Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Thomas Huntley · 14 May 2023 · Robert Simpson, Hampshire, Portsmouth and Southampton
“The final area of concern is the lack of certified Safer Cells at HMP Winchester. The inquest heard evidence that these had either never existed at HMP Winchester or had not done so for many years.”
judiciary.uk/…/thomas-huntley-prevention-of-future-deaths-report
What was promised
Stated action 1 · response to Thomas Huntley (14 May 2023) · stated timescale: end of 2023
“HMP Winchester is currently delivering monthly training and awareness sessions for all staff which incorporates both ACCT v6 and SASH training.”
judiciary.uk/…/2023-0461-Response-from-HM-Prison-and-Probation-…
Stated action 2 · response to Thomas Huntley (14 May 2023) · stated timescale: none stated
“The Safety Intervention Meeting (SIM) is a multi-disciplinary safety risk management meeting, chaired by the Senior Management Team (SMT), providing support and multi-disciplinary guidance to Case Coordinators and case review teams.”
judiciary.uk/…/2023-0461-Response-from-HM-Prison-and-Probation-…
Stated action 3 · response to Thomas Huntley (14 May 2023) · stated timescale: none stated
“All establishments are required to have an ACCT quality assurance process in place that ensures that quality assurance is carried out at a level and frequency that enables meaningful insight into how effectively support through ACCT is being implemented.”
judiciary.uk/…/2023-0461-Response-from-HM-Prison-and-Probation-…
3 further stated actions are listed on the full chain page.
What recurred
- 21 Dec 2023 · Wyndham Thomas · Laurinda Bower
- 1 Dec 2025 · Stuart Berry · Sean Horstead · Closely related · confidence 0.80 (moderate)
- 10 Dec 2025 · Mesut Olgun · David Reid · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Thomas Huntley · 14 May 2023
“The final area of concern is the lack of certified Safer Cells at HMP Winchester. The inquest heard evidence that these had either never existed at HMP Winchester or had not done so for many years.”
Later · Mesut Olgun · 10 Dec 2025
“I am concerned that as long as”
What happened next
No evidence found either way · stated action 1
“Action required by: HMPPS HQ X Governors X Public Sector Prisons X Heads of Group X Contracted Prisons The Probation Service X Under 18 Young Offender Institutions (ACCT policy only)”
Prison Safety Policy Framework · assets.publishing.service.gov.uk/…/prison-safety-policy-framewo…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 2
“This glossary provides an alphabetical guide to some of the terminology in our reports. We review this glossary regularly, but please let us know if you find any entries that need updating. Email us at [HMIPrisons.Enquiries@hmiprisons.gov.uk](mailto:HMIPrisons.Enquiries@hmiprisons.gov.uk)”
Glossary of terms – HM Inspectorate of Prisons · hmiprisons.justiceinspectorates.gov.uk/glossary-of-terms
“Prison Safety Policy Framework Re-issue Date: 14 January 2026 Implementation Date: 01 January 2025 Replaces the following documents (e.g. PSIs, PSOs, Custodial Service Specs) which are hereby cancelled: PSI 64/2011 Management of prisoners at risk of harm to self, to others and from others (Safer Custody) - chapters 1-11 and 14 and Annex to PSI 64/2011 (ACCT version 6). Introduces amendments to the”
Prison Safety Policy Framework · assets.publishing.service.gov.uk/…/prison-safety-policy-framewo…
“His Majesty's Prison and Probation Service | Headquarters at [102 Petty France](https://en.wikipedia.org/wiki/102_Petty_France "102 Petty France"), London | | [Executive Agency](https://en.wikipedia.org/wiki/Executive_Agency "Executive Agency") overview | | Formed | 2004 (2004) (as NOMS) | | Jurisdiction | England and Wales, [United Kingdom](https://en.wikipedia.org/wiki/United_Kingdom "United Kingdom”
HM Prison and Probation Service - Wikipedia · en.wikipedia.org/wiki/HM_Prison_and_Probation_Service
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
The Prison Safety Policy Framework requires all establishments to implement an ACCT quality assurance process, but it does not specify a timeframe for implementation.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “Following Mr [name redacted] death, HMP Winchester undertook a review of the quality assurance checks in place to ensure these are being completed appropriately, and which resulted in the implementation of a system for accountability which has robust procedures to follow up any identified concerns and promote effective practice throughout the staff group.”
“This document was developed as part of a multiyear cooperative agreement between the National Institute of Corrections (NIC) and the Crime and Justice Institute (CJI) for an initiative entitled Implementing Effective Correctional Management in the Community.”
Implementing Evidence-Based Practice in Community ... · pa.gov/…/EBP1.pdf
“Accountability and Models for Accountability Association for the Prevention of Torture and the Office for Democratic Institutions and Human Rights, Monitoring Places for Detention: A Practical Guide for NGOs [non-governmental organizations], December 2002, https://tortureprevention.ch/content/files_res/monitoring-guide-for-ngos-en.pdf accessed 6/19/2020”
IMPROVING ACCOUNTABILITY AND TRANSPARENCY IN ... · cipp.org/uploads/3/7/5/7/37578255/2_25_2021.pdf
“Prisons- Transparency and Accountability Policy Overview As jails and prisons are inherently closed institutions, persons detained in them are particularly susceptible to abuse and human rights violations, violence, overcrowding, sexual assault, and poor living and working conditions.”
Prisons— Transparency and Accountability · opengovpartnership.org/…/Open-Justice_Justice-II_Prisons_Dec202…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “The final concern raised relates to ligature points in cells. HMPPS is currently undertaking a review of ligature-resistant cells, which have been designed to eliminate ligature points as far as possible.”
The promised review of ligature-resistant cells is described as ongoing without a specific completion date.
No evidence found does not mean the action did not happen.
No evidence found either way · stated action: “We recognise that prisoners may feel vulnerable during their time in custody and HMPPS uses the Assessment, Care in Custody, Teamwork (ACCT) case management approach to support people at risk of self-harm and suicide. As part of any case review, those present will consider a range of measures to mitigate risk, including the prisoner's location and whether any possessions need to be removed or returned, and this may include moving the prisoner to a cell that is more appropriate to manage their risk”
“Working to make government more effective”
Performance Tracker 2026: Prisons and probation | Institute for Government · instituteforgovernment.org.uk/…/prisons
“Prisons Strategy White Paper December 2021 CP 581 Prisons Strategy White Paper Presented to Parliament by the Deputy Prime Minister, Lord Chancellor and Secretary of State for Justice by Command of Her Majesty December 2021 CP 581 © Crown copyright 2021”
[PDF] Prisons Strategy White Paper - GOV.UK · assets.publishing.service.gov.uk/…/prisons-strategy-white-paper…
“Work to expand the prison estate by installing the first of 500 temporary, single occupancy cells will begin from today, as part of the Government's unprecedented action to protect the public and NHS during the Coronavirus pandemic.”
Prison estate expanded to protect NHS from coronavirus risk · gov.uk/…/prison-estate-expanded-to-protect-nhs-from-coronavirus…
No evidence found does not mean the action did not happen.