Ligature points in unprotected cells
His Majesty's Prison and Probation Service received 2 coroners' reports about this hazard between 19 Jul 2022 and 21 Dec 2023.
They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.
No published response from His Majesty's Prison and Probation Service was found for the earlier reports.
The story, report by report
Spacing grows with the time between reports.
“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”
Original on judiciary.uk ↗ No published response from His Majesty's Prison and Probation Service was found for this report.
- 1 year 5 months later
Raised again · 1st time
Wyndham Thomas↗
21 Dec 2023 · Laurinda Bower · Nottingham City and Nottinghamshire
Identical hazardConfidence 0.90 · higha different coroner“There is a lack of local and national system of in-cell ligature point risk assessments, and no ligature point maps available to staff.”
Original on judiciary.uk ↗ His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗
“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”
Web search (Tavily): No evidence found either way
Performance Tracker 2026: Prisons and probation | Institute for Government ↗ - All reports to His Majesty's Prison and Probation Service
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.
2022 → 2023Wyndham Thomas1 year 5 months after Ezra Tamiem · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the risk of self‑inflicted death by ligature due to the absence of safer cells with ligature points removed. They each note that prisoners at risk are placed in ordinary cells without adequate assessment or mapping of ligature hazards.
Ezra Tamiem · 19 Jul 2022
“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”
Original on judiciary.uk ↗ Wyndham Thomas · 21 Dec 2023
“There is a lack of local and national system of in-cell ligature point risk assessments, and no ligature point maps available to staff.”
Original on judiciary.uk ↗
No published response from His Majesty's Prison and Probation Service was found for this report.
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”
What happened next: No evidence found either way
The promised approach to managing risk for vulnerable prisoners is described in policy documents, but no source confirms it was implemented or provides evidence of its execution.
“Working to make government more effective”
“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”
“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.”
No evidence found does not mean the action did not happen.
- 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 His Majesty's Prison and Probation Service 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 |
|---|---|---|---|---|
| 2022 → 2023 | 0.74 | 0.30 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for His Majesty's Prison and Probation Service
- Obscured observation panels hinder monitoring3 reports · 2024–2026
- Lack of basic first aid training and CPR among prison officers12 reports · 2015–2026
- Inadequate ACCT training leading to incomplete documentation16 reports · 2014–2026
- Lack of certified safer cells outside segregation unit4 reports · 2023–2025
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.