Wyndham Thomas
21 Dec 2023 · Coroner Laurinda Bower · Nottingham City and Nottinghamshire
This report repeats 1 earlier warning, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. in-cell ligature points
“There is a lack of local and national system of in-cell ligature point risk assessments, and no ligature point maps available to staff”
2. absence of Safer Cells
“There is no mandatory requirement for a HMP Prison to have access to a Safer Cell”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“Mr [name redacted] was housed in a cell on the healthcare wing. Head of Safety at HMP Bedford told the court that was for both security”
This report
“There is a lack of local and national system of in-cell ligature point risk assessments, and no ligature point maps available to staff.”
Closely relatedConfidence 0.80 · moderate
This report
“There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points).”
Later report
“A further concern raised by the evidence relates to the lack of any attempt to cost structural cell improvements to mitigate, in at least some cells on each wing, the most obvious of ligature points in the Victorian Prison estates' cells, namely the readily accessible fixed bars at the windows.”
Closely relatedConfidence 0.86 · high
This report
“There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points).”
Later report
“as long as "safer cells" are not made available away from the segregation unit at the HMP Hewell, an important measure for reducing the risk of suicide or self-harm is being withheld from vulnerable prisoners at that prison.”
Responses
2023-0547-Response-from-HM-Prison-and-Probation-Service.pdf ↗· His Majesty's Prison and Probation Service
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”