PPO Confirms Concerns Raised By Inspection of HMP Nottingham

The Prisons and Probation Ombudsman, who investigates deaths and complaints in prisons, echoed the findings of the Chief Inspector of Prisons’ report of an inspection at HMP Nottingham.

The Acting PPO, Elizabeth Moody, said: “It is highly troubling that HMP Nottingham has a history of failing to implement recommendations from our investigations into deaths at the prison”.

The PPO makes recommendations following investigations into deaths in prisons so that the prison service can learn from mistakes and prevent them being made in the future.  Final PPO reports on deaths investigations are not published until the end of inquests but important findings and recommendations that could lead to greater safety in a prison are shared with the prison and HM Prison and Probation Service (HMPPS) as they emerge.

Elizabeth Moody added: “It is a matter of great concern that we found some similarities, not only between the deaths of the five prisoners who took their own lives last autumn, but also with deaths which happened earlier in the year and before.  The Chief Inspector is right to highlight the apparent inability of the prison to learn lessons and I agree that until it can demonstrate progress in this critical area the risk of future deaths will remain high.”

She also said: “Complaints from prisoners frequently indicate poor custodial care.  I am troubled that my office upheld proportionately more complaints from prisoners at HMP Nottingham, than in other similar prisons.  This is consistent with the findings of the Chief Inspector and should be a source of concern to the management of HMPPS.”

The Chief Inspector, Peter Clarke, wrote publicly to David Gauke on 18 January, invoking a new procedure to demand urgent action on HMP Nottingham from the Justice Secretary. He raised concerns over eight apparent self-inflicted deaths at HMP Nottingham in the two years up to January 2018, as well as high levels of self-harm.

At the same time, Elizabeth Moody raised key concerns with the Ministry of Justice which had been identified in her investigations into recent deaths at the prison:

  • The importance of initial identification in prisoners of risk of suicide or self-harm.
  • Assessment and management of those individuals, particularly applying multi-disciplinary assessment rather than relying on the way the prisoner presents and talks on arrival in the jail.
  • Referring mental health concerns and issues to healthcare or other experts.
  • The importance of staff responding, in line with HMIP expectations, when prisoners press their cell call bells and of staff entering cells promptly when prisoners are found unresponsive.
  • Keeping proper medical records.
  • Effective emergency response.

Elizabeth Moody said: “HMPPS is preparing an Action Plan to address the urgent concerns raised by the Chief Inspector, particularly in relation to suicide and self-harm at HMP Nottingham. It is vital that, this time, HMPSS fully incorporates PPO recommendations into the Action Plan. That will help HMP Nottingham create a new culture of safety and protection for vulnerable prisoners. Put simply, it will help save lives and prevent a repetition of the tragedies we saw in 2017.”

Approved premises need more effective focus on drug testing and managing the risks of substance abuse, says Ombudsman


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Approved Premise (APs), home to people released from prison or on bail or court orders, need more effective drug testing practices and better staff guidance to identify and address the risks associated with substance misuse, and support individuals, according to a report by the Prisons and Probation Ombudsman (PPO).

Overdoses of opiate and other drugs, including alcohol, by people released from prison remain a significant risk, the PPO ‘Learning Lessons’ bulletin found. People are at a higher risk of overdose if they slip back into drug and alcohol use after periods of abstinence or detoxification.

The bulletin – Approved Premises – substance misusebased on findings from deaths in APs investigated by the PPO also raised significant concerns about New Psychoactive Substances (NPS). These range from stimulants to hallucinogens and are commonly seen in prisons and the community as synthetic cannabinoids, known by names such as Spice and Mamba.

Elizabeth Moody, the acting Ombudsman, said: “The rise of New Psychoactive Substance use in the prison estate is well documented and is widely recognised, in the words of the previous Ombudsman, as a “game-changer”. However, it is clear from our investigations that the implications of NPS for the AP estate have not yet been fully understood or addressed by the National Probation Service (which is responsible for APs).”

The PPO examined 29 of their investigations into AP deaths that were drug-related, or where there was a history of substance misuse. The bulletin expressed concern that testing for NPS in APs “appears to lag behind that in prisons and does not draw on the experience of prisons”. One case study in the bulletin discloses that AP staff were unable to test a man despite their concern he had taken NPS.

The PPO found some good practice in the management and care for those who misuse drugs and alcohol. However, Elizabeth Moody added, “we also see cases with too little focus on the risk of relapse and overdose.”

Some of the PPO investigations identified deficiencies in information sharing and in welfare checks. The bulletin made a number of recommendations relating to:

  • Ensuring a good flow of information between stakeholders, which is critical, particularly for managing substance misuse where there is a clear requirement for effective multi-disciplinary working. PPO investigations found this did not always happen.
  • Checks on the welfare of AP residents – another important way to ensure the risks associated with substance abuse are well managed. PPO investigations found checks were not always carried out effectively.
  • An overarching need for the National Probation Service to improve the AP manual to give staff better guidance on NPS use, information sharing and making welfare checks.

Elizabeth Moody said:

“We know offenders can be at heightened risk of death following their release into the community. I hope this bulletin will help AP staff apply the learning from our investigations to improve the ways they identify, monitor and address the risk factors associated with substance misuse.”

The bulletin is available here – https://www.ppo.gov.uk/?p=10336

Prison Deaths From New Psychoactive Substances Rises To 79 Says Ombudsman


The number of prisoner deaths in which the use of new psychoactive substances (NPS) may have played a part has now risen to at least 79, said Prisons and Probation Ombudsman (PPO) Nigel Newcomen. Tonight (11/7/2017) he addressed the All-Party Parliamentary Group on Penal Affairs at the House of Lords.

Looking back at his six-year tenure, and discussing the rise in self-inflicted deaths in prisons, Mr Newcomen said the prison system was yet to emerge from a crisis. He discussed major themes that have emerged from his investigations and studies into deaths in custody that need to be acted upon, and mentioned the problem of mental ill-health among prisoners, which needs to be better recognised by staff and, if recognised, better managed.


Nigel Newcomen said:

“As well as mental ill-health, another contributory factor to the increase in suicide in prison is the epidemic of new psychoactive substances. My researchers have now identified 79 deaths between June 2013 and September 2016 where the deceased was known or strongly suspected to have taken NPS before death or where their NPS use was a key issue during their time in prison. Of these investigations, 56 were self-inflicted deaths.

In the past, Mr Newcomen has highlighted the four types of risk from NPS:

  • a risk to physical health – NPS use may hasten the effects of underlying health concerns;
  • a risk to mental health, with extreme and unpredictable behaviour and psychotic episodes, sometimes linked to suicide and self-harm;
  • behavioural problems, where the NPS user has presented violent or aggressive behaviour, which is often uncharacteristic for that prisoner; and
  • the risk of debt or bullying, as the use of NPS often results in prisoners getting into debt with prison drug dealers.

Nigel Newcomen said:

“Establishing direct causal links between NPS and the death is not easy, but my investigations identified a number of cases where my clinical reviewers considered that NPS led to psychotic episodes which resulted in self-harm. In other cases, NPS led to bullying and debt of the vulnerable, also resulting in self-harm.

“NPS is a scourge in prison, which I have described as a “game-changer” for prison safety. Reducing both their supply and demand for them is essential.

“But neither mental ill-health, nor the availability of NPS wholly explain the rise in suicides in prison. Every case is an individual tragedy with numerous triggers. And, in such complex circumstances, the safety net of effective suicide prevention procedures is essential. Unfortunately, too often my investigations identify repeated failings in prison suicide prevention procedures.”

Mark Leech editor of The Prisons Handbook said: “This further rise in prison deaths attributable to NPS is deeply concerning, it shows that despite a range of measures introduced by HMPPS, and a Thematic Review by the Chief Inspector of Prisons in December 2015, these dangerous drugs continue to cause deaths inside our prisons.

“Research shows that synthetic cannabinoids, usually known as Spice or Black Mamba, form the only category of illicit drugs whose use by prisoners is higher in prisons than in the community, 10% compared to 6%, and there is no easy answer to it – many of those who take NPS say they do so for reasons of boredom one solution therefore is to resource the Prison Service to deliver the active purposeful regimes that have been steadily stripped away since 2010.”

The Prisons Handbook: Further reading and research on NPS can be found at the following links

■ NPS in Prisons – a Toolkit for Staff: http://www.nta.nhs.uk/uploads/9011-phe-nps-toolkit-update-final.pdf

■ Drug Misuse: Findings from the 2015/16 Crime Survey for England and Wales https://www.gov.uk/government/statistics/drug-misusefindings-from-the-2015-to-2016-csew

■ Changing patterns of substance misuse in adult prisons and service responses. A thematic review by HM Inspectorate of Prisons https://www.justiceinspectorates.gov.uk/hmiprisons/ wp-content/uploads/sites/4/2015/12/Substance-misuseweb-2015.pdf

■ Adult substance misuse statistics from the National Drug Treatment Monitoring System (NDTMS)1st April 2015 to 31st March 2016 http://www.nta.nhs.uk/uploads/adult-statistics-from-thenational-drug-treatment-monitoring-system-2015-2016[0].pdf

■ HM Chief Inspector of Prisons for England and Wales Annual Report 2014–15 https://www.justiceinspectorates.gov.uk/hmiprisons/wpcontent/uploads/sites/4/2015/07/HMIP-AR_2014-15_TSO_ Final1.pdf

■ HM Chief Inspector of Prisons for England and Wales Annual Report 2015–16 https://www.justiceinspectorates.gov.uk/hmiprisons/wpcontent/uploads/sites/4/2016/07/HMIP-AR_2015-16_web-1. pdf

■ Spice: the bird killer (User Voice May 2016) http://www.uservoice.org/wp-content/uploads/2016/05/ User-Voice-Spice-The-Bird-Killer-Report-Low-Res.pdf

■ Project NEPTUNE guidance, 2015 www.neptune-clinical-guidance.co.uk/wp-content/ uploads/2015/03/NEPTUNE-Guidance-March-2015.pdf

■ Harms of Synthetic Cannabinoid Receptor Agonists (SCRAs) and Their Management. Novel Psychoactive Treatment UK Network NEPTUNE http://neptune-clinical-guidance.co.uk/wp-content/ uploads/2016/07/Synthetic-Cannabinoid-ReceptorAgonists.pdf

■ Ministry of Justice press release, 25 January 2015 www.gov.uk/government/news/new-crackdown-ondangerous-legal-highs-in-prison

■ Centre for Social Justice, ‘Drugs in prison’, 2015 http://www.centreforsocialjustice.org.uk/library/drugs-inprison

■ EMCDDA, European Drug Report 2015: ‘Trends and developments’, June 2015 www.emcdda.europa.eu/publications/edr/trendsdevelopments/2015

■ Drugscope, ‘Not for human consumption: an updated and amended status report on new psychoactive substances and ‘club drugs’ in the UK’,2015 http://www.re-solv.org/wp-content/uploads/2015/06/Notfor-human-consumption.pdf

■ PHE, ‘New psychoactive substances. A toolkit for substance misuse commissioners’, 2014 www.nta.nhs.uk/uploads/nps-a-toolkit-for-substancemisuse-commissioners.pdf

■ Home Office, ‘Annual report on the Home Office Forensic Early Warning System (FEWS). A system to identify new psychoactive substances (NPS) in the UK’, September 2015 https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/461333/1280_EL_FEWS_Annual_ Report_2015_WEB.pdf

■ Global Drug Survey 2016 https://www.globaldrugsurvey.com/past-findings/theglobal-drug-survey-2016-findings/

A copy of the speech can be found on the PPO’s web site from 14 July 2017. Visit www.ppo.gov.uk.

Older Prisoners: 4 Years & 5 Justice Secretary’s After Justice Committee Produced A Report on Older Prisoners – Still No Progress

elderlyHM Prison and Probation Service needs a national strategy to address the needs of the increasing numbers of elderly prisoners living – and dying – in jail so that they can be managed and cared for more appropriately, said Prisons and Probation Ombudsman (PPO) Nigel Newcomen. Today he published a report on older prisoners.

One of the most marked changes in prisons in recent years has been the increase in the number of older prisoners. This shift has been driven largely by increased sentence length and more late-in-life prosecutions for historic sex offences. The number of prisoners over 60 has tripled in 15 years and the projections are all upwards, with 14,000 prisoners over 50 predicted by June 2020.

The Care Act of 2014 clarified that local authorities are responsible for assessing the care needs of older prisoners and providing support. This legislation, along with national and international expectations that prisoners should be able to access a level of care equal to that in the community, are positive developments. However, faced with such a rapid increase in older prisoners and without a properly resourced and coordinated strategy for this group, an already stretched prison system is struggling to meet need.

Today’s report reviews PPO investigations into naturally caused deaths of prisoners over 50. It examines 314 investigations between 2013 and 2015 and offers 13 lessons on six areas where recommendations are frequently made following investigations into deaths in custody of older prisoners. The six areas are healthcare and diagnosis, restraints, end of life care, family involvement, early release and dementia and complex needs. Among those lessons are:

  • prisons should ensure that newly arrived prisoners have an appropriate health screen that reviews their medical history and conditions and identifies any outstanding appointments and relevant conditions;
  • use of restraints should be proportionate to the actual risk posed by the prisoner, given his or her current health condition;
  • prisons should ensure that terminally ill prisoners who require intensive palliative care are treated in a suitable environment;
  • prisons should ensure that, with the consent of the prisoner and agreement of the family, trained family liaison officers involve families in end-of-life care and promptly notify them when the prisoner is taken to hospital;
  • risk assessments associated with applications for compassionate release should be based on an assessment of actual risk given the prisoner’s current health condition; and
  • prisons should ensure that patients with complex health needs have personalised care plans in place.


Nigel Newcomen said:

“The challenge to HM Prison and Probation Service is clear: prisons designed for fit, young men must adjust to the largely unplanned roles of care home and even hospice. Increasingly, prison staff are having to manage not just ageing prisoners and their age-related conditions, but also the end of prisoners’ lives and death itself – usually with limited resources and inadequate training.

“There has been little strategic grip of this sharp demographic change. Prisons and their healthcare partners have been left to respond in a piecemeal fashion. The inevitable result, illustrated in my review, is variable end of life care for prisoners and a continued inability of many prisons to adjust their security arrangements appropriately to the needs of the seriously ill. I still find too many cases of prisons shackling the terminally ill – even to the point of death.

“I have personally seen examples of impressively humane care for the dying by individual staff, as well as glimpses of improved social care and the development of some excellent palliative care. However, I remain astonished that there is still no properly resourced older prisoner strategy. This is something I have called for repeatedly and without which I fear my office will simply continue to expose unacceptable examples of poor care.”

Mark Leech, editor of The Prisons Handbook said: “In 2012 I raised with the Justice Committee the growing problem of older prisoners, they took up my suggestion and in September 2013 published their Report on Older Prisoners (http://www.prisons.org.uk/JC-092013-olderprisoners.pdf)

“Four years and five Justice Secretary’s later, as this report makes clear, little or nothing has been done and the problem is now acute – I have invited the Justice Committee to revisit this vital area of our prison system which is simply being forgotten.”

A copy of the report can be found on our website from 20 June 2017. Visit www.ppo.gov.uk.

Six prison homicides in one year reflect unacceptable level of prison violence, says Ombudsman

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Homicides in prison are still rare but the number has increased, vividly illustrating the unacceptable level of violence in prisons in England and Wales, said Nigel Newcomen, Prisons and Probation Ombudsman (PPO). Today he published a bulletin on lessons that can be learned from his investigations.

The PPO investigates all deaths in custody and his remit is to examine the circumstances surrounding the death and establish whether anything can be done to help prevent similar tragedies in the future. In December 2013 he published a bulletin which looked at 16 prison homicides investigated from 2003-4 to 2012-13, an average of 1.6 per year. The 2013 bulletin identified a number of concerns, in particular the need to improve the management of risk that vulnerable prisoners pose to one another. It led to operational changes in high security prisons.

In the three years that followed, from 2013-14 to 2015-16, another 13 prisoners were killed by another prisoner or prisoners (an average of 4.3 homicides per year). This bulletin considers the learning from six of those 13 homicides where investigations have been completed, and another two from the beginning of 2013.

The bulletin highlights the need for:

  • prisons to have a coordinated approach to identifying indicators and risks of bullying and violent behaviour, including the impact of new psychoactive substances and associated debt, and taking allegations of intimidation seriously;
  • prisons to have an effective security and cell-searching strategy, enabling weapons to be found and removed;
  • concerns about potentially vulnerable prisoners to be properly recorded and action taken to ensure prisoners are located in a place of safety; and
  • the police to be notified without delay when a prisoner appears to have been seriously assaulted, evidence preserved and all prisoners involved in an incident to be held separately until police arrive.


Nigel Newcomen said:

“The killing of one prisoner by another in a supposedly secure prison environment is particularly shocking, and it is essential to seek out any lessons that might prevent these chilling occurrences in future.

“The cases we studied had little in common beyond their tragic outcome. Nevertheless, what is clear is that the increased number of homicides is emblematic of the wholly unacceptable level of violence in our prisons.

“The bulletin does identify a number of areas of learning: the need to better manage violence and debt in prison, not least that associated with the current epidemic of new psychoactive substances; the need for rigorous cell searching to minimise the availability of weapons; the need for careful management of prisoners known to be at risk from others and the need to ensure prisons know how to respond when they have an apparent homicide.”

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

“The rising tide of violence in our prisons is what happens when staffing levels are cut beyond safe levels, when budgets are slashed that allow already attenuated regimes to deteriorate further and when the Prison Service has yet to get to grips with the impact of high levels of New Psychotic Substances which are increasingly widely available across the entire prison estate.

“When you strip away the political rhetoric, the promises of more staff, the assertions that the Prison Service is doing all it can, the simple fact is that you cannot run a modern, safe, prison service on tuppence ha’penny – that’s the shockingly simple truth of the matter at the end of the day.”

A copy of the bulletin is here.

Better Safety Must Underpin Prison Reform Says Ombudsman As Suicides, Homicides and Deaths From Natural Causes Reach Record Levels

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The past year saw a 34% rise in prison suicides, more deaths from natural causes and the highest number of homicides in prison for many years, said Prisons and Probation Ombudsman Nigel Newcomen. Today he published his fifth and final annual report and warned that prison reform could stall without a focus on safety and fairness.

The Prisons and Probation Ombudsman (PPO) independently investigates the circumstances of each death in custody and identifies lessons that need to be learned to improve safety. In 2015-16:

  • PPO investigations were started into 304 deaths, 21% more than the year before;
  • the PPO began 10% more investigations into deaths from natural causes (172 deaths), largely as a consequence of rising numbers of older prisoners (the average age of those who died of natural causes was 61);
  • investigations were started into 103 self-inflicted deaths, the highest number in a single year since the Ombudsman began investigating deaths in custody, and a 34% increase from 2014-15;
  • there were six apparent homicides, compared with four the previous year; and
  • a further 11 deaths were classified as ‘other non-natural’ (usually drug related) and 12 await classification.

Nigel Newcomen said:

“Over the past year, deaths in custody have risen sharply, with a shocking 34% rise in self-inflicted deaths, steadily rising numbers of deaths from natural causes and the highest number of homicides since my office was established.

“Together with rising levels of violence and disorder, these figures are evidence of the urgent need to improve safety and fairness in prison. Progress in prison reform will be limited unless there is a basic underpinning of safety and fairness on which to build.

“Unfortunately, I have been saying many of the same things for much of my time in office. While resources and staffing in prisons are undeniably stretched, it is disappointing how often – after invariably accepting my recommendations – prisons struggle to sustain the improvement I call for. Ensuring real and lasting improvement in safety and fairness needs to be a focus on the new prison reform agenda.”

On suicides, he said:

“It is deeply depressing that suicides in custody have again risen sharply but it is not easy to explain this rising toll of despair. Each death is the tragic culmination of an individual crisis. Some major themes do emerge from my investigations, for example the pervasiveness of mental ill-health and the destructive impact of an epidemic of new psychoactive substances, but no simple explanation suffices.

“In such a complex context, effective and thoughtful efforts at prevention by prison staff are vital. Unfortunately, too often my investigations identify repeated procedural failings. For example, I have frequently identified gaps in the assessment of risk of suicide and self-harm and poor monitoring of those identified as being at risk. More can and should be done to improve suicide and self-harm prevention in prison”

The other principal part of the PPO’s remit is the independent investigation of complaints. In 2015-16:

  • the total number of new complaints received was 4,781, a 4% decrease on the previous year;
  • 2,357 investigations were started, just 23 cases fewer than the year before;
  • overall, 2,290 investigations were completed, a 6% increase on 2014-15;
  • in 40% of the investigations, the PPO found in favour of the complainant, compared with 39% the previous year; and
  • the largest category of complaints was about lost, damaged and confiscated property.

Nigel Newcomen said:

“The ability to complain effectively is integral to a legitimate and civilised prison system. In each of my annual reports, I have listed the raft of challenges facing the prison system, which go some way to explaining the sustained levels of complaints reaching my office. These strains in the system may also be reflected in the increasing proportion of complaints from prisoners that I uphold because prisons got things wrong, often in contravention of their own national policies.

“Avoiding mistakes and ensuring basic fairness will also need to be at the heart of any prison reforms. Greater autonomy for governors must be balanced by clear statements of minimum entitlements for prisoners.”

The recommendations made as a result of PPO investigations are key to making improvements in safety and fairness in custody. The past year also saw the publication of a range of learning lessons publications which look across individual investigations to identify broader themes. In 2015-16, bulletins looked at how to avoid the increase of suicides by prisoners in segregation units, how to address deaths associated with new psychoactive substances and how to manage those at risk of suicide in the early days of custody. A thematic study looked at the issue of mental ill health, and a bulletin looked at how legal mail should be dealt with.

Nigel Newcomen said:

“I pay tribute to my staff who have worked so hard to enable me to deliver the commitments that I made on my appointment five years ago: to develop a new programme of learning lessons publications, to improve the quality and timeliness of fatal incident and complaint investigations and to do more with less. We will have to do still more in 2016-17. I know my staff will rise to the challenge.”

A copy of the report can be found here www.ppo.gov.uk.

Use of Force ‘should be a last resort in Jails’ says Ombudsman

useofforceStaff face enormous challenges in keeping order and control in prisons, and the use of force must always be an option, but it should be a measure of last resort, said Prisons and Probation Ombudsman (PPO) Nigel Newcomen. Today he published a bulletin on further lessons that can be learned from investigations into complaints about the use of force.

Prison Service policy on the use of force is set out in Prison Service Order (PSO) 1600 which says that “the use of force is justified and therefore lawful, only if: it is reasonable in the circumstances, it is necessary, no more force than necessary is used and it is proportionate to the seriousness of the circumstances.” PSO 1600 makes clear that the type of harm the member of staff is trying to prevent should be considered. This may cover risk to life or limb, risk to property or risk to the good order of the establishment. The PSO also states that staff should always try to prevent a conflict where possible and that control and restraint (C&R) “must only be used as a last resort after all other means of de-escalating the incident, not involving the use of force, have been repeatedly tried and failed.”

A previous bulletin on this subject, published in 2014, highlighted learning for prisons from investigations into complaints about the use of force. Additional lessons have been identified from more recent investigations. A number of these cases involved ‘planned removals’ where a decision has been taken to move a prisoner from their cell to another location and a C&R team of three staff wearing helmets and carrying a shield are assembled to carry out the removal.

The report found that:

  • in a number of cases, there had been no attempts to de-escalate the situation once the C&R team has arrived at the cell;
  • in some cases the team were told at a briefing that they should only give the prisoner “one more chance” to comply and then use force, which pre-disposed the team to use force;
  • there were some occasions where the Supervising Officer deferred to the lead (“Number One”) officer rather than taking a supervisory role throughout the incident;
  • sometimes officers find it difficult when prisoners blatantly disregard their orders and may use one-on-one force rather than alternative disciplinary methods;
  • some prisoners don’t get a proper healthcare examination immediately after an incident involving force, because they are too worked up; and
  • in some cases there have been suspicious similarities of language in Use of Force statements provided by different officers.

The lessons from the bulletin are that:

  • the arrival of the C&R team in a planned removal should be treated as a new situation;
  • briefings prior to a planned removal should cover the likely risks rather than being prescriptive about when force should be used;
  • the roles of the Supervising Officer and the Number One Officer in the C&R team are different;
  • a one-on-one use of force is very risky and should be used only if there is immediate risk to life or limb;
  • a brief view by a nurse through the hatch of a cell door will not meet the requirement for a prisoner to be examined by a healthcare practitioner following a use of force; and
  • staff must write their Annex A Use of Force statements independently.

Nigel Newcomen said:

“In some ways it is reassuring that there are relatively few complaints to my office about alleged physical abuse of detainees by custodial staff. In 2014-15, of 2,303 complaints eligible for investigation, only 50 involved such allegations.

“They are, however, among the most serious and important complaints that I receive as they go to the heart of the humanity and legitimacy of the prison system. Ensuring independent investigations into allegations of physical abuse is, therefore, essential to maintaining safety and giving assurance of the proper treatment of those in custody. My investigations also ensure that staff are held to account for misbehaviour and I have had to recommend disciplinary action on a number of occasions. Equally, in other cases, my investigations have provided assurance that use of force by staff was appropriate and their behaviour exemplary in difficult circumstances.

“Prisons can be violent places and recorded levels of prisoner-on-prisoner and prisoner-on-staff assaults are at an all time high. Staff face enormous challenges in keeping order, so use of force must always be an option. However, it is only lawful if it is reasonable, necessary and proportionate. Use of force should always be a measure of last resort.”

Mark Leech, editor of The Prisons Handbook for England and Wales said it was concerning that the bulletin ‘had to state the obvious.’

Mr Leech said: “Of course use of force should be a last resort, this bulletin however is concerning as that it finds it necessary to state the obvious.

“Violent incidents in our prisons have rocketed recently, and so this timely reminder of the rules is welcome, although it seems even basic lessons and Use of Force rules have been forgotten.”



  1. A copy of the report can be found on our website from 17 May 2016. Visit www.ppo.gov.uk.
  2. The PPO investigates deaths that occur in prison, immigration detention or among the residents of probation approved premises. The PPO also investigates complaints from prisoners, those on probation and those held in immigration removal centres.
  3. Prisons and Probation Ombudsman Learning Lessons Bulletin: Use of Force, published in 2014, is available online: http://www.ppo.gov.uk/?p=3722
  4. Please contact Jane Parsons, PPO Press Office, on 020 3681 2775 or 07880 787452 if you would like more information. Alternatively please send requests or feedback to Prisons and Probation Ombudsman, PO Box 70769, London, SE1P 4XY.


selfharmSome improvement has been made in managing the mental health needs of prisoners, but there is still a long way to go, said Prisons and Probation Ombudsman Nigel Newcomen. Today he published a review on prisoner mental health arising from his investigations into deaths in custody.

Mental ill-health is one of the most prevalent and challenging issues in prisons and is closely associated with high rates of suicide and self-harm in custody. These mental health needs range from mild forms of depression to serious and enduring conditions, such as psychotic illnesses and severe personality disorders, which can be much more difficult to manage. Echoing previous research, the review found that 70% of the prisoners who killed themselves had one or more identified mental health needs.

The report considers the deaths of 557 prisoners who died in prison custody between 2012 and 2014, including 199 self-inflicted deaths, where the prisoner had been identified as having mental health needs. It goes on to identify the lessons learned from these investigations.

The review makes clear the importance of identifying mental health issues, as without accurate diagnosis, it is very difficult to provide appropriate treatment and support. Once a need is identified, effective intervention is required. However, the identification and treatment of mental health issues among prisoners was variable and many areas for improvement remain.

One particular challenge for prisons is that some mental health conditions cause sufferers to present very challenging behaviour, which staff may deal with as a behavioural, rather than a mental health problem. This may lead to a punitive, rather than a therapeutic, response. Often this only worsens the prisoner’s underlying mental ill-health, further compromising their ability to cope.

Among other findings, the report found a number of cases where:

  • there was poor information sharing, failure to make referrals to mental health professionals, inappropriate mental health assessments and inadequate staff training;
  • there was a lack of coordinated care, with little evidence of prison staff and healthcare staff working together or a lack of joined-up work between primary healthcare, mental health in-reach and substance misuse services; and
  • prisoners with mental health needs sometimes find it difficult to understand the importance of taking their medication and staff did not always remind or encourage them to do so.

Prisoners with mental health needs can sometimes be very difficult to manage. Commendably, investigations also found impressive examples where staff went to great lengths to ensure that prisoners in crisis received excellent care.

Nigel Newcomen said:

“While there were many examples of very good practice, there were also too many cases where practice could and should have been better. Issues ranged from poor monitoring of compliance with medication and lack of encouragement to take prescribed drugs, to inappropriate care plans which were not reviewed and updated. There have also been investigations in which we found that the provision of mental health care was simply inadequate.

“Given the scale of mental ill-health in prison and the pressures in the system, it is perhaps not surprising that this review identifies significant room for improvement in the provision of mental health care.”

– ENDS –


  1. A copy of the report can be found on our website from 19 January 2016. Visit www.ppo.gov.uk.

Inmate dies after prison assault

HMP Rochester
HMP Rochester

A prisoner who was allegedly punched by another inmate at HMP Rochester has died.

Fraser Stent, 28, died in hospital a week after the alleged incident at HMP Rochester, a Prison Service spokeswoman said.

Kent Police were called to the jail on October 12 and a 23-year-old man was arrested on suspicion of assault and bailed until February.

He has since been returned to prison, police said.

A force spokeswoman said inquiries were continuing to establish the circumstances surrounding the man’s death.

The Prison Service spokeswoman said: “Following an incident at HMP Rochester, Fraser Stent was pronounced dead at an outside hospital on Sunday October 19.

“Officers from Kent Police have been informed and are investigating.

“As with all deaths in custody, there will be an investigation by the independent Prisons and Probation Ombudsman.”



Prisons must improve how they risk assess, monitor and care for prisoners to help prevent suicides, said Nigel Newcomen, the Prisons and Probation Ombudsman (PPO). Today he published two reports on the lessons that can be learned from PPO investigations into self-inflicted deaths in custody.

There has been a sharp and troubling increase in self-inflicted deaths in custody in recent months. In 2013-14 there were 89 self-inflicted deaths in prison, an increase of 37 (71%) on 2012-13 when there were 52. The PPO independently investigates the circumstances of all deaths that occur in prisons in England and Wales and identifies lessons that need to be learned to improve safety. The PPO also investigates complaints from those held in prison.

The first report, Learning from PPO investigations: risk factors in self-inflicted deaths in prisons, uses information from investigations into 361 such deaths investigated between 2007 and 2013. It examines the characteristics of those who died, the events in the 72 hours leading to their deaths, and the prisons’ approaches to assessing and managing risk. Although various different groups of prisoners were looked at, the findings about the assessment and management of their risk were broadly similar. Too often prison staff placed too much weight on judging how the prisoner seemed, or ‘presented’ rather than on indications of known risk, even when there had been recent acts of self-harm.

Other findings include:

  • risk changes over time and in response to context and events;
  • contact with health services was common in the final 72 hours and represents a key opportunity for suicide prevention;
  • prisoners often withhold their distress from staff and other prisoners, and processes must be in place to respond effectively when family or friends raise concerns;
  • reception screening needs to take fully into account concerns raised by police, escort services or the courts; and
  • Prison Service Instructions should list being held on remand as a risk factor and the risk factors for suicide and self-harm should be presented clearly and concisely.

The second report, Learning from PPO investigations: Self-inflicted deaths of prisoners on ACCT looks at 60 investigations where the prisoner was being monitored under the Prison Service suicide and self-harm prevention procedures, the Assessment, Care in Custody and Teamwork Plan (ACCT), at the time of their death. At any one time around 2% of the prison population are on ACCT monitoring. When implemented properly, ACCT provides a comprehensive, multi-disciplinary framework to address the underlying cause of a prisoners’ distress. To be effective, ACCT requires a concerted, joined-up and holistic approach. The report finds that the ACCT process was not correctly implemented or monitored in half the cases in the PPO sample.

Other findings include:

  • the goals in ACCT plans should be realistic, achievable and relevant;
  • the trigger and warning signs section should be completed on all ACCT plans and reviewed and updated as and when necessary;
  • staff from across the prison and agencies working within it should be encouraged to attend ACCT reviews and offer input into an individual’s care;
  • all staff who come into contact with an individual should be responsible for updating the ACCT plan if they feel that their risk of self-harm or suicide is heightened; and
  • all staff should be up to date on their ACCT training.

Nigel Newcomen said:

“While I recognise the challenges facing busy prison staff and that my investigations have the benefit of hindsight, too often we find that assessments of risk of self-harm place insufficient weight on known risk factors and too much on staff perceptions of the prisoner’s behaviour and demeanour. While the professional judgment of staff is an essential ingredient in ensuring safety in custody, better staff awareness, consideration and training about risk factors could improve safety in custody.

“Nearly a decade after the introduction of ACCT (and a range of other safer custody measures) which saw self-inflicted deaths in custody fall, such deaths have risen sharply in recent months. It is too early to be sure why this rise is occurring, but the personal crisis and utter despair of those involved is readily apparent, as is the state’s evident inability to deliver its duty of care to some of the most vulnerable in custody.

“Learning the lessons from these two reports ought to help the Prison Service improve the implementation of ACCT and ensure greater safety in custody. However, given the repeated weaknesses in practice we identify and the rising toll of self-inflicted deaths, I believe it is also now necessary for the Prison Service to review and refresh its safer custody strategy in general and ACCT in particular.”


  1. A copy of the reports can be found on the PPO website. Visit www.ppo.gov.uk.
  2. The PPO investigates deaths that occur in prison, secure training centres, immigration detention or among the residents of probation approved premises. The

PPO also investigates complaints from prisoners, young people in secure training

centres, those on probation and those held in immigration removal centres.

  1. Prison Service Instructions provide a detailed guide to suicide and self-harm prevention through assessment, monitoring, staff and peer support. First night and induction procedures are intended to provide extra support for prisoners who are newly arrived in custody. The instructions also specify a non-exhaustive list of factors and triggers that indicate prisoners are at heightened risk. This includes having a history of self-harm, mental health issues, substance misuse problems, certain offence types, receiving a life sentence and being in the early days of custody.
  2. Assessment, Care in Custody and Teamwork plan (ACCT) was introduced in 2005-06 and built on a previous monitoring system known as F2052SH, introduced a decade earlier.
  3. Contact us: Please contact Jane Parsons, PPO Press Office, on 020 3681 2775 or 07880 787452 if you would like more information, or email mail@ppo.gsi.gov.uk