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recurance

Douglas Birch

13 Jul 2015 · Coroner Patricia Harding · Mid Kent and Medway

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. failure to elicit response from prisoner upon unlocking cell

    “Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response from the prisoner upon unlocking a cell or were aware but did not act in accordance with the order especially where they assumed the prisoner was asleep”
  2. 2. non-receipt or non-reading of Prison Service Orders and Instructions

    “Prison officers were either not receiving Prison Service Orders and Instructions or if they did receive them, did not read them”

Linked reports

Raised again laterSean Davies8 Aug 2024 · 9 years 1 month later
Closely relatedConfidence 0.92 · high

This report

“Prison officers were either not aware of PSI 75/2011 requiring that officers should elicit a response from the prisoner upon unlocking a cell or were aware but did not act in accordance with the order especially where they assumed the prisoner was asleep”

Later report

“It was clear from CCTV evidence that prison officers and operational support group officers were not conducting roll call welfare checks and other welfare checks in line with national guidance or local policies”
Original on judiciary.uk ↗
Full chain: Welfare checks missed and undocumented

Responses

2015-0274-Response-by-NOMS.pdf ↗· HMP Swaleside

Stated action · 10 August 2015

“issued at HMP Swaleside on 10 August 2015. It sets out the local procedure for ensuring compliance with the mandatory requirement in PSI 75/2011 to which you refer, and requires staff and a supervising officer to sign to confirm that the welfare checks have taken place on each occasion.”
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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