Prison: Deaths, Assaults and Self-Harm – and the facts no amount of spin can conceal

 

By Mark Leech

 

 

Look, I get it.

When your back is against the wall and you’re up against it, when every single piece of evidence shows no matter what you do it stubbornly isn’t working, there is a real temptation to find virtue in anything.

But there is no virtue to be found in the latest safety in custody quarterly statistics, where every single one of the key indicators show a continuing annual rise in deaths, violence and self-harm.

Just look at the plain, stripped-of-spin, painful facts.

  • In the 12 months to March 2019, that’s just four weeks ago by the way, there were 317 deaths in prison custody, up 18 from the previous year – of these, 87 deaths were self-inflicted, up 14 from the previous year.
  • Self-harm incidents rose to 55,598 in 2018, a new record high.
  • Incidents requiring hospital attendance rose to a record high of 3,214 in 2018 and the number of self-harm incidents requiring hospital attendance increased by 5% on the previous year to 3,214.
  • Assault incidents increased to 34,223, a record high level in 2018.
  • Annual assault incidents reached a record high of 34,223 incidents in 2018, a 16% increase from 2017.
  • Assaults in the October to December 2018 quarter show a 5% increase on the same quarter of the previous year.
  • The proportion of assaults on staff continue to rise. The proportion of assaults on staff increased to 30% of all incidents in 2018, an increase from 29% in 2017, and a steady increase from 20% between 2008 and 2011.
  • The proportion of assaults on staff (38%) in female establishments in 2018 was higher than in male establishments (29%).
  • In the 12 months to December 2018, there were 3,918 serious assault incidents, up 2% from the previous year.
  • While serious prisoner-on-prisoner assaults decreased by just 1% since the previous year, serious assaults on staff rocketed by 15% (to 995) in the same period.

Now you tell me what has anyone who can read, talk and walk upright, got to applaud here?

When every single indicator across the quarter is at a higher figure than 12 months ago – often reaching yet more ‘new record highs’ – I find nothing to applaud at all.

But Prisons Minister Rory Stewart did.

Indeed despite the reality that every single annual indicator on deaths, assaults and self-harm showed increases, Rory made a video.

In it he managed to keep a straight face while celebrating the fact that, as he saw it, we have turned a corner, there is now light at the end of the tunnel, the signs of success are there he said, and we should all take comfort from the fact that he has it all under control.

No he doesn’t.

It’s one thing to mistake a swallow for the arrival of Summer, but it’s insane to look at these figures and say a single grain of sand means we’ve all arrived on a beach in Ibiza and it’s now Party Time.

No its not.

You can’t look at one quarter’s figures in this custodial world and make presumptions or try and extrapolate it into the future – especially when every single key annual indicator is still on the rise.

This is not a world where exact science works at all.

The prison population is constantly changing,  it’s fluid, it’s a world where there are people with mental illnesses, addictions, learning difficulties, impulsive behaviour issues, gang allegiances, where skilful manipulators and sophisticated fraudsters are at work.

It’s a place where there isn’t and never has been a one size fits all solution to anything.

It’s a world where when you think you’ve got something cracked the whole thing goes tits up proving you haven’t cracked it at all .

Exactly 25 years ago six Exceptional Risk Category A prisoners escaped from the ‘impregnable prison within a prison’ Special Secure Unit at Whitemoor prison, having managed to acquire a gun and ammunition they shot one prison officer and made it out of the unit over two walls and through a fence to short-lived freedom on the other side – the later Woodcock report revealed they’d also managed to smuggle into the SSU one pound of Semtex high explosive.

What seems calm and controlled one minute can blow up in your face the next – and then drop back down again as if nothing has happened just minutes later.

It’s a world where people aren’t afraid of consequences, being sent to prison doesn’t bother them – they’re already there – and they’ve largely spent a lifetime sticking two fingers up to authority and saying ‘fuck you’ whatever may then befall them.

You can take nothing for granted in this custodial world – and certainly not the fragile seeds of hope that even on the best view these figures do not represent.

I know,  I spent 14 years in prison,  during a prison career of riots and roof-top protests, segregation, ghost trains, and 62 different prisons until one day I arrived at Grendon Underwood where the healing process started, where for once I was treated with decency and respect and where my head was taken off and screwed back on the right way round and I haven’t looked back.

But in 61 other prisons it was ‘them and us’ – and consequences were irrelevant; which is why telling the public that the Government has doubled the sentence for assaults on prison officers may appear like progress, but in the real world of prison it’s utterly meaningless – neither prevention nor cure work here, only reasoning succeeds in the end.

I don’t doubt at all that Rory Stewart and David Gauke have the best of intentions but they are political animals, they have a concave view of the world in which they tell lies for a living – no disrespect, it’s just what politicians do – they call it putting a spin on things but to many people it’s just lying.

Yes, the 10 Prisons Project has had some success, I don’t deny that, it was inevitable and it would be strange if the investment in those prisons didn’t see cleaner wings, brighter landings, fresher environments and progress – but there are another 108 prisons where that simply isn’t the case; in fact there are another 108 prisons where things are going from bad to worse and no amount of spin or fresh paint can conceal it.

Don’t take my word for it, just go to the IMB web site and just read the latest annual reports just published.

IMB at HMP Durham: ….The prison has seen large increases in the use of force, assaults, death in custody and illegal use of drugs

IMB at HMP Haverigg …. widespread use of Psychoactive Substances (PS), not only with respect to those addicted to its use but on the general prison population, staff and also on the overall regime.

IMB at HMP Channings Wood …. decline in both the safety and well-being of the prisoners and in the physical condition of their surroundings with a significant increase in the use of the drug Spice and a serious deterioration in the state of the men’s living blocks.

IMB at HMP Hewell say the prison isn’t even fit for the 21st Century – 20 years after we entered it, widespread use of illicit drugs and mobile phones….

And so it goes on.

A splash of spin and a coat of paint can’t conceal reality – Queen Victoria thought the world smelt of fresh paint because, wherever she went, ten feet in front of her was a man with a paint brush; but had she turned the corner, had she gone off-tour, she would have collided with a reality where filth, stench and danger were obvious to anyone who cared to look.

Well, I care to look.

I want to be optimistic, I want to see progress, but equally I refuse to be deceived and distracted by political spin from the reality of a prison world that is, on the statistical facts, one where in terms of violence, death and self-harm it is getting worse not better.

When we’ve had 12 months not 12 weeks (and we haven’t had a single week across all four key indicators yet let’s not forget) of falling figures on deaths, self-harm and assaults in our prisons, when anecdotal evidence matches the figures and confirms that control has been regained and retained then – and not until then – we can say that progress has genuinely been made; rather than just a second-rate video that frankly was as risible to watch as it was as laughable to listen to.

Mark Leech FRSA is the Editor of The Prisons Handbook for England and Wales. @prisonsorguk

Prison Safety Crisis Continues – latest deaths, assaults and self harm figures show increases in all four key areas

Safety in Custody Statistics: Deaths in Prison Custody to March 2019, Assaults and Self-harm to December 2018

New figures released this morning show that once again the levels of violence and self-harm in our prisons are unacceptably high – and show no sign of reducing.

The latest figures show increases across all of the key categories.

Number of deaths have increased compared to the previous 12 month period. In the 12 months to March 2019, there were 317 deaths in prison custody, up 18 from the previous year. Of these, 87 deaths were self-inflicted, up 14 from the previous year.

Self-harm incidents rose to 55,598 in 2018, a new record high, but decreased in the latest quarter. Self-harm incidents reached a record high of 55,598 incidents in 2018, a 25% increase from 2017. The number of incidents between October and December decreased by 7% to 14,313 since the previous quarter.  

Incidents requiring hospital attendance rose to a record high of 3,214 in 2018, although the proportion of incidents requiring hospital attendance has decreased. The number of self-harm incidents requiring hospital attendance increased by 5% on the previous year to 3,214 while the proportion of incidents that required hospital attendance decreased by 1.1 percentage point to 5.8%.

Assault incidents increased to 34,223, a record high level in 2018, but decreased in the latest quarter. Annual assault incidents reached a record high of 34,223 incidents in 2018, a 16% increase from 2017. Assaults in the October to December 2018 quarter decreased to 8,150, a decrease of 11% from the previous quarter, but a 5% increase on the same quarter of the previous year.

The proportion of assaults on staff continue to rise. The proportion of assaults on staff increased to 30% of all incidents in 2018, an increase from 29% in 2017, and a steady increase from 20% between 2008 and 2011. The proportion of assaults on staff (38%) in female establishments in 2018 was higher than in male establishments (29%).

Of the 34,223 assault incidents in 2018, 3,918 (11%) were serious. In the 12 months to December 2018, there were 3,918 serious assault incidents, up 2% from the previous year. Serious prisoner-on-prisoner assaults decreased by 1% since the previous year (to 2,987), and serious assaults on staff increased by 15% (to 995) in the same period. Serious assaults (by 4%), serious prisoner-on-prisoner assaults (by 5%), and serious assaults on staff decreased in the last quarter (by 4%).

Mark Leech, Editor of The Prisons Handbook said the latest prison safety figures show ‘a worrying increase yet again’

Mr Leech said: “These are truly shocking figures yet again, the resignation of the Prisons Minister who promised to go unless he reduced these numbers now seems certain.”

View the LATEST Quarterly Bulletin

Diabetic prisoner died after ‘truly shocking’ treatment report says


A diabetic prisoner who died after being restrained and left on a cell floor in isolation for 21 hours was subjected to “truly shocking” treatment, a report has found.

Staff at the privately-run HMP Peterborough believed Annabella Landsberg was “play-acting” and that they spent “far too long” before carrying out proper examinations despite her being critically ill, the Prisons and Probation Ombudsman said.

An inquest jury on Thursday also found there were “failings” by the Sodexo-operated prison in Cambridgeshire, as well as by custody officers, healthcare staff and doctors.

The mother-of-three, who was 45 and lived in Worthing, West Sussex, was restrained by prison staff on September 2 2017 and left without examination by healthcare staff for 21 hours.

When she was finally examined the following day, she was found to be “extremely ill” and sent to hospital where she died on September 6, the report found.

“The events leading up to Ms Landsberg’s death are truly shocking,” it said.

“Both discipline and nursing staff assumed initially that Ms Landsberg was play-acting and it took them far too long to seek managerial intervention and to carry out appropriate clinical examinations.”

The inquest in Huntingdon heard that duty nurse Lesley Watts said Ms Landsberg was “wasting staff’s time” and was “clearly faking medical issues”.

She was suffering from multiple organ failure when she was taken to hospital as a result of her diabetes.

After the hearing, sister Sandra Landsberg said: “It was very distressing to learn that my sister was left on her cell floor for so long when she was so unwell, repeatedly considered to be ‘faking it’.

“My sister will not come back, but no other family should have to go through this. Prisoners should be properly supported and looked after.”

Deborah Coles, the director of the Inquest charity, which represented the Landsbergs, said she “suffered dehumanising, ill treatment”.

“Annabella was a black woman with multiple vulnerabilities,” she said.

“That she came to die a preventable death in such appalling circumstances is shameful.

“Distress of black women in prison is too often disbelieved and viewed as a discipline and control problem.”

Damian Evans, director at HMP Peterborough, said: “It is clear that the care Annabella Landsberg received whilst she was at HMP Peterborough fell short of the standard we expect and we are very sorry for this.

“Our thoughts continue to be with Annabella’s family and friends.

“Since Annabella’s death we have undertaken a thorough review of the delivery of healthcare services at HMP Peterborough and accepted all the recommendations from the initial Prison and Probation Ombudsman’s report into her death.

“This has led to many changes and improvements being made.

“We will consider the jury’s extensive findings and conclusions with great care and continue to make improvements.”

Read the Report

“MASS INTOXIFICATION” At Cumbria Prison – As Prisons Minister Rory Stewart Does A Photo Call At Bristol Prison 250 Miles Away

In their latest annual report published today 1st March 2019 the IMB at HMP Haverigg, Cumbria’s only prison says there is continuing concern about the impact of widespread use of Psychoactive Substances (PS) not only on those addicted to its use but on the general prison population, staff and but also on the overall regime.

The report is published on the day that the Prisons’s MP – and Prisons Minister – Rory Stewart – spends the day 250 miles away at Bristol Prison.

Death risk from Psychotic Drugs

 It is disturbing to note in two reports from the Prisons and Probation Ombudsman, that PS may have been a contributory factor in two deaths in custody which occurred during the year within weeks of each other. Near fatalities in the latter half of the year have only been prevented by the swift and effective action of officers and healthcare staff.

Increased surveillance systems initially disrupted the supply chain of illicit drugs into the prison, but access to PS resumed, despite the best efforts of the management.

IMB Chair Lynne Chambers explains

“The Board has observed on a weekly and sometimes daily basis, the effects of the use of illicit substances, and on one day in November, when seventeen prisoners were found to be under the influence of PS in a ‘mass intoxication’

The impact on the populations of South and West Cumbria of the concentration of Northwest Ambulances at the prison throughout that day is likely to have been significant”.

Emotional challenges

The geographical isolation of HMP Haverigg, the limitations of public transport and an underdeveloped road network present both practical and emotional challenges to prisoners and their families in maintaining links. However, the Board commends the innovative work of the “Visitors and Children’s Support Group” in hosting a range of events for Families, Lifer/Long term prisoners, Enhanced prisoners, and the Kainos “Challenge to Change” programme.

Although tackling the use of PS and other illicit substances, has, necessarily, been of high priority throughout the reporting year, the Board has, nonetheless, observed the good progress and positive impact of the Rehabilitative Culture initiative on the prison population.

Mark Leech, Editor of The Prisons Handbook for England and Wales, said it was a “shocking report”.

Mr Leech said: “Rory Stewart, who is not only a Cumbrian Member of Parliament but also Prisons Minister, should not be all smiles and shaking hands 250 miles away outside Bristol Prison – but right outside Haverigg main gate answering questions as to what on earth he is going to do to correct the defects identified in this shocking report.

“It seems Rory Stewart couldn’t care less”

Key Report Findings  

Are prisoners treated fairly?  

The effectiveness of the Rehabilitative Culture and Restorative Justice initiatives have had a significant impact on the outcome of adjudications with the IMB receiving just two applications from prisoners arising from this process. The Independent Monitoring Board is of the view that prisoners are treated fairly.

Are prisoners treated humanely?

The Board is of the opinion that the prison continues to have an emphasis on humane treatment and has regularly observed sensitive and respectful interaction between staff and prisoners. However, there have been occasions when some prisoners have had to endure unacceptable and adverse living conditions.,

Are prisoners prepared well for their release?

The Board has received a large number of applications from prisoners relating to sentence management and of these a third concerned preparations for release including accommodation, approved premises, bank accounts, support services and medication, for example. The Board is concerned that lack of preparation and resources to support prisoners in the community after release may increase the risk of re-offending.

For further information contact: the Independent Monitoring Board at HMP Haverigg:

Notes

The Independent Monitoring Board is a body of volunteers established in accordance with the Prison Act 1952 and the Asylum Act 1999 which require every prison and IRC [Immigration Removal/Reception Centre] to be monitored by an independent Board, appointed by the Secretary of State for Justice, from members of the community.

To carry out these duties effectively IMB members have right of access to every prisoner, all parts of the prison and also to the prison’s records.

HMP Haverigg opened over 50 years ago, is on an old military airfield site dating from World War II and some of the original wartime buildings, are still in use.

Most of the prisoners are serving sentences of four or more years, although a significant number are serving a life sentence and a small number are of foreign nationality.

Read The Report

HMP Durham: Must Address Violence, Drugs and Deaths says Inspectors

HMP Durham, a heavily overcrowded prison, was found by inspectors to have significant problems with drugs and violence and worryingly high levels of self-harm and self-inflicted and drug-related deaths.

Durham became a reception prison in 2017. Around 70% of the 900 men in the jail were either on remand or subject to recall and over 70% had been in Durham for less than three months. On average, 118 new prisoners arrived each week. Significant numbers of prisoners said they arrived at the jail feeling depressed or suicidal. Self-harm was very high.

Peter Clarke, HM Chief Inspector of Prisons, said: “Our overriding concern was around the lack of safety. Since the last inspection in October 2016, there had been seven self-inflicted deaths, and it was disappointing to see that the response to recommendations from the Prisons and Probation Ombudsman (which investigates deaths) had not been addressed with sufficient vigour or urgency.

“There had also been a further five deaths in the space of eight months where it was suspected that illicit drugs might have played a role.” Drugs were readily available in the jail and nearly two-thirds of prisoners said it was easy to get drugs; 30% said they had acquired a drug habit since coming into the prison. “These were very high figures”, Mr Clarke said, though the prison had developed a strategy to address the drugs problem.

The leadership, Mr Clarke added, was “immensely frustrated by the fact that they had no modern technology available to them to help them in their efforts to stem the flow of drugs into the prison. We were told that they had been promised some modern scanning equipment but that it had been diverted to another prison.” The scale of the drugs problem and related violence meant that technological support was urgently needed.

Since the last inspection at Durham in 2016, violence had doubled and the use of force by staff had increased threefold, though some of the increase in force may have been due to new staff who were not yet confident in using de-escalation techniques. Governance of the use of force had improved.

Mr Clarke added: “There were some very early signs that the level of violence was beginning to decline, but it was too early to be demonstrable as a sustainable trend.”

Alongside these concerns, inspectors noted “many positive things happening at the prison.” These included the introduction of in-cell phones and electronic kiosks on the wings for prisoners to make applications, which had “undoubtedly been beneficial”. The disruption caused by prisoners needing to be taken to court had been reduced by the extensive use of video links.

A new and more predictable daily regime had recently been introduced, increasing access for men to amenities such as showers and laundry on the wings. “For a prison of this type, the time out of cell enjoyed by prisoners was reasonable and it was quite apparent that, despite its age, the prison was basically clean and decent,” Mr Clarke said. It was also good that the leadership saw new staff as an opportunity to make improvements, not an inexperienced liability.

Overall, Mr Clarke said:

“There was no doubt that there was an extent to which HMP Durham was still going through the process of defining, refining and responding to its role as a reception prison. The very large throughput of prisoners gave rise to the risk that taking them through the necessary processes could predominate over identifying individual needs and ensuring favourable outcomes. However, the prison was aware of this risk. The most pressing needs are to get to grips with the violence of all kinds, make the prison safer and reduce the flow of drugs. Only then will the benefits flow from the many creditable initiatives that are being implemented.”

Mark Leech, Editor of The Prisons Handbook for England and Wales said:

“Apart from security, safety must be the primary function of any prison but the number of deaths at Durham, and particularly the failure to implement the recommendations of the Prisons and Probation Ombudsman designed to reduce deaths in custody, is deeply worrying.

“Only yesterday I wrote an open Letter about this issue to the Ombudsman, and this report reinforces the point that prisons must have the resources to implement PPO recommendations otherwise what is the use of them in the first place?”

Prisons minister Rory Stewart said: “We are determined to install full airport-style security with the right dogs, technology, scanners and search teams to detect drugs.

“We will install the technology in Durham and we will be rolling it out across our local prisons. Tackling drugs is vital for reducing violence.”

Deaths in Custody: The Noose Around The Ombudsman’s Neck

pdf version

open letter from Mark Leech The Editor of The Prisons Handbook for England and Wales, to The Prisons and Probation Ombudsman

 

Dear Sue,

Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation.

Did you bother reading each of those words – or notice I had inserted a number in one of them?

Actually, I didn’t, but you went back anyway and read them again; right?

Unfortunately, that isn’t what happens to the ‘Recommendations’ you make in your Fatal Incident Reports into deaths in custody; people don’t go back and read them again.

When you set out your ‘Recommendations’ designed to learn lessons and reduce deaths in custody, no one takes a blind bit of notice of them – and, what’s worse, your Office ignores the fact they’re ignored too.

Tragically you’re not alone in looking the other way. Independent Monitoring Boards (IMBs) in whose prisons these deaths take place, and to whom monitoring the implementation of these Recommendations should be a priority, ignore them too. Year after year, they simply airbrush them out of their Annual Reports as if they have never been made; I will return to this shortly.

Every single Prisons Ombudsman that’s gone before you in the last 25 years at least had the excuse that they’ve never unlocked a prison cell door and found a prisoner swinging dead with a noose around their neck; but as a former Prison Governor you don’t have the luxury of that excuse. You know exactly what it’s like: the shock, horror, frantic attempts at resuscitation, and the wave of utter devastation that then descends on the whole prison afterwards.

Yet, despite that personal experience deaths in custody keep happening and frequently too; as I write this we are six weeks into 2019 and already 20 people have died in our prisons – 17 of whom have seemingly taken their own lives, and eight definitely have.

Your Office still keeps investigating these deaths, still keeps writing their reports, still keeps making recommendations, and still does absolutely nothing when, time after time, those recommendations are ignored – lamentably this week you’ve done it again.

John Delahaye was 46 years old when he was found dead in his cell at Birmingham Prison on 5 March 2018; let me remind you of the catalogue of errors that lead up to it.

Ten weeks before his death Mr Delahaye was taken from Birmingham prison and admitted to hospital almost certainly having taken an insulin overdose; he returned to prison 24 hours later.

In your report into his death published this week, you write:

“When Mr Delahaye returned to Birmingham on 1 January following this overdose, there was no handover between hospital and prison healthcare staff and prison healthcare staff did not know he had returned to prison until the next day. 

I am also concerned that suicide and self-harm monitoring procedures (known as ACCT) were not started until the day after he had returned to prison. In addition, I have concerns about the way the ACCT procedures were managed when they were started. Staff did not effectively investigate why Mr Delahaye had taken the overdose and healthcare staff were not involved. The ACCT was closed prematurely two weeks later, with little having been done to identify or mitigate Mr Delahaye’s risk to himself. This was compounded by the fact that Mr Delahaye was discharged from mental health services after just one appointment.

I am concerned to be repeating recommendations to Birmingham about suicide and self-harm prevention procedures. [emphasis added]

“It is very difficult to understand why Mr Delahaye was allowed to have his insulin back in his possession less than a month after his overdose. I am concerned that NHS guidelines were not followed when this decision was made. 

“I also have serious concerns about the way staff at Birmingham conducted roll checks and unlocks. When Mr Delahaye was found on the morning of 5 March, he had clearly been dead for some time and it seems possible that no member of staff had seen him for more than 13 hours.

“This needs to be rectified urgently. 

“Staff also failed to use an emergency code when they found Mr Delahaye unresponsive. Although this did not affect the outcome for Mr Delahaye, it could make a critical difference in other cases.” 

Now, take a moment to look too at the Birmingham Prison IMB Annual Report published just 10 weeks ago and covering the period in which Mr Delahaye died in the prison. Neither his name, the circumstances of his death, nor the fact that your repeated recommendations had been ignored, are ever mentioned; not even once – they’re airbrushed out of existence; small wonder then why so many consider the IMB as completely and utterly useless?

I would remind you that your Office is not investigating the loss of someone’s property here, but the loss of someone’s life; yet it consistently fails to understand this vital distinction.

I accept the fact you are new to this role, and while there are those who say that as a former Prison Governor you are not the right person to be holding this critical Independent Office, I’m not yet one of them. I think your experience as a Governor means you know where to look, what questions to ask, what answers to demand and having opened cell doors and cut dead people down you know exactly how important all this really is.

The question is: when will we see action from your Office and not just words that everyone, including IMBs, totally ignore?

Yours sincerely,

Mark Leech

Editor: The Prisons Handbook for England and Wales

@prisonsorguk

HMP Bedford inmate took his own life after two days in jail

A mentally ill prisoner was found hanged in his cell hours after telling staff he heard voices “telling him to kill himself”, a report has found.

Michael Berry was deemed to be “high risk” when he was remanded at HMP Bedford in March 2017, appearing in a “fragile” state and detoxifying from heroin and crack cocaine use.

The report by the Prisons and Probation Ombudsman found Mr Berry told staff he was “finding it hard to ignore the voices telling him to kill himself, was distressed, hopeless, teary and prone to acting impulsively”, prompting staff to increase self-harm monitoring observations from twice an hour to five times an hour.

Staff and prisoners said they heard Mr Berry, 24, calling from his cell, although a doctor said the prisoner would not engage with him. He was also described as “arguing with himself and seemed tormented”.

A subsequent check by staff noted Mr Berry was “pacing up and down in his cell and talking to himself”. Around 20 minutes later, he was found hanged.

The watchdog found failings previously identified in the mental health support offered to inmates at the jail had not been properly heeded.

It said Mr Berry was at Bedford jail having been charged with 22 offences including violence, kidnap and sexual assault of an adult male.

He had a significant history of drug and alcohol abuse and had recently been admitted to a mental hospital twice, including following an attempt to jump out of a window.

The report said it was “concerning” there was no record of an email from the court to theprison explaining Mr Berry’s fragile mental state and the risk of self-harm.

Mr Berry was the eighth prisoner to take his own life at Bedford since 2013.

In six of the investigations, the ombudsman found staff operated suicide and self-harm prevention procedures ineffectively and recommendations were made to improve the assessment, care in custody and teamwork (ACCT) process.

Four of the investigations identified failings in the mental health support offered to prisoners and, as Mr Berry’s case shows, this continued to be an issue.

There has been a further self-inflicted death at Bedford since Mr Berry, the watchdog said.

Read the Report

Recent PPO Fatal Incident (Death in Custody) Reports

The Prisons & Probation Ombudsman has published the following self-inflicted death in custody reports in the last seven days.

Mr Robert McLoughlin was found hanging in his cell at HMP Leeds on 20 February, and died in hospital five days later, on 25 February, never having regained consciousness. He was 32 years old. I offer my condolences to Mr McLoughlin’s family and friends. Although Mr McLoughlin was subject to Prison Service suicide and self-harm monitoring procedures at the time of his death, I am concerned that the prison did not properly address or mitigate his risk factors. Had the suicide and self-harm monitoring procedures operated more effectively, staff might have made more informed decisions about how best to support him. I am concerned that I have repeatedly criticised the management of suicide and self-harm at Leeds and note that the Chief Inspector of Prisons has raised similar concerns. It is essential that the lessons from Mr McLoughlin’s tragic death are quickly and effectively acted upon.

Full report.

Mr Mark Doyle was found hanged in his cell on 22 March 2017 at HMP Pentonville and died in hospital six days later. Mr Doyle was 45 years old. We offer our condolences to Mr Doyle’s family and friends. The investigation into Mr Doyle’s death found deficiencies in the management of the ACCT process, specifically in assessing risk and delivering appropriate levels of observations. Control room staff did not immediately call an ambulance when the emergency was raised. Faulty cell bells were not reported and were not checked daily as required. We are troubled that mental health staff did not consider all available information in considering Mr Doyle’s referral. There have been six self-inflicted deaths at Pentonville since 2016. We are very concerned to repeat in this report recommendations that have been made in previous investigations into deaths at Pentonville. Given these concerns, the Prisons Group Director for London and Thames Valley should commission a review on the operation and management of the ACCT process at HMP Pentonville. As part of this review, he should, in particular, assure himself that HMP Pentonville has effectively implemented all PPO recommendations following self-inflicted deaths at the prison in the last five years and provide a report to me outlining progress within 3 months of receiving this report.

Full report.

Mr Jack Denison died of sepsis and pneumonia at hospital on 31 May 2016, while a prisoner at HMP Wymott. He was 86 years old. I offer my condolences to Mr Denison’s family and friends. Mr Denison was a frail man with several health conditions which healthcare staff managed well. I am satisfied that his care in prison was equivalent to that he could have expected to receive in the community and healthcare staff could not have prevented his death. Although it did not affect the cause of death, I am concerned that poor communication between HMP Garth and Wymott resulted in Mr Denison missing vital hospital appointments. There was no medical input to the security risk assessment when Mr Denison was taken to hospital and managers gave insufficient consideration to the impact of his health on his level of risk. It is also a concern that Mr Denison’s next of kin details were not updated when he arrived at Wymott.

Full report.

Mr Gary Lines was found hanged in his cell at HMP Northumberland on 18 September 2015. He was 44 years old. I offer my condolences to Mr Lines’ family and friends. Prison staff had begun suicide and self-harm prevention procedures when Mr Lines harmed himself on 13 September, but case reviews were not multidisciplinary and healthcare staff were not involved. No one checked Mr Lines’ community prescription from the time he arrived in prison on 8 August and he was not prescribed antidepressants, which he said he needed to help drive off suicidal thoughts, until the day before he died. While I consider it would have been difficult to predict that Mr Lines was at high and imminent risk of suicide, I am concerned that a lack of effective information sharing and consideration of his risk factors led to his risk being underestimated and a low level of observations. On the morning he was found hanged, I am not satisfied that staff checked Mr Lines’ wellbeing effectively.

Full report.

Mr John Duffey was found hanged in his cell at HMP Liverpool on 16 July 2016. He was 44 years old. I offer my condolences to Mr Duffey’s family and friends. Mr Duffey was a military veteran with a diagnosis of post-traumatic stress disorder and depression. He had a long history of illicit drug use and alcohol abuse. The investigation found deficiencies in the operation of suicide and self-harm prevention procedures at the prison. I am concerned that this is not the first time that I have found suicide and self-harm prevention procedures to be inadequate at Liverpool. However, I do not consider that staff at Liverpool could have predicted that Mr Duffey intended to take his own life when he did and, therefore, could not have prevented his actions. Fellow prisoners said that Mr Duffey was a regular user of ‘Spice’, a new psychoactive substance, that he was being bullied and was in debt for drugs, but the investigation found no evidence to corroborate these claims. Nevertheless, I note the ease with which Mr Duffey appeared to have been able to acquire illicit drugs at Liverpool and the prison needs to increase its efforts to combat the risks posed to prison safety particularly by new psychoactive substances.

Full report.

Did prisoners take their lives because they could no longer face violent, drug-ridden jail? – Chief Inspector

Peter Clarke, HM Chief Inspector of Prisons, has asked whether prisoners in HMP & YOI Nottingham took their own lives because they could no longer face life in the violent, drug-ridden jail.

In one of the most disturbing inspection reports in recent years, Mr Clarke posed the question in relation to eight apparent self-inflicted deaths between inspections in February 2016 and January 2018, part of an “appalling and tragic” picture of suicide and self-harm in Nottingham.

The formal cause of death in those cases will be decided by inquests but Mr Clarke said: “For too long prisoners have been held in a dangerous, disrespectful, drug-ridden jail. My fear, which may prove to be unfounded, is that some could face it no longer and took their own lives.”

HM Inspectorate of Prisons (HMIP) inspected the East Midlands jail in 2014. That was, like the vast majority of inspections, an unannounced visit. Safety then was assessed as poor, the lowest grade. The following inspections in 2016 and 2018 were, unusually, announced in advance. Despite this, safety was yet again found to have remained at a poor assessment. This spurred Mr Clarke to invoke the first ever use of a new ‘Urgent Notification’ protocol, which requires the Secretary of State for Justice, publicly, to take personal responsibility for improving a jail with significant problems. This centred on a “dramatic decline” at Nottingham and a “persistent and fundamental lack of safety”.

Mr Clarke said: “This prison will not become fit for purpose until it is made safe. It was clear from our evidence that many prisoners at Nottingham did not feel safe.” Inspectors identified disturbing findings:

  • Forty per cent of prisoners in the inspection survey said they felt unsafe on their first night in the jail; 67% that they had felt unsafe at some point during their stay; and 35% that they felt unsafe at the time of the inspection. Well over half reported bullying or victimisation.
  • Reported violence had not reduced since 2016, with 103 assaults against staff in the six months before the inspection. In the same period, there were nearly 200 incidents of prisoners climbing on the safety netting between landings. Inspectors said the overall level of disorder “contributed to a tense atmosphere at the prison.”
  • Well over half of prisoners said drugs were easily available and 15% had acquired a drug problem since entering the prison.
  • Use of force by staff had increased considerably since 2016 with nearly 500 incidents in the six-month period prior to the inspection, yet governance and supervision of such interventions were weak.
  • Just under half of prisoners had mental health needs and a “very high” 25% – 116 prisoners – were under psychiatric care. A quarter of prisoners said they felt suicidal on arrival in Nottingham.
  • Levels of self-harm were far too high, with 344 occurrences recorded in the six months up to the inspection.

Not surprisingly, Mr Clarke said, “in a prison which could be defined by the prevalence of drugs and violence, the level of suicide and self-harm was both tragic and appalling. Since our previous visit, eight prisoners had taken their own lives, with four of these tragedies occurring over a four-week period during the autumn of 2017.  Just a few short weeks after this inspection, a ninth prisoner was believed to have taken his own life.

“We were concerned that some repeated criticisms related to these deaths made by the Prisons and Probation Ombudsman (PPO) (which investigates prison deaths) had not been adequately addressed. For example, cell call bells were still not being answered promptly.”

Mr Clarke added: “We do not claim that the prison had been completely inactive in the face of these challenges. A new violence reduction strategy had been prepared in late 2017… However, this work was fitful and had yet to have an impact.” The prison also had a drug supply reduction policy, though it was not embedded and was not effective.

Inspectors also acknowledged an increase in staff numbers in recent months, though they noted that “too many staff were passive, lacked confidence in dealing with issues or in confronting poor behaviour, and prisoners did not yet see them as reliable or able to deal with the many daily frustrations they faced.”

Health care was reasonably good, and there were plans to improve mental health provision. Daily routines were more predictable and more activities were available for prisoners. There were also “some creditable efforts to prepare men for release”.

The prison governor assured inspectors they had understood the scale of the problems. Mr Clarke said: “I am hopeful that the Urgent Notification will galvanise Her Majesty’s Prison and Probation Service (HMPPS) to provide the support the prison needs to make it an acceptable environment in which to hold prisoners. If this is to happen, there will need to be levels of supervision, support and accountability that have been absent in the past.” The HMPPS action plan drawn in response to the Urgent Notification in January 2018 promised “much that is welcome in terms of review, audit and analysis. However, this must all be translated into tangible action to improve the day-to-day experience, safety and well-being of prisoners. Unless this happens, I fear that progress will be neither substantial nor sustainable.”

Overall, Mr Clarke said:

“This was yet again a very poor inspection at Nottingham that left me with no alternative but to bring matters directly to the attention of the Secretary of State by invoking the urgent notification procedure. The record of failure, as set out in this report, cannot be allowed to continue.”

Michael Spurr, Chief Executive of Her Majesty’s Prison & Probation Service, said:

“We published an immediate response to the Chief Inspector’s concerns on 14 February and have today published a comprehensive plan setting out the practical actions we are taking to improve conditions at HMP Nottingham. Drug testing has been increased, specialist staff are working with vulnerable prisoners and safety is the absolute priority for the Governor and staff every day. We have strengthened management arrangements, are providing external support and will monitor progress closely over the coming months.”

A copy of the full report, published on 16 May 2018, can be found on the HM Inspectorate of Prisons website at: www.justiceinspectorates.gov.uk/hmiprisons