healthcare professionals. • The … (AI summary)
Responded
PPO death in custody recommendations(14)
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 …
The Governor
The Governor should ensure that staff understand that where there is an immediate threat to life, they can enter a cell alone at night where it is safe to do so.
The Governor
The Governor should ensure staff are aware that where there is a threat to life, they may enter a cell alone at night if they feel safe to do so.
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.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that staff enter cells as quickly as possible in life threatening situations.
The Director
The Director should ensure that staff understand that they can enter cells at night in medical emergencies without the permission of the night orderly officer in line with PSI 24/2011.
The Governor
The Governor should ensure that subject to a dynamic risk assessment, staff enter a cell as quickly as possible, where there is a risk to life or concerns about a prisoner’s welfare.
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.
The Governor
The Governor should ensure that all prison staff understand their responsibilities during a medical emergency, including that staff use an emergency code promptly to communicate the nature of an emergency.
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.
The Governor
The Governor should ensure that all staff understand their responsibilities during medical emergencies, including calling an immediate emergency code when there is a threat to life, in line with PSI 03/2013.
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 …
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;
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 …
IMB individual recommendations(9)
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.
Governor / Director
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).
Governor / Director
Grendon (2022)
Reporting on response times to cell bells (4.2.4).
Governor / Director
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.
Governor / Director
Isis (2024)
With regard to ECBs, how is the prison monitoring whether the guidance in the Prison Officers’ Guide 2023 is being followed?
Governor / Director
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.
HMPPS
In Progress
Isis (2024)
Who is responsible for attending when an ECB is rung over the lunch period or during morning briefings – times when our investigation shows that the time taken to answer is very long?
Governor / Director
Buckley Hall (2021)
Ensure that all prisoners have ready access to a cell courtesy key (5.1.13)
Governor / Director
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)
Governor / Director
Article 2 learning points(5)
— 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.
HMPPS
— 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.
HMPPS
— LP Q
The daily cell fabric check should include the inspection of the securing bolts on the anti-barricade lock plates.
HMPPS
— LP O
HMP Brixton should review the availability of a locksmith in the evenings and at weekends.
HMPPS
— 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.
HMPPS
Accepted
LGO / SPSO decisions(2)
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. …
SPSO (Scottish Public Se…
Prisons
Not Upheld
May 2014
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 …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Jan 2017