A coroner has demanded action after the death of a vulnerable prisoner in HMP Preston.
Christopher Talbot, 65, suffocated himself in December 2014 after untrained reception staff failed to record details he was at risk of suicide.
Nicholas Rheinberg, assistant coroner for Preston and West Lancashire, was told in an inquest that a prison officer who saw Mr Talbot lying on his back in his cell with a plastic bag had failed to ask for immediate assistance, and did not keep him under constant observation.
A similar death had also happened at the jail, which not all staff knew.
Following a probe by the Prisons and Probation Service Ombudsman the Governor implemented a recommendation that night staff with concerns about a prisoner at risk of suicide or self-harm, should request immediate assistance and keep the prisoner under observation until help arrives.
In a report to the Prisons Minister and Mr Rheinberg requested the recommendation should be rolled out nationally and said: “In my opinion there is a risk that future deaths will occur unless action is taken.”
The Home Office has been contacted for a response.