Lack of certified safer cells outside segregation unit
His Majesty's Prison and Probation Service received 4 coroners' reports about this hazard between 14 May 2023 and 10 Dec 2025.
They came from 4 different coroners in 4 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 3 of the 3 earlier reports, stating 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“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.”
Original on judiciary.uk ↗ His Majesty's Prison and Probation Service responded, stating 5 specific actions.Response (PDF) ↗
“HMP Winchester is currently delivering monthly training and awareness sessions for all staff which incorporates both ACCT v6 and SASH training.”
Stated timescale: end of 2023
Web search (Tavily): No evidence found either way
Prison Safety Policy Framework ↗“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.”
Web search (Tavily): No evidence found either way
Glossary of terms – HM Inspectorate of Prisons ↗3 more stated actions in the Promises tab.
- 7 months later
Raised again · 1st time
Wyndham Thomas↗
21 Dec 2023 · Laurinda Bower · Nottingham City and Nottinghamshire
“There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points).”
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 ↗ - 1 year 11 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“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.”
Original on judiciary.uk ↗ Repeated from the earlier report:cellligaturepointsPrison
His Majesty's Prison and Probation Service responded.Response (PDF) ↗
- 0 months laterClosely relatedConfidence 0.90 · higha different coroner
“I am concerned that as long as”
Original on judiciary.uk ↗ His Majesty's Prison and Probation Service responded.Response (PDF) ↗
- 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.
2023 → 2025Stuart Berry1 year 11 months after Wyndham Thomas · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight failures to mitigate ligature points in prison cells to prevent self‑harm by hanging. The earlier report calls for mandatory safer cells with reduced ligature points, while the later report stresses the need to assess and fund structural fixes for obvious ligature points such as window bars.
Wyndham Thomas · 21 Dec 2023
“There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points).”
Original on judiciary.uk ↗ Stuart Berry · 1 Dec 2025
“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.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“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”
2023 → 2025Mesut Olgun2 years 7 months after Thomas Huntley · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight the insufficient availability of safer/ligature‑resistant cells for prisoners at risk of self‑harm. The earlier report notes a general lack of certified safer cells at HMP Winchester, while the later report points out that the existing safer cells at HMP Hewell are confined to the segregation unit.
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.”
Original on judiciary.uk ↗ Mesut Olgun · 10 Dec 2025
“I am concerned that as long as”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“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.”
2023 → 2025Mesut Olgun2 years after Wyndham Thomas · different coronerClosely relatedConfidence 0.86 · high
Closely relatedConfidence 0.86 · highBoth reports highlight that prisoners at risk of self‑harm do not have adequate access to safer cells designed to reduce ligature points. The earlier report notes a nationwide lack of mandatory safer cells, while the later report observes that existing safer cells are confined to the segregation unit.
Wyndham Thomas · 21 Dec 2023
“There is no mandatory requirement for a HMP Prison to have access to a Safer Cell (one with reduced ligature points).”
Original on judiciary.uk ↗ Mesut Olgun · 10 Dec 2025
“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.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“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”
Stated action · 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.”
What happened next: No evidence found either way
No source confirms that monthly training sessions incorporating ACCT v6 and SASH were delivered by end of 2023.
“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)”
No evidence found does not mean the action did not happen.
Stated action
“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.”
What happened next: No evidence found either way
The promised description of the Safety Intervention Meeting (SIM) as a multi-disciplinary safety risk management meeting chaired by the Senior Management Team is not explicitly confirmed or denied in the provided sources.
“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)”
“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”
“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”
No evidence found does not mean the action did not happen.
Stated action
“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.”
What happened next: No evidence found either way
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.
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.”
What happened next: No evidence found either way
The promised review of quality assurance checks at HMP Winchester is not mentioned in any of the provided sources.
“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.”
“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”
“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.”
No evidence found does not mean the action did not happen.
Stated action · timescale: too early to say
“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.”
What happened next: No evidence found either way
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.
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.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- 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 |
|---|---|---|---|---|
| 2023 → 2025 | 0.79 | 0.29 | Closely related · 0.80 | different |
| 2023 → 2025 | 0.80 | 0.35 | Closely related · 0.90 | different |
| 2023 → 2025 | 0.84 | 0.36 | Closely related · 0.86 | 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
- Widespread new psychoactive substances in prison5 reports · 2016–2025
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.