Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier 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.”
judiciary.uk/…/stephen-sleaford-prevention-of-future-deaths-rep…
What was promised
Stated action 1 · response to Stephen Sleaford (14 Oct 2024) · stated timescale: August 2023
“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”
judiciary.uk/…/2024-0550-Response-from-HMPPS-received-by-CCO-24…
What recurred
- 24 Mar 2026 · Ronald Meikle · Sean Cummings · Identical hazard · confidence 0.90 (high)
- 29 Jun 2026 · Johnpaul Digweed · Christopher Long · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Stephen Sleaford · 14 Oct 2024
“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.”
Later · Johnpaul Digweed · 29 Jun 2026
“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.”
What happened next
No evidence found either way · stated action 1
“The new BS 8599-1:2019+A1:2026 workplace first aid kits standard came into force on 30 April 2026”
Workplace First Aid 2026: Are You Compliant? | Garland Training · chrisgarlandtraining.co.uk/hse-first-aid-requirements-2026-uk
“Workplace first aid is evolving-and employers need to be ready”
Workplace First Aid Has Changed. Are You Ready? · safetyequipment.org/…/workplace-first-aid-has-changed-are-you-r…
No evidence found does not mean the action did not happen.