Welfare checks missed and undocumented
HMP Swaleside received 3 coroners' reports about this hazard between 13 Jul 2015 and 8 Aug 2024.
They came from 1 coroner. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response from the prisoner upon unlocking a cell or were aware but did not act in accordance with the order especially where they assumed the prisoner was asleep”
Original on judiciary.uk ↗ HMP Swaleside responded, stating 1 specific action.Response (PDF) ↗
“issued at HMP Swaleside on 10 August 2015. It sets out the local procedure for ensuring compliance with the mandatory requirement in PSI 75/2011 to which you refer, and requires staff and a supervising officer to sign to confirm that the welfare checks have taken place on each occasion.”
Stated timescale: 10 August 2015
- 6 years 6 months later
“That measures put in place following Mr. [name redacted] death to ensure welfare checks are conducted are not overlooked”
Original on judiciary.uk ↗ HMP Swaleside responded, stating 1 specific action.Response (PDF) ↗
“HMP Swaleside has introduced a welfare check that staff conduct at approximately 8am. Staff must open the cell door and ensure they gain a verbal response from the occupant so they can assure themselves of the prisoner's wellbeing. The completion of the check must be recorded in the wing assurance book.”
Stated timescale: approximately 8am
- 2 years 6 months laterClosely relatedConfidence 0.92 · high
“It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies”
Original on judiciary.uk ↗ Repeated from the earlier report:prisonofficers
The most recent report. A response may not be due or published yet.
- All reports to HMP Swaleside
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2024Sean Davies9 years 1 month after Douglas Birch · same coronerClosely relatedConfidence 0.92 · high
Closely relatedConfidence 0.92 · highBoth reports highlight failures by prison staff to carry out required welfare checks of prisoners. The earlier report focuses on checks when unlocking cells, while the later report concerns roll‑call and other welfare checks.
Douglas Birch · 13 Jul 2015
“Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response from the prisoner upon unlocking a cell or were aware but did not act in accordance with the order especially where they assumed the prisoner was asleep”
Original on judiciary.uk ↗ Sean Davies · 8 Aug 2024
“It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies”
Original on judiciary.uk ↗ 2022 → 2024Sean Davies2 years 6 months after Idris Habib · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in ensuring that welfare checks are properly carried out and recorded. The earlier report focuses on checks being overlooked and undocumented, while the later report shows officers not performing the checks as required.
Idris Habib · 24 Jan 2022
“That measures put in place following Mr. [name redacted] death to ensure welfare checks are conducted are not overlooked”
Original on judiciary.uk ↗ Sean Davies · 8 Aug 2024
“(2) It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“HMP Swaleside has introduced a welfare check that staff conduct at approximately 8am. Staff must open the cell door and ensure they gain a verbal response from the occupant so they can assure themselves of the prisoner's wellbeing. The completion of the check must be recorded in the wing assurance book.”
Stated action · timescale: 10 August 2015
“issued at HMP Swaleside on 10 August 2015. It sets out the local procedure for ensuring compliance with the mandatory requirement in PSI 75/2011 to which you refer, and requires staff and a supervising officer to sign to confirm that the welfare checks have taken place on each occasion.”
Stated action · timescale: approximately 8am
“HMP Swaleside has introduced a welfare check that staff conduct at approximately 8am. Staff must open the cell door and ensure they gain a verbal response from the occupant so they can assure themselves of the prisoner's wellbeing. The completion of the check must be recorded in the wing assurance book.”
No published response from HMP Swaleside was found for this report. It is the most recent report, so a response may not be due or published yet.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to HMP Swaleside at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2024 | 0.67 | 0.07 | Closely related · 0.92 | same |
| 2022 → 2024 | 0.68 | 0.28 | Closely related · 0.90 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.