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recurance

Obscured observation panels hinder monitoring

Identical hazardConfidence 0.90 · high3 reports · 2024–2026 One-page brief (print or PDF)

His Majesty's Prison and Probation Service received 3 coroners' reports about this hazard between 14 Oct 2024 and 29 Jun 2026.

They came from 3 different coroners in 3 coroner areas. 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 1 specific action.

3
reports
3
different coroners
2024–2026
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Stephen Sleaford↗

    14 Oct 2024 · I M Cartwright · Leicester City and South Leicestershire

    “The evidence revealed that despite clear instruction to officers, by way of Notices to Staff from senior management at the prison, to the effect that obscuring cell door observation panels on the inside by prisoners was not permitted practice and was to be challenged and remedied, routine practice by prison officers meant observation panels were permitted to be obscured, without challenge or sanction.”
    Original on judiciary.uk ↗

    His Majesty's Prison and Probation Service responded, stating 1 specific action.Response (PDF) ↗

    “attention. The HMPPS First Aid Policy Framework was re-issued nationally in August 2023. The revised policy highlights the training requirements for Emergency First Aid and First Aid in prisons, including the importance of Governors ensuring that there is an appropriate number of trained staff on duty at all times. To achieve this, a detailed local first aid risk assessment must be produced to determine the number of First Aiders at Work (FAW) and Emergency First Aiders at work (EFAW) required at an”

    Stated timescale: August 2023

    Web search (Tavily): No evidence found either way

    Workplace First Aid 2026: Are You Compliant? | Garland Training ↗
  2. 1 year 5 months later

    Raised again · 1st time

    Ronald Meikle↗

    24 Mar 2026 · Sean Cummings · Milton Keynes

    Identical hazardConfidence 0.90 · higha different coroner
    “blocked observation panels were not consistently challenged or cleared, and that visual welfare checks were therefore not always effective”
    Original on judiciary.uk ↗

    Repeated from the earlier report:observationpanelschallenged

    His Majesty's Prison and Probation Service responded.Response (PDF) ↗Response (PDF) ↗

  3. 3 months later

    Raised again · 2nd time

    Johnpaul Digweed↗

    29 Jun 2026 · Christopher Long · Lancashire and Blackburn with Darwen

    Identical hazardConfidence 0.90 · higha different coroner
    “Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:Evidencepracticeprisoner'sobservationpanelscell

    His Majesty's Prison and Probation Service responded.Response (PDF) ↗

  4. All reports to His Majesty's Prison and Probation Service

Next

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.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error