Johnpaul Digweed
29 Jun 2026 · Coroner Christopher Long · Lancashire and Blackburn with Darwen
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. lack of ACCT opening for self-harm incidents
“despite several staff being aware of incidents of self-harm involving a prisoner at HMP Garth an Assessment, Care in Custody Teamwork process (ACCT) was not opened”
2. obscured observation panels
“regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“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.”
This report
“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.”