Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0054, written 4 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Feb 2026 |
|---|---|
| Reference | 2026-0054 |
| Deceased | Ryan Harding Prevention of future deaths report |
| Coroner | David Regan |
| Coroner area | South Wales Central |
| Category | Alcohol, drug and medication related deaths · Wales prevention of future deaths reports (2019 onwards) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
GRAEME HUGHES HIS MAJESTY’S SENIOR CORONER SOUTH WALES CENTRAL CORONER AREA ANNEX A CORONER’S OFFICE THE OLD COURTHOUSE COURTHOUSE STREET PONTYPRIDD CF37 1JW REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Governor of HM Prison Parc 1 2 3 CORONER I am David Regan, Assistant Coroner, for the Coroner’s area of South Wales Central. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST A Coronial investigation was commenced on 3rd February 2023 into the death of Ryan Harding. The Investigation concluded at the end of an inquest which I conducted with a jury on 19th – 28th January 2026. The conclusion of the jury was that Mr Harding’s death was drug related. The medical cause of death was 1(a) Sudden unexpected death in a Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 man with epilepsy (following head injury), and Hashimoto’s thyroiditis, who had ingested receptor agonists, . CIRCUMSTANCES OF THE DEATH These were recorded as:- “Ryan Harding died between 7th – 8th January 2023 in his cell overnight, as a result of consuming drugs.” . CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. While none of those matters directly caused the death of Ryan Harding, in my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (3) The inquest heard evidence that the windows of Alpha and Bravo blocks did in 2023 and continue to require upgrading in order to reduce the ability of illicit the prison. materials including drugs and mobile phones to enter (3) The gate house continues to require upgrading to enable enhanced security to be afforded to reduce the ability of illicit materials including drugs and mobile phones to enter the prison. (3) On the morning of 8th January 2023, the scheduled morning welfare check did not take place. The evidence of officers was that this was delayed for lack of a staff member and had been delayed on other occasions. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action. YOUR RESPONSE Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 4 5 6 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 3rd April 2026 . I, the Coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to Mr Harding’s family and to the following, who may find it useful or of interest: The Chief Executive of the Cwm Taf Morgannwg University Health Board; The Ministry of Justice. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 4 February 2026 SIGNED: David Regan Assistant Coroner 8 9 Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862 Coroner’s Office, The Old Courthouse, Courthouse Street, Pontypridd, CF37 1JW Phone/Ffôn (01443) 281100 Fax/Ffacs (01443) 485862
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
CLYDE&CO Clyde & Co LLP 2 New Bailey Square HM Assistant Coroner Mr D Regan Stanley Street South Wales Central Coroner’s Court M3 5GS The Old Courthouse Courthouse Street Pontypridd — Fs BY oma 0: www.clydeco.com Our Ref: Your Ref: Date: Pe | | enon’ Dear Sir Inquest touching the death of Ryan Harding We write in response to your Regulation 28 report to prevent future deaths dated 4 February 2026 addressed to The Governor of HMP &YOI Parc. Ongoing Concerns Identified: 1. The inquest heard evidence that the windows of Alpha and Bravo blocks did in 2023 and continue to require upgrading in order to reduce the ability of illicit materials including drugs and mobile phones to enter the prison. 2. The gate house continues to require upgrading to enable enhanced security to be afforded to reduce the ability of illicit materials including drugs and mobile phones to enter the prison. 3. On the morning of 8" January 2023, the scheduled morning welfare check did not take place. The evidence of officers was that this was delayed for lack of a staff member and had been delayed on other occasions. Response: 1. The inquest heard evidence that the windows of Alpha and Bravo blocks did in 2023 and continue to require upgrading in order to reduce the ability of illicit materials including drugs and mobile phones to enter the prison. His Majesty's Prisons & Probation Service (HMPPS) (“the Authority”) oversaw the construction of HMP & YOI Parc leading to the establishment becoming operational in 1997. Following sign-off and approval of the construction works, operational responsibility for HMP & YOI Parc was handed over by HMPPS to G4S Care & Justice Services (UK) Limited (G4S). The original installation cell windows were fully compliant with prison building standards applicable at the time. Any changes to the building's design must be approved and funded by the landlord, HMPPS. G4S is contracted solely to manage and maintain the current facility. At the time of the original construction, HMP & YOI Parc was made up of houseblocks Alpha, Bravo, Charlie and Delta, the ‘high risk’ areas and Young Persons Unit. 10574717 (Inquest touching the death of Ryan Harding (G4S Care & Justice Services (UK) Limited)) Clyde & Co LLP is a limited liability partnership registered in England and Wales under number OC326539 and is authorised and regulated by the Solicitors Regulation Authority under number 460690. A list of members is available for inspection at its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR. Clyde & Co LLP uses the word "partner" to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications. CLYDE&CO With the recent advent of developments in drone technology and other emerging technological advancements contributing to ingress of contraband, the Authority and HMP & YOI Parc identified a potential vulnerability relating to the design of the original installation windows. Regular meetings and dialogue took place, and continues to take place, with the Authority, including lengthy discussions about steps required to address these issues. As any window replacement works involve adaptions to the fabric of the building, HMPPS must approve and oversee any work undertaken. In mid-2024, agreement was reached to move forward with a programme of window replacement works to replace the designated windows as quickly as possible, whilst maintaining the integrity of the establishment, allowing HMP & YOI Parc to remain fully operational. The significant cost of the replacement works (each replacement window unit costing in excess of £3,500) is being shared by HMPPS and G4S. A timetable for the replacement programme has been agreed with the Authority. Practical issues dictate the speed at which window replacement works can be achieved. The windows, by their very nature and purpose, require specialist manufacture and there are a very limited number of HMPPS approved suppliers manufacturing the windows to the requisite specification. Such suppliers are in demand, not only in relation to manufacturing replacement windows for existing prisons across the nationwide prison estate, but also manufacturing windows for new establishments currently under construction. Works to install the replacement windows can only be undertaken by HMPPS approved contractors. All works must be completed under strict controls to maintain the security and safety of the establishment. Prior to any replacement works being undertaken, prisoners must be moved from a cell and relocated to another location. This can be challenging when the prison is operating at full capacity. It is not possible to undertake widescale replacement works in one go, because of logistical difficulties in safely relocating the individuals residing on the unit, and due to the nature of equipment that is required to undertake the works, for example to safely lift the windows. The location of some of the cells requiring replacement windows causes disruptions to internal fencing and other secure barriers, which requires operational and strategic planning and oversight. HMPPS and G4S are working together to deliver a programme of upgrading up to four windows each day, which is achievable from the contractors’ perspective and allows for the programme to continue without the loss of accommodation and significant disruption to the men in the care of HMP & YO! Parc. The presence of external contractors on a unit creates potential safety risks in terms of the presence of tools and materials required for the works. It also takes some time to replace a window unit, which needs time for the sealant and other materials used to dry, before the cell can be used by prisoners, otherwise the windows can just be kicked out or otherwise damaged by prisoners. The new windows are manufactured to the highest current specification. They are the latest design of sealed units available to HMPPS for use in prisons. The replacement programme has targeted first the most potentially vulnerable parts of the prison in terms of drone ingress. Replacement windows have been installed in all cells which face out to the north perimeter wall and this is now sealed. Replacement works are now focussed on internal windows facing into the prison. 2. The gate house continues to require upgrading to enable enhanced security to be afforded to reduce the ability of illicit materials including drugs and mobile phones to enter the prison. HMP & YOI Parc is designated a Category C prison, and as such, was not originally funded or risk assessed to provide full Enhanced Gate Security. Increased and changing security challenges, including those enabled by technological advancements and changes to the make-up and nature of contraband items, have led to agreement by HMPPS that the prison should now be funded and risk assessed for Enhanced Gate Security, and the Director has, since June 2024, prioritised addressing identified requirements in Enhanced Gate Security provision. HMP & YO! Parc currently lacks the physical space within the existing Gate House to facilitate the equipment required for the standard HMP Enhanced Gate Security model used in other establishments. G4S is engaging with HMPPS to plan expansion works to HMP & YOI Parc, with completion expected by 2029/30. The new Gate House is designed to accommodate Enhanced Gate Security for managing staff entry, and the 10574717 (Inquest touching the death of Ryan Harding (G4S Care & Justice Services (UK) Limited)) Clyde & Co LLP is a limited liability partnership registered in England and Wales under number 00326539 and is authorised and regulated by the Solicitors Regulation Authority under number 460690. A Sst of members is available for inspection at its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR. Clyde & Co LLP uses the word “partner” to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications. CLYDE&CO current Gate House will be refurbished to accommodate Enhanced Gate Security for managing domestic and professional/legal visitors. The conventional scanning equipment which is part of the traditional Enhanced Gate Security model will be installed within the new Gate House building once it is constructed. Pending construction of the new Gate House building, G4S identified a solution to the current logistical restriction by purchasing specialist technological equipment, similar to the latest equipment used in some airports. This equipment is now routinely used to screen staff, professional visitors and social visitors coming into the prison. HMP & YO! Parc was the first prison in the UK to deploy this technology, following a review of best practice across other sectors. G4S previously submitted a proposal to HMPPS for a temporary extension (modular building) to accommodate Enhanced Gate Security. Understandably, this was not seen as the best use of finances since the local team had introduced interim measures to support and enhance the searching of staff and visitors, albeit not to the same level of searching achievable with Enhanced Gate Security provision. Any changes to the design of the building must be approved and funded by HMPPS. Enhanced Gate Security is provided by a range of additional tools and measures which are already being used at HMP & YOI Parc. Bag scanners and handheld metal detectors are routinely used by staff to support improved searching when visitors and staff enter the prison. The Director has expanded the size of the Specialist Searching Team, significantly increasing the frequency and quality of searches, and there are now an average of approximately 1,700 staff entry and exit searches per month, which represents a significant increase compared with 2022. This compares favourably with the majority of establishments within the prison's comparative prison group. G4S has funded additional external dog patrols which have worked to significantly reduce the number of throwovers experienced at HMP & YOI Parc. Dog handlers are also deployed on site, providing support for staff and visitor searching to reduce the risk of substances being brought into the establishment. The number of illicit or prohibited items recovered from searches is considered healthy. Many items detected are innocently forgotten items (such as lighters or smart watches) rather than illegal substances, however, the detection rate demonstrates the effectiveness of the searching protocols. The prison is currently in communication with the Authority around submission of a business case seeking funding for additional staffing to support searching seven days a week during core hours (from the time the door opens until it is secured for night state), together with additional searching dogs to support this activity. During their visit in January 2026, HMIP inspectors were not able to identify any additional actions to prevent drug ingress that were not already being taken at the prison and this was reflected in a score of good progress. 3. On the morning of 8" January 2023, the scheduled morning welfare check did not take place. The evidence of officers was that this was delayed for lack of a staff member and had been delayed on other occasions. The procedure in place at HMP Parc in January 2023 relating to unlock procedures, and specifically conducting welfare checks during unlock, was as follows: “At unlock staff should physically check the presence of the occupants in every cell. You must have a positive response from the prisoners occupying the cell either through verbal communication or physical movement being observed. The purpose of the check is to confirm the well-being of the prisoner is not in any doubt and they are present where they should be. Officers are reminded of their responsibility to ensure the safety and well-being of prisoners at all times.” Welfare checks could, and can, safely be conducted by a single officer and there was and is no requirement for officers to conduct welfare checks in pairs. Any person seeking to become a Prisoner Custody Officer (PCO) at HMP & YOI Parc must undergo comprehensive training prior to commencing operational duties. New recruits undergo a nine week Prison Officer Initial Training Course, followed by a period of on-site learning, shadowing experienced officers, before they can commence operational duties. Since at least 2018, the unlock procedures outlined above have been taught to all PCOs undergoing the Initial Training Course. New recruits continue to receive this training with slight 10574717 (Inquest touching the death of Ryan Harding (G4S Care & Justice Services (UK) Limited)) Clyde & Co LLP is a limited liability partnership registered in England and Wales under number 0C326539 and is authorised and regulated by the Solicitors Regulation Authority under number 460690. A Sst of members is available for inspection at its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR. Clyde & Co LLP uses the word “partner” to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications. CLYDE&CO modification to reflect a change in the timing of the welfare checks. PCOs have also received refresher training, and written and verbal instructions, confirming the correct way to conduct unlock procedures and welfare checks. Following Mr Harding's death, written instructions on correct unlock procedures and reminders of the correct process to follow when conducting welfare checks were re-issued to staff. Reminders on the correct process were also given at safety meetings. In addition, enhanced managerial checks were introduced to ensure compliance with the instructions, including daily checks being done by the prison’s Senior Managers via CCTV footage. HMPPS national policy regarding performance of welfare checks is set out in Prison Service Instruction (PSI) 75/2011 Residential Services re-issued 24 April 2025, which states at paragraph 2.3 that there needs to be in place at the prison clearly understood systems for staff to assure themselves of the wellbeing of prisoners during or shortly after unlock. PSI 75/2011 specifically states, that where, for example, a prisoner is expected to leave their cell for an activity shortly after being unlocked, such as with a wing worker who is unlocked to commence their duties, then it will be sufficient for there to be a check on any prisoner who does not leave the cell as expected. Where prisoners are not necessarily expected to leave their cells, then staff need to check on their well-being, for example, by obtaining a response during the unlock process. The Management of Internal Security Procedures (Closed Prisons) Policy Framework (HMPPS Framework) was implemented by HMPPS on 10 January 2025 and reissued on 26 June 2025. Every prison must conduct at least four routine roll checks per day, although there is discretion for prisons to conduct a greater number, and at HMP & YOI Parc, there are six routine roll checks per day and one additional check on Fridays and at weekends. The HMPPS Framework introduces a requirement to conduct ‘enhanced’ roll checks. Prior to this, roll checks were undertaken to ensure that all prisoners were present and where they were supposed to be. There was no requirement to obtain a verbal or physical response from every prisoner and no need to wake prisoners, if they appeared to be asleep, and there did not appear to be any well-being concerns. The Framework now requires staff when undertaking a roll check to assure themselves that prisoners are (1) present in their cells and (2) that they appear alive and well by obtaining a clear view of the prisoner's face, and, if necessary, by waking them up. Following the introduction of the HMPPS framework, the HMP & YO! Parc Senior Leadership Team carefully considered measures to ensure the correct performance of enhanced roll checks and welfare checks during morning unlock resulting in a decision to align the local policy at HMP & YO! Parc with national policy set out in PSI 75/2011 and the HMPPS Framework. The Prison Officer Initial Training Course has been updated to include specific instruction on the correct performance of contact with prisoners during unlock including: At EVERY unlock staff should physically check the presence of the occupants in every cell. You must have a positive response from the prisoners occupying the cell, either through verbal communication or physical movement being observed. The purpose of this check is to confirm the wellbeing of the prisoner is not in any doubt and they are present where they should be. You are reminded of your responsibility to ensure the safety and wellbeing of prisoners at all times. A Notice To Colleagues (NTC) entitled “Changes to Welfare Checks on Residential Units” has been issued to all officers to communicate updated procedures. This instructs staff that the physical welfare check has been incorporated into the morning unlock procedure to safeguard prisoners and staff by ensuring that any health concerns not detected at roll count are addressed at unlock. A physical welfare check is required at the time of morning unlock. All prisoners’ doors are unlocked at medication time and officers will conduct a welfare check. There are no set times for completion of the welfare checks because different units within the prison unlock cells at slightly different times compared to other units. 10574717 (Inquest touching the death of Ryan Harding (G4S Care & Justice Services (UK) Limited)) Clyde & Co LLP is a limited liability partnership registered in England and Wales under number 0C326539 and is authorised and regulated by the Solicitors Regulation Authority under number 460690. A Sst of members is available for inspection at its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR. Clyde & Co LLP uses the word “partner” to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications. CLYDE&CO Officers are required to record the welfare checks in the unit ledger each day to acknowledge that all prisoners have been checked on and that they are not concerned for the prisoners’ welfare. The Residential Wing Ledger has been amended to include the following wording: OFFICIAL Physical welfare check at AM unlock. All prisoners’ doors will be unlocked at medication time to conduct a welfare check. Those who need to attend for medication or work will be let out, those who are not required to attend medication or work will have their doors secured after the welfare check is completed. You will then record your welfare checks in the unit ledger to acknowledge that all prisoners have been checked on and that there are no concerns for their welfare. These checks are to be completed AM daily, including weekends on all units. Physical welfare checks must elicit a verbal or physical response to confirm all prisoners are well. Physical Welfare Check of All Prisoners Completed while Unlocking for AM Medication Sign Landing 1 Landing 2 Landing 3 Landing 4 Time Completed Physical welfare checks are completed daily in the morning on all units including at weekends. Officers working in high risk areas (the Safer Custody Unit (SCU) and the Phoenix Unit (CSU)) also complete an afternoon welfare check for all prisoners on those units and the Residential Wing Ledger for these units includes requirement to sign to confirm afternoon welfare checks have been completed. Quality assurance processes have been enhanced to ensure compliance. The Duty Directors Ledger completed daily by the Duty Director links to a compliance check/spread sheet to be completed daily by a Senior Manager or Functional Head who undertakes compliance checks each day for one unit within the prison on a random rotational basis to ensure welfare checks are being performed correctly. The compliance checks are informed by reviewing CCTV footage. The information is collated on the check/spread sheet. The Senior Manager informs the manager of the relevant unit of any compliance issues and the unit manager is required to speak to any staff identified to reinforce the correct process. Any issues of concern are discussed at the Senior Leadership Team morning meetings which take place daily and are linked to a database managed and overseen by the Safety Team at HMP & YOI Parc. The following information is collated during the daily quality assurance checks: Date [wing ‘Duty Victor 23 Completing Check issues noted |Comments (Please also comment on any [Olticers name (only to be [Debriet sheet (only to be [Name of OM and SOM advised of any a positive practice seen) ‘completed where issues are completed where Issues | concerns recorded. 2 oxoazo26 [ar | = I 4 [pamaze2s [ex ~ I 5 [pamanozs le a I 10574717 (Inquest touching the death of Ryan Harding (G4S Care & Justice Services (UK) Limited)) Clyde & Co LLP is a limited liability partnership registered in England and Wales under number 0C326539 and is authorised and regulated by the Solicitors Regulation Authority under number 460690. A list of members is available for inspection at Its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR. Clyde & Co LLP uses the word “partner” to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications. CLYDE&CO A form is embedded within the database for completion where issues are noted and for use in order to debrief relevant staff members. Each month a multidisciplinary Safety Meeting takes place at HMP & YO! Parc at which a Safety Team Senior Manager will discuss the welfare checks completed the preceding month in relation to completed quality assurance and areas where issues have been raised. This will allow in-depth discussion, understanding of any issues and identification of trends and individuals requiring further support and/or performance management. Senior Managers have been reminded by the Deputy Director of the requirement to conduct daily compliance checks. We trust this information is of assistance and provides reassurance to the extent that HMP & YOI Parc is able to take action. Yours faithfully 10574717 (Inquest touching the death of Ryan Harding (G4S Care & Justice Services (UK) Limited)) Clyde & Co LLP is a limited liability partnership registered in England and Wales under number OC326539 and is authorised and regulated by the Solicitors Regulation Authority under number 460690. A list of members is available for inspection at Its registered office The St Botolph Building, 138 Houndsditch, London EC3A 7AR. Clyde & Co LLP uses the word “partner” to refer to a member of the LLP, or an employee or consultant with equivalent standing and qualifications.
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