Teenagers attack staff ‘for honour’ in Feltham A youth prison

Reported in The Times today 6th August 2019.

Inmates are attacking officers as a “mark of honour” at a young offender institution plagued by gang allegiances and rivalries.

Staff at Feltham A in west London are also being assaulted by teenagers when they try to stop them attacking each other. Separating gangs has dominated prison life to such an extent that any work and education routines have collapsed, causing more resentment and violence, according to Peter Clarke, the chief inspector of prisons.

He has demanded that the justice secretary produce an action plan for improvement after inspectors found a “collapse” in safety and care.

One prison officer said that the “perfect cocktail” of inexperienced staff, gang rivalries and a hard core of violent teenagers aged 15 to 18 was behind the rising unrest. “There is a huge issue with gangs, members of postcode gangs in London, who are in the jail. They have an ethos of loyalty to the gang and they want to attack members of other gangs in the units. We have had situations where they are actually fighting staff to get to each other. It is a degree of honour for them to get at the other person,” the officer said.

The officer said that inmates were also attacking staff to prove themselves to their peers at the institution which holds just over 100 offenders aged 15 to 18, many of whom have been convicted of violent crimes including murder.

“They attack staff. There is an honour in attacking staff. They get an elevated position in their own peer group if they attack staff. They go to the top of the pile,” he said.

Staff have suffered serious injuries including broken jaws and damaged eye sockets. In April, 13 prison officers needed hospital treatment after they were attacked by inmates. Figures show that assaults rose from 230 to 325 in the six months to June, including a rise of attacks on staff from 62 to 152.

The prison has adopted a “keep apart” policy where inmates from rival groups are kept separate. This involves officers escorting them to education and healthcare appointments as well as ensuring that they are not in the same classes or at the gym together. As a result many are unable to get education or training and remain in their cells for long periods.

“They spend longer in their cells because we have to keep them apart and they get isolated and frustrated. Their coping skills are not good so they use violence as a way of getting attention”, the officer said.

The difficulties facing the prison have been compounded by the loss of experienced officers as a result of budget cuts. They are now being replaced by new staff with limited skills in how to cope with troubled and disruptive teenagers.

“Some recruits are not much older than the prisoners. They are young and have very limited experience to draw upon when dealing with young men who have complex needs and are violent,” the officer said.

Ministers stopped sending teenagers to Feltham A after Mr Clarke’s demand for urgent action to deal with what he described as an “extraordinary” decline in safety and care.

A prison service spokeswoman said: “The governor, who is still relatively new in post, is working hard to drive improvement in an establishment which has one of the highest and most concentrated proportions of violent offenders in the country. She and her team are incredibly dedicated to turning Feltham A around and we will respond with a formal action plan.”



HM Chief Inspector of Prisons has called on the Secretary of State for Justice to intervene urgently in Feltham A Young Offender Institution (YOI) after an inspection last week disclosed an “extraordinary” decline in safety, care and activity for the children held there.

Inspectors found very high levels of violence, between boys and against staff, high use of staff force, poor care, long periods of lock-up in cells and escalating self-harm.

Peter Clarke invoked the rarely-used Urgent Notification (UN) process because of disturbing inspection findings at the unit holding boys aged under 18 in West London. The Secretary of State must respond within 28 days, in public, with action to improve conditions.

Feltham A had previously been subject to a full inspection in January 2019. The report on that inspection, published in early June 2019, warned of deterioration in safety and care after a period of drift. Mr Clarke also took the unusual step, based on intelligence from a number of sources about Feltham A, of announcing that the Inspectorate would return to the children’s unit in early July to inspect both Feltham A and Feltham B, the linked prison for 18–21-year-olds.

The Urgent Notification relates only to Feltham A which, Mr Clarke said, “has for many years been recognised as a challenging and complicated establishment.”

Mr Clarke added: “We found that in the six months since the last inspection there had been what can only be described as a collapse in performance and outcomes for the children being held in Feltham A… The speed of this decline has been extraordinary.”

In his UN letter to David Gauke, sent on 22 July, Mr Clarke set out his key findings:

 40% of children said they had felt unsafe at some point during their stay at Feltham A

  • the number of violent incidents had risen by 45% since January 2019, though the number of children held had fallen
  • the number of assaults against staff, some of which were very serious, had risen by around 150% since January
  • levels of self-harm had tripled since the previous inspection and were 14 times higher than in January 2017
  • use of force by staff had risen to very high levels: 74% of children reported they had been physically restrained at Feltham A and there had been over 700 incidents in the last six months
  • fewer than one in five children felt cared for by staff, less than half felt most staff treated them with respect, and only 45% reported there was a member of staff they could turn to for help
  • frontline staff were working in an extremely challenging environment and were frequently victims of antisocial behaviour and violence
  • a third of children said they were out of their cells for fewer than two hours during the week; at the weekend this figure rose to nearly three- quarters
  • resources were being wasted as health care staff, education facilities and resettlement intervention services stood idle waiting for children to arrive
  • many children were being released from Feltham A without stable accommodation, without education, training or employment being in place, and without support from family or friends.

Mr Clarke wrote to Mr Gauke: “I do not for one moment underestimate the challenges facing the leaders and staff at HMYOI Feltham A. During recent months they have often faced violence, some of it very serious. The atmosphere feels tense, and I could sense that many staff were anxious. Some were clearly frustrated about the situation in which they found themselves. They wanted to do their best for the children in their care.

“The overriding issue behind the extraordinary decline in performance over the past 18 months is the approach to dealing with violence and managing the behaviour of children. Of course, there is a need to keep children safe from each other, and for staff themselves to be safe in their workplace. However, the response at Feltham A, for many years, has been to focus too heavily on containing the problems rather than addressing them. As a result, ‘keep apart’ policies – developed so that children from rival gangs, or who for other reasons are likely to be violent to each other, are kept separate – have come to dominate.

“This has led to a collapse of any reasonable regime, has prevented many children from getting to education or training, delayed their access to health care, isolated them from meaningful human interaction and frustrated them to the point where violence and self-harm have become the means to express themselves or gain attention.

“There clearly needs to be a new approach which looks fundamentally to change behaviour and goes beyond merely trying to contain violence through ever more restrictive security and separation.”

Mark Leech, Editor of The Prisons Handbook, the definitive 1,600-page annual guide to prisons in England and Wales – the new 21st annual edition of which is published on 1st August 2019 – said the report was “shocking”.

Mr Leech said: “This is a shocking report where an increasing number of children in this establishment, unable to cope, have flipped into self-destruct.

“Levels of self-harm have tripled since the previous inspection – and they are now 14 times higher than they were in January 2017.

“Today we will have a new Justice Secretary after the resignation of David Gauke following Boris Johnson’s election as Prime Minister – to them I say: ‘welcome to the real world of prisons’ – and please deal with this urgently as the Notification requires.”

Read the Urgent Notification Letter

Read the Urgent Notification Letter & Full Notice

HMP BRISTOL – Chief Inspector Issues Urgent Notification

The country’s most senior prison inspector has demanded the Justice Secretary take action over the squalid and dangerous conditions at HMP Bristol – issuing his fifth ever Urgent Notification.

Peter Clarke invoked a rarely-used protocol forcing David Gauke to respond publicly after inspectors found high levels of violence, filthy cells and poor training and education.

Click to Download Urgent Notification in pdf

Mr Clarke warned the Justice Secretary that the category B men’s prison had not improved at all despite being placed in special measures after a worrying inspection in 2017.

In the letter, Mr Clarke said inspectors had found rates of self-harm had increased since 2017 and remained higher than most local prisons.

Despite two suicides since the last inspection, recommendations for improvements had not been implemented and inspectors saw instances of “very poor” care of at-risk prisoners.

Inspectors also found the prison to be dirty, with many of the 600-plus inmates living in overcrowded cells.

Recorded levels of violence, a lot of it serious, were found to have increased since the 2017 inspection, and was much higher than average for local prisons.

Nearly two thirds of prisoners said they had felt unsafe at some point while held in HMP Bristol, and over a third said the currently felt unsafe.

A hotline for family and friends of prisoners in crisis to report their concerns had not been checked for over two weeks before the inspections, Mr Clarke said.

It was found the prison had enough activity places for all prisoners to take part in education, training or work for at least part of the day, but only half of prisoners had been allocated an activity.

Of these, on average only half attended their activity.

Under the terms of the urgent notification protocol, within a month the justice secretary must come up with a plan to improve the prison.

In the letter, Mr Clarke said: “The chronic and seemingly intractable failings at Bristol have now been evident for the best part of a decade.”

He added the prison had “demonstrably been in a state of drift and decline for many years” and that additional investment had not led to any visible improvement in conditions.

Mr Clarke said: “Some of the efforts to improve have, in reality, been a case of too little, too late.

“Some we saw had only just been implemented, and some were introduced during the inspection itself.

“On the basis of this latest inspection, I can have no confidence that HMP Bristol will achieve coherent, meaningful or sustained improvement in the future.”

The urgent notification protocol was added to the existing protocol between the prisons’ inspectorate and the Ministry of Justice in November 2017, signed by then-justice secretary David Lidington.

Bristol is the fifth prison to trigger the protocol since it came into force, Mr Clarke has also demanded urgent action over HMPs Nottingham, Birmingham, Bedford and Exeter.

The unannounced inspection took place between May 20 and June 7 of this year.

Prisons Minister Robert Buckland said: “We know Bristol faces serious challenges and we have been providing additional support.

“That has resulted in more prison officers and reductions in drug use, but some of the chief inspector’s findings make very difficult reading and it is clear that much more work is needed.

“We have immediately addressed the issues around prisoner phone support lines to make sure those problems can never happen again, and will publish an action plan within 28 days to reduce violence and self-harm and help turn the prison around.”


• Bristol is a frontline local prison, receiving prisoners from the courts, many with vulnerabilities and often with no previous experience of prison. In light of this, we were disappointed to see first night arrangements had only improved marginally and that many of these improvements were only introduced during the course of the inspection.

• In our survey, nearly two-thirds of prisoners said they had felt unsafe at some point during their stay at the prison, with over a third feeling unsafe at the time of the inspection itself. Recorded violence, much of it serious, had increased since our last inspection and was much higher than the average for local prisons. We saw that there was a new violence reduction strategy, some good security initiatives and some very important work to combat illegal drugs, but some of this was poorly coordinated, not measured for effectiveness and not applied with sufficient rigour to give us the assurance it will be impactful or sustained. Despite the high levels of violence, there were no prisoners being managed under CSIP (the agreed casework approach to managing perpetrators and victims of violence), which meant that perpetrators were not being monitored and challenged and victims were not being supported.

• The use of segregation, the number of adjudications and use of force incidents were all high and, to a large extent, reflected the levels of violence in the prison. Most work to improve processes was very recent and untested. Work to incentivise prisoners was too new to assess its effectiveness, and the poor management of adjudications led to a situation where so many charges were not proceeded with that it risked creating a culture of near impunity for those prisoners who behaved poorly. Of the 1,075 adjudications so far in 2019, only 400 had reached a conclusion.

• The rate of self-harm had increased since the last inspection and remained higher than most other local prisons. There had been two self-inflicted deaths since our last inspection, and significant recommendations made following Prisons and Probation Ombudsman investigations had not been implemented. An extraordinarily high number of prisoners – one in 10 – were identified as being at risk of suicide and self-harm and were being managed through assessment, care in custody and teamwork (ACCT) case management processes. We believe this was unmanageable. There was no effective strategy to reduce levels of self-harm and this was an indication of risk aversion rather than considered risk management. This was poor practice and potentially an impediment to care for those in crisis.

• We saw examples of very poor care for prisoners identified as being at risk of suicide and self-harm. One prisoner being managed on ACCT became very distressed one evening and smashed up his cell. Despite this, staff did not review his case that evening, nor was the level of observations on him increased. He was left overnight, and all the following day, in his damaged cell.

• Our confidence in the prison’s competence to support those at risk of self-harm was severely undermined when we found that prisoners had been unable to telephone the Samaritans from their in-cell phones since 15 May 2019 because the prison had not kept the number topped up with credit.

• We were extremely concerned to find that a hotline for the family and friends of those in crisis, to call and report their concerns, had not been checked by staff at all for the two weeks before the inspection. When inspectors asked for records, staff retrieved 21 voicemail messages which required action. Three of the prisoners concerned had already been released from Bristol.

• When we last inspected we were concerned about the lack of care, particularly social care for some very vulnerable prisoners with physical disabilities. At this inspection, the social care arrangements were still completely inadequate, leaving several prisoners we observed with unmet care needs. One of these men had been at the prison since October 2018. He was not able to walk unaided. He had a wheelchair, but it did not fit through his cell door. His cell had no adjustments made and he spent most of his day lying in bed, with a urine bottle tucked under his sheets. A fellow prisoner helped him by getting his meals, making sure he had clean bedding and clothing and lifting him in and out of his cell, but this prisoner was neither trained nor supervised. An initial social care referral was made in December 2018. A care assessment was made during our inspection on 5 June.

• Most accommodation remained bleak and grubby with too many overcrowded cells. C and G wings were the poorest environments. There remained a substantial backlog of maintenance work, infestations of cockroaches were common and many cells lacked sufficient basic furniture. A bulk order of new furniture had been placed in January 2019, but had still not arrived.

• There were currently sufficient activity places for all prisoners to engage in education, training or work for at least part of the day, yet only half had been allocated and of these on average only about half attended. Leaders and managers had not prioritised purposeful activity, were largely unaware of the poor attendance rates, and their expectations were too low, despite significant investment in education facilities. Classes were often cancelled. The quality of teaching, learning and assessment was weak: too many prisoners failed to make any progress, complete their course or gain any qualification or tangible outcome. Time out of cell for the many prisoners not allocated to activity was limited to around two hours each day, and during the working day we found just under a third of prisoners locked in their cells.

• Bristol prison has an important role to play in resettling and reintegrating the many prisoners it releases. About 80 prisoners were released from Bristol every month, but a staggering 47% were released homeless or into temporary accommodation, which did little to enhance their chances of rehabilitation.

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

The one thing that stands out about this Urgent Notification is not the shocking conditions, squalor, lack of decency, care of vulnerable prisoners (whose critical care telephone line had not been answered in a fortnight) nor the high levels of violence, all that regrettably is part and parcel of the criteria for an Urgent Notification and I expected all that.

What is most concerning is that all of that took place in a prison that was both fully staffed and which has, for the last two years, been subject to HM Prison and Probation Service ‘Special Measures’ designed to bring failing prisons back up to par with added resources and managerial input.

In the words of the Chief Inspector Peter Clarke, Special Measures “have clearly failed at HM Prison Bristol.”

What’s more the prison clearly had no excuse or explanation for its failings either: 

“Despite repeated requests, the prison failed to provide us with any meaningful objectives, action plans or assessment of the impact of ‘special measures’” wrote the Chief Inspector.

Of the 76 recommendations made by the Prisons Inspectorate in 2017 at HMP Bristol, by the time of this visit a dismal 22 had been achieved – and when it came to safety there was even more incredulity – especially after two years added senior Ministry of Justice ‘special measures’ attention:

“Incredibly, for a prison that has been judged as unsafe in successive inspections, only one of the 11 recommendations made under ‘safety’ in 2017 had been fully achieved…

“In 2017 I had grounds to think that the leadership at Bristol might be able to make some progress, called for them to be allowed to continue at Bristol, and expressed some cautious optimism.

“Two years later, there has been no significant improvement. My understanding is that ‘special measures’ are intended to provide support for the Governor of a struggling prison.

“If that is the intention, they have clearly failed at HMP Bristol.”

The Chief Inspector’s Urgent Notification is a damning assessment of failure in a fully staffed prison, subject to extra resources and the added management support ‘special measures’ are designed to deliver, and which should never have found itself in this position in a month of Sundays.

The Prison Officers Association were quick off the blocks, after news of the Urgent Notification was leaked two days ago to the BBC prior to its publication today; National Chairman Mark Fairhurst said on Twitter:

“HMP Bristol gets an [Urgent Notification] not because of a poor Governor or a lack of committed staff. It’s because of a lack of investment and a reluctance to act at the very top. Start listening to your staff and @POAUnion⁩ and let’s make our prisons safe/ decent.”

The uncomfortable reality for Mark Fairhurst, however, is that there has been investment, and far from a reluctance to act from the top, there has been more than two years’ worth of added attention at Bristol.

All the evidence points to failure by the prison itself to make the most of the opportunity special measures gave to it, and that failure starts and ends at a local level, indeed right at the heart of the prison in Bristol itself.

Mark Leech is the Editor of The Prisons Handbook for England and Wales – follow him on Twitter @prisonsorguk

Read the Urgent Notification

Birmingham prison action plan published – as MOJ Reject HMIP Calls For Urgent Inquiry

Ministry of Justice Rejects Calls By Chief Inspector for Inquiry Into Birmingham

  • 200 prisoners already moved out following unprecedented ‘step-in’
  • 3 Wings to be closed for refurbishment
  • 32 extra experienced prison officers and additional senior staff already in post
  • Cell refurbishment is ongoing and experienced estate managers continue to support urgent improvement to living conditions
  • Dedicated Prison Service safety team training staff to better manage vulnerable offenders
  • The ‘step-in’ will result in no additional cost to the taxpayer

The Government has rejected a watchdog’s call for an urgent inquiry to establish how one of Britain’s largest jails slipped into crisis.

Chief Inspector of Prisons Peter Clarke said there could be “little hope” of improvement until there has been an independent assessment of the failings at HMP Birmingham last month.

However, the step was ruled out on Monday by Justice Secretary David Gauke as he published details of his department’s plans to improve standards at the prison.

In a letter to Mr Clarke, Mr Gauke wrote: “I strongly believe that we already understand what happened at HMP Birmingham.

“Through your assessment of the prison and that of the IMB, as well as our own investigation following the serious disturbance in December 2016, we have gained significant insight.”

The prison system in England and Wales came under intense scrutiny a month ago when the Chief Inspector raised the alarm over “appalling” squalor and violence at HMP Birmingham.

His report warned staff were fearful and unsafe while violent prisoners could act with “near impunity” and blatant use of illegal substances went largely unchallenged amid a “looming lack of control”.

Mr Clarke triggered the “urgent notification” scheme, which requires the Government to respond after an inspection identifies serious concerns at a prison.

As his findings were revealed, the MoJ confirmed it had taken over running of the jail from G4S for at least six months.

As part of the unprecedented “step in”, a public-sector governor was placed in charge of the prison.

publishing an action plan drawn up in response to Mr Clarke’s urgent notification, the MoJ said a 300-person reduction in HMP Birmingham’s population is two-thirds complete and expected to be finished by the end of this month.

In other measures, 32 additional officers have been drafted in, safety teams are working to reduce self-harm and violence and cell refurbishments are ongoing.

Mr Gauke said: “We acted decisively at HMP Birmingham by taking it over from G4S, just as we are addressing issues in the wider estate by investing heavily in more staff and measures to improve safety and security.

“This plan sets out in more detail exactly what we are doing to establish an effective regime, restore safety and decent living conditions, and allow staff to focus on rehabilitating offenders.”

Built in 1849, HMP Birmingham is a category B facility for adult male inmates. It was the scene of a major riot in 2016.

The Ministry of Justice (MoJ) has published detailed plans to improve standards at HMP Birmingham which follow the unprecedented decision to take over running of the prison from G4S on 20 August, for at least the next six months.

[EXCLUSIVE: What challenges does the new Step In Governor at HMP Birmingham face? published tomorrow in Converse the only other Step In Governor ever to have done this, explains what lays ahead.]



The Ministry of Justice (MoJ) has published detailed plans to improve standards at HMP Birmingham which follow the unprecedented decision to take over running of the prison from G4S on 20 August, for at least the next six months.

The Prison Service placed a new experienced Governor, Paul Newton, in charge immediately and has also brought in 32 skilled prison officers and five new custodial managers (who oversee teams of officers) to provide support to colleagues and offenders and improve safety.

The 300-person reduction in HMP Birmingham’s population which the MoJ committed to after ‘step-in’ is two-thirds complete and is expected to be finished by the end of September, with four local courts now diverting some of those convicted or on remand to other prisons. This reduction will allow the prison to empty and improve three wings in the Victorian section of the prison which are most in need of refurbishment.

Safety teams brought in by the Prison Service are working with all staff at HMP Birmingham to reduce self-harm and violence. They have developed a tailored safety plan which will be implemented by the end of September, and training is already underway with all staff to immediately improve the way vulnerable offenders are managed.

Two senior and experienced facilities management staff are working with the prison to drive urgent improvement in living conditions. They will support ongoing work to refurbish wings and cells, replace damaged furniture and improve cleanliness throughout the establishment.

The action plan published today is the formal response to HMIP’s Urgent Notification – a system set up by this Government to allow the inspectorate to immediately flag serious concerns during an inspection.

Justice Secretary David Gauke said:

We acted decisively at HMP Birmingham by taking it over from G4S, just as we are addressing issues in the wider estate by investing heavily in more staff and measures to improve safety and security.

The Prison Service had been working with G4S for many months to drive up standards at Birmingham, but it became clear that they would not be able to make the necessary improvements alone.

That’s why we took over the running of the prison, appointed a strong governor to turn it around, brought in extra staff and began improvements to the building itself.

This plan sets out in more detail exactly what we are doing to establish an effective regime, restore safety and decent living conditions, and allow staff to focus on rehabilitating offenders.

Other actions included in this initial plan include:

  • The work that Governor Paul Newton has done with G4S to consider short-term workforce issues, effective management of workforce plans and training requirements. Together they have developed and introduced recruitment, training and mentoring strategies for all staff, including senior managers.
  • The national drugs taskforce undertaking an assessment of what further action is required to tackle drug supply and reduce demand, and improve the treatment and recovery of those with misuse problems.
  • A review of the Samaritans’ Listener scheme to ensure vulnerable prisoners have swift access to support.
  • New processes to ensure maintenance of cell call bells systems is undertaken on a regular basis and to improve cell bell response times.
  • Improvements to training and work-related activities and to support prisoners on release.
  • Two new physical education instructors brought in to improve the wellbeing of prisoners, with another due imminently.


  • Read the full action plan.
  • The final inspection report for HMP Birmingham will be published by HM Chief Inspector later this year.

Prisons Inspectorate Issues 4th Urgent Notification About HMP Bedford

Inmates have effectively taken control at a violent, overcrowded and vermin-infested jail, a watchdog report has warned

Chief Inspector of Prisons Peter Clarke raised the alarm over the potential for a “complete breakdown” in order and discipline at HMP Bedford.

Pressing the Government to take urgent action, he said a recent inspection of the prison had revealed a “dangerous lack of control”.

Mr Clarke’s assessment, sent to Justice Secretary David Gauke on Thursday, detailed how “extremely inexperienced” staff struggled to exert their authority.

Prisoners regularly and blatantly ignored rules and staff instructions, often without sanction or challenge.

Mr Clarke said: “Despite the best efforts of staff at all levels, there was a dangerous lack of control in many parts of the prison, leading us to fear that there could all too easily be a complete breakdown in order and discipline.

“At times it felt as if prisoners were effectively in control, choosing when or if to comply with directions and consent to authority.”

On one occasion during the visit, an inspector found prisoners throwing food from higher landings.

Mr Clarke said: “Prisoners’ behaviour was very rowdy and unrestrained and the incident had the potential to escalate.

“Staff were unwilling to go upstairs to intervene, and prisoners told the inspector this was not unusual.”

Mr Clarke triggered the “urgent notification” scheme, which means the Government must respond within a month to set out its response to the findings.

The inspection at HMP Bedford, which concluded last week, found:

– Assaults on staff had risen dramatically, with the rate – 116 in the last six months – the highest in the country;

– There had been five self-inflicted deaths since the last inspection;

– The smell of cannabis and other drugs being smoked “pervaded” some of the wings;

– Living conditions were poor, often overcrowded, dirty and vermin-infested.

It emerged in May that HMP Bedford had been placed into “special measures” after the Prison Service determined it needed additional, specialist support to improve performance.

In November 2016, the facility for adult male inmates was hit by a major disturbance, which reportedly caused £1 million of damage.

Bedford is the fourth jail to be subject to a notice under the urgent notification scheme since it was introduced less than a year ago.

Last month, Mr Clarke triggered the process as he published a scathing assessment of HMP Birmingham.

Mark Day, of the Prison Reform Trust, said: “This fourth urgent notification issued against a local prison since January this year should be a wake-up call to ministers.

“The Chief Inspector highlights an unchecked decline in standards over the space of nine years and so no-one can say that they didn’t see this coming.”

Prisons minister Rory Stewart said: “Bedford prison faces serious challenges. We placed it in special measures before the inspection was conducted and we are bringing in senior experienced managers.

“Our focus will be on reducing violence and drugs along with supporting our prison officers to turn Bedford around. It is abundantly clear that further action is needed.”

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

“Its truly shocking – honestly, how could it have got to this?

“Peter Clarke reports [page 4]: ‘Two prisoners who were amputees were unable to shower regularly as they didn’t have the necessary adaptations. One said he had only had five showers this year and to wash himself he had to sit on the floor of his cell and try to splash water on himself from the sink.’

“Come on, be honest; what if that was your son – and if it isn’t yours, it will be someone’s right?

“Charles Dickens wrote books about prisons like this and, were he alive and able to walk its landings, a lot of what he saw he would still recognise as Bedford Prison today.

“Does the Ministry of Justice have no shame?”

Main Points

HMP Bedford has:

  • Had NINE YEARS of unchecked decline in standards
  • Managed to implement just 21 of the 68 Inspectorate Recommendations made in 2016;
  • The highest rate of assaults at any prison in the whole of England and Wales;
  • Prison Staff where well over three quarters of the total compliment have less than ONE YEAR Prison Service experience;
  • Cannabis smoke pervading through the wings, and;
  • Deplorable conditions in which no one should be made to live or work.



1. Safety

Reception processes were good but many prisoners were not supported well enough on their first night. Too many prisoners felt unsafe and violence, particularly against staff, was very high. Perpetrators of violence faced few challenges or sanctions. Victims of violence were poorly supported. Use of force was exceptionally high. Conditions in the segregation unit were appalling and managerial oversight was weak. There was a lack of order and control on some wings. Drugs were easily available. A good local supply reduction plan was in place but was undermined by a lack of investment nationally. Levels of self-harm were high and prisoners at risk of suicide and self-harm were not well supported. Outcomes for prisoners were poor.

Early days in custody

Reception staff and prisoner orderlies were welcoming but holding rooms were bland and provided little to occupy prisoners.

Initial safety interviews were now conducted in private and had a suitable focus on risk issues.

Shortages of prisoner kit meant some new arrivals were not issued with sufficient clothing and bedding. Too often new prisoners did not go to the dedicated first night unit as it held prisoners who could not be located elsewhere. Instead they were located wherever there was a space, and these cells were not well prepared. Wing staff were often unaware of new arrivals and did not routinely check on their welfare.

In our survey, less than half of prisoners said they felt safe on their first night.

Induction was adequate, but many prisoners did not attend all elements. Peer worker involvement was positive but was not overseen by staff.

Managing behaviour: Encouraging positive behaviour

In our survey two-thirds of prisoners said they had felt unsafe at some time and over one-third felt unsafe at the time of the inspection.

Recorded levels of assaults, when measured over 12 months, had increased significantly since the last inspection and were much higher than all but one local prison. Assaults on staff had risen sharply and were higher than at any other local prison.

Some detailed work had been undertaken to understand the causes of violence and a comprehensive safety strategy was in place, but there was no dynamic action plan to monitor actions to make the prison safer.

The Governor chaired the safer custody meeting which was well structured, but minutes showed a lack of engagement from some key areas.

The current prisoner violence reduction scheme was largely ineffective. There were few challenges or sanctions faced by perpetrators of violence beyond use of the incentives and earned privileges (IEP) and formal adjudications processes, which in themselves were not effective.

There was still no specific violence reduction strategy for young adults who were over-represented in violent incidents.

Support for victims of violence was inadequate.

Vulnerable prisoners located on the dedicated vulnerable prisoner wing received a reasonable regime but others located elsewhere across the prison were often intimidated by other prisoners and had a poor regime.

The IEP scheme was ineffective. It did too little to incentivise good behaviour and was applied inconsistently. Too many IEP reviews did not take place on time. Target setting for prisoners on the basic level of the scheme was poor. Some prisoners were given generic targets, and others no targets at all.

The adjudication system was not used effectively to tackle more serious concerns and challenge poor prisoner behaviour. Over the last six months only around one-third of adjudications had been completed. The prison had begun to address the dysfunctional process for police referrals.

Use of force

Use of force was very high, at four times that at the last inspection and almost three times that of similar prisons we have inspected. Baton use was high. We found numerous occasions where special accommodation was used but not recorded.

Although there was some analysis of available data to identify hotspots and trends, managerial oversight was insufficient and the use of force committee did not review videos or incident paperwork. Almost all dossiers were incomplete and none included an injury to prisoner form.


• Use of segregation was similar to last time and to that of other local prisons.

It was evident that the unit managed some extremely challenging behaviour, but it was chaotic and managerial oversight of both the unit and segregated prisoners on normal location was lacking. Recording of individual behaviour was poor and the daily occurrence log was rarely used.

The environment and conditions in the segregation unit and overspill landing were appalling. General areas and cells were dirty and in constant need of repair, toilets did not flush properly and some cell call alarms were inoperative. The regime for those currently on the unit was poor.

There was some evidence of previous reintegration of prisoners back onto normal location, but too many prisoners were transferred out of the prison without their issues being addressed.


The lack of order and control on some wings was a major concern. Staff struggled to contain an act of concerted indiscipline during our visit and we frequently observed periods where staff control was tenuous.

Dynamic security was poor and we witnessed little effective engagement from staff on some residential wings.

Intelligence was well managed and searching resulted in regular finds of drugs and other contraband, but too few searches and suspicion drug tests were completed.

The prison was focused on known and emerging threats, including organised gang activity, drug supply and associated debt. There was an appropriate focus on the risks posed by extremism.

• Almost half of all prisoners surveyed said it was easy to get illicit drugs and a fifth said they had developed a drug problem at Bedford. Random drug testing rates were at 27%. We regularly smelt cannabis and other substances being burnt throughout the prison. A supply reduction strategy and action plan was in place, but it was hampered by a lack of funding and investment in available technology.

Safeguarding: Suicide and self-harm protection

There had been five self-inflicted deaths since the previous inspection, the most recent a year ago. Progress against Prisons and Probation Ombudsman (PPO) recommendations was too slow and some actions had not been completed.

The number of incidents of self-harm had increased substantially since the previous inspection and was higher than in similar establishments.

ACCT processes (case management for prisoners at risk of suicide or self-harm) were weak. Initial assessments were mostly adequate but some care plans were missing or failed to address the issues of concern to prisoners. Many staff comments were observational rather than demonstrating quality interaction.

In our survey only a third of prisoners who had been subject to ACCTs felt cared for, and any care provided was severely undermined by poor living conditions and a lack of purposeful activity.

There were too few Listeners to meet the needs of the population and they were not available during the night.


2. Respect

Most staff were extremely inexperienced and struggled to exert their authority. Prisoners regularly and blatantly ignored rules and staff instructions – often without sanction or challenge. Living conditions were poor, often overcrowded, dirty and vermin-infested. Access to clean clothing and bedding was inadequate. Food and purchasing arrangements were reasonable overall. The number of complaints was high and too many were responded to too late or not at all. Equalities work was developing but too little was done to support most minority groups and outcomes for some disabled prisoners were particularly poor. Health care and substance misuse services were reasonable overall but mental health provision required improvement. Outcomes for prisoners were poor.

Staff-prisoner relationships

Staff-prisoner relationships had deteriorated since the last inspection and were of considerable concern.

The prison was managing a challenging, dynamic mix of prisoners, with a particularly inexperienced staff group. Seventy-seven per cent of available officers had less than one year’s experience and almost half of middle managers were temporarily promoted.

Staff at all levels were committed to their work and trying to do their best, but as a group they were out of their depth. This lack of experience was having a significant adverse impact on many aspects of prison life.

Some prisoners routinely and blatantly disregarded rules and appropriate standards of behaviour, without challenge. We frequently observed prisoners refusing to do as instructed by staff – and getting away with it. Poor supervision and control of prisoners created unacceptable risks.

Daily life Living conditions

Living conditions were poor. Common areas in most wings were not kept clean. A wing, in particular, was filthy. Despite recent attempts to control vermin, rats, pigeons and cockroaches were everywhere.

There were too few working showers in some wings. Many shower rooms were dirty and in poor physical condition. Some were decrepit.

Many cells were overcrowded and cramped. Cleanliness was variable and many cells were grubby and poorly decorated. Some toilets were dirty and many were poorly screened. There was much graffiti, some of it offensive.

Most cells had basic equipment such as kettles and TVs, although some had insufficient furniture. Some bunk beds were broken and a number had no ladders. Some cells had missing windows and many had broken, or blocked, observation panels.

There was a huge backlog of general repairs and maintenance. Many cells were vandalised and assessed as not fit for habitation, but we nevertheless found a prisoner located in one.

Laundry facilities were inadequate. Prisoners struggled to get access to essentials such as sufficient clean clothing. Towels and sheets were changed only every four weeks which was deplorable.

Residential services (catering and shop)

The food was of reasonable quality, although breakfast packs were meagre. Having the main meal at lunchtime was not popular. The kitchen, despite a period of severe understaffing, was well organised and standards of hygiene and cleaning were high, but non-core work such as consultation and special event menus had suffered.

The weekly small-item purchasing system worked well, but prisoners had to wait up to 10 days for their first full order which increased the likelihood of debt. The catalogue order system had improved, but many electrical items had been delayed for weeks awaiting testing.

Prisoner consultation, applications and redress

Prisoner consultation arrangements were adequate.

Until recently oversight of the applications process was poor. We were not assured applications were dealt with in a timely manner, or at all.

The number of complaints submitted was high. Too many responses were late and 12% in a recent three-month period had not been responded to.

Most complaint responses were adequate. However, some had not been properly investigated and apologies were not always offered when warranted.

Some complaints about staff were not always investigated by an appropriately senior or independent person.

Insufficient support was available to help prisoners with their legal needs.

Equality, diversity and faith

There was now an established pattern of equality meetings and protected characteristic forums. Our survey showed relatively few major differences in perception between minorities and others, although staff-prisoner relationships stood out as the one area where black and minority ethnic and Muslim prisoners had more negative perceptions than others.

There was good use of local data to look for evidence of inequity between different groups. However, there were, as yet, few real actions coming from the processes of consultation and analysis, except in a few cases such as the library.

There were prisoner equality representatives, and equality officers had been identified but were not yet active. The handling of discrimination incident reports had improved, but the quality of investigation was inconsistent.

Foreign nationals who spoke little English were disadvantaged by a lack of translated material and low use of telephone interpretation, and were at risk of being very isolated. Visiting immigration staff, whose visits were irregular, were the only source of information, though forums had been held.

Prisoners with disabilities were identified to some extent, but for those on the wings there were no care plans and insufficient attention to meeting their basic needs. A few with significant disabilities were living in very poor conditions.

A transgender prisoner was given reasonable care. No current prisoners had identified themselves as gay or bisexual. There was no positive affirmation of different sexual orientations to encourage openness.

There was no distinct provision either for under-21s or for older prisoners, though the latter were largely content with their treatment.

Faith and religion

• The chaplaincy team was now much stronger; it was well led and core tasks were carried out efficiently. Additional services were provided, such as bereavement counselling, yoga and some through-the gate work through faith channels. There was insufficient focus in the establishment on enabling worship sessions to start on time with full attendance.

Health, well-being and social care

Health care services had improved since our last inspection, but some concerns remained regarding mental health provision.

A range of primary care services was available, but the team was struggling to engage podiatry services which had been absent for four months. Waiting lists were acceptable for most clinics.

The confidential health complaints process was not routinely used by prisoners, and forms were not widely available. Prisoners had to ask wing staff and peer workers for health care application forms, which was inappropriate.

Inpatients received a good level of care from all staff and had good access to a range of activities.

One prisoner was receiving social care. Processes for referral and assessment were effective.

Medication administration on the main wings was poorly supervised by prison staff and was not confidential.

Dental facilities had improved since our last inspection, and the service was good.

A well-integrated mental health team offered a limited range of primary support, but lacked capacity to provide sufficient levels of therapeutic interventions. Secondary care was reasonable. Urgent referrals were seen promptly but routine referrals took too long to be assessed.

Overall provision for prisoners with substance misuse issues had improved, although only 55% of new arrivals requiring stabilisation were located on D wing, the designated drug treatment wing, which was unsatisfactory. Twenty-four-hour monitoring and observation was now taking place for most prisoners. Clinical care was good and we observed good joint working between clinical and psychosocial support services. Psychosocial support for prisoners with drug and alcohol problems had improved, and a third of all prisoners were engaged with the service. While one-to-one support was available to all, there was still limited access to group work for those not located on D wing.


3. Purposeful activity

Time unlocked was poor for most prisoners and when they were unlocked most had nothing purposeful to do. Library and PE services were adequate. The leadership and management of education, skills and work activity were inadequate. There were sufficient education, skills and work places for all prisoners to work at least part-time, but very few prisoners chose to attend. Far too many were unemployed. The range of provision was narrow and low level. The quality of provision, including teaching and learning, was inadequate and prisoners made too little progress. Too few prisoners completed their courses and gained a qualification. Outcomes for prisoners were poor.

Time out of cell

Time out of cell was poor and few prisoners used it constructively, mostly spending it on the wings with nothing purposeful to do.

A restricted regime had been in place for many months but there were often lengthy delays in locking and unlocking prisoners and moving them to activities.

The few prisoners who engaged in work, education and training had up to five and a half hours out of cell most week days. Most others had about two and a half hours.

Too many prisoners, around 39%, were locked in cells during the working day.

Library and PE

Access to the library was reasonable and facilities were good. An adequate range of materials was available but activities to promote literacy were too limited.

The gym was a well-equipped facility and the PE department offered a range of recreational PE activities, but nothing for older prisoners. We were not assured that access to PE was monitored for fairness.

Education, skills and work activities

Leadership and management of education, skills and work activities

Leaders and managers had made very slow progress in tackling the weaknesses identified at the last inspection. All of the past weaknesses remained, most notably prisoners’ low attendance and involvement in activities and induction, prisoners’ poor punctuality, and the narrow and low-level range of provision.

Further weaknesses at this inspection included some key aspects of teaching and learning which were still not good enough, a sharp fall in the number of prisoners attending initial skills assessments, and the low proportion of prisoners completing their courses and gaining qualifications.

The prison’s quality improvement arrangements were ineffective. Regular externally-led evaluations of purposeful activity provided thorough and accurate assessments about the quality of provision but ultimately charted a progressive decline in its effectiveness. Leaders’ strategic planning did not lead to clear or systematic action planning. The prison did not promote a culture which recognised education, work and skills as a means of rehabilitation.

There were enough activity places for all prisoners to attend work, training or education at least part time. But we found only around 20% of prisoners were engaged in any form of purposeful activity at any one time. Too many sentenced prisoners were not allocated to an activity and a third of prisoners were recorded as being unemployed.

The community rehabilitation company (CRC) had begun to provide prisoners with pre-release support to enter employment, training or education, but this was mostly  recent and poorly attended. The education provider had begun to provide some useful information advice and careers guidance. Prison managers did not gather meaningful or accurate data to monitor prisoners’ involvement in education, training or employment after release.

Quality of teaching learning and assessment

Teachers were professional, committed and resilient but were not all providing consistently effective teaching and learning. Teachers’ expectations of learners were not routinely high enough and there was a lack of challenge for prisoners generally.

Planning for individual learning was too often ineffective, not least because most teachers did not know routinely who was going to attend a class. The few instances of prisoners’ poor behaviour were not always managed well enough by teachers which led to low-level disruption of learning.

Prisoners were not all making enough progress in sessions observed or over time.

No specialist learning support was available to the substantial number of prisoners requiring it.

Personal development and behaviour

Prisoners’ behaviour in sessions observed had improved since the previous inspection but was still not consistently good. However, interactions observed between prisoners and with their teachers were generally positive and respectful.

Very few of the prisoners we interviewed valued their learning or believed it would enhance their prospects on release.

The accreditation of prisoners’ skills developed through work was poor.

Too few prisoners actually attended following enrolment on a course, and too many arrived at sessions determined to be sent back to the wings.

Achievements and outcomes for prisoner

Too many prisoners started but did not complete an accredited course or gain the qualification. This was particularly the case in full functional skills courses in English and mathematics, ESOL and employability. The relatively few prisoners who did complete an accredited course usually achieved their qualification.

Too many prisoners left the prison no more qualified or skilled for work than on entry to the prison.


4. Rehabilitation and release planning

Work with children and families was adequate. A majority of sentenced prisoners, including all high-risk prisoners, received regular and meaningful offender supervisor contact. However, the offender management of low- and medium-risk prisoners – about 40% – had effectively ceased because of staff shortages. Many prisoners did not have an up-to-date OASys. Home detention curfew (HDC) processes were not effectively managed. Prisoners struggled to progress and move on to other suitable prisons. Public protection arrangements were reasonably good. The need for housing and debt support was high but provision was too limited and too many prisoners were released homeless. Demand for release planning was high and resettlement needs were identified promptly on arrival, but there was no assurance they were met. Outcomes for prisoners were not sufficiently good.

Children, families and contact with the outside world

• There was a good new strategy document on children and family ties, but the level of delivery had reduced, with no parenting courses or family ‘craft box’ sessions. Children’s visits were held regularly, a cycle of quarterly family days had begun, and a community worker provided a valuable service for families of prisoners who lived locally.

• The visits hall, although of limited size, was well run, with good assistance from Ormiston Trust staff and volunteers. The environment was tired with fixed rigid furniture but with a good cafe and play facilities. Visits booking was now working reasonably well.

Reducing risk, rehabilitation and progression

Strategic management of reducing reoffending remained weak. The reducing reoffending strategy was thoughtful but aspirational and based on a limited needs analysis. The reducing reoffending committee rarely met and did not drive improvement. There was no action plan to monitor progress.

A lack of staff and experience undermined the work of the offender management unit (OMU). The CRC remained under-resourced and the two were not well integrated.

Those prisoners supervised by on-site probation officers (amounting to about 60% of sentenced prisoners), including all high-risk men, were well managed, and had regular, meaningful contact.

Uniformed offender supervisors were constantly cross-deployed which meant that about 40% of the OMU’s caseload, of low- and medium-risk prisoners, had little or no ongoing contact.

About 40% of all eligible prisoners did not have an up to date OASys assessment and many others had already transferred without an assessment to inform their move.

Basic, but critical, administrative tasks such as sentence calculation were not promptly completed, which frustrated prisoners and affected outcomes in areas like release planning.

HDC processes were not effectively managed. Some prisoners who should have been considered for HDC were not.

There was insufficient oversight to ensure the appropriate and prompt transfer and progression of sentenced prisoners.

Public protection

There was a regular interdepartmental risk management team (IRMT) meeting with an appropriate scope, but attendance from other departments was weak and high-risk prisoners were considered too close to release to allow time for remedial action.

There was good information exchange between community offender managers and on-site probation officers in most high-risk cases we looked at.

Mail and telephone monitoring arrangements were generally well managed and reviewed in a timely manner.


The introduction of the Reactiv8 programme (a sports-based approach to improve thinking skills) was very positive and suitably focused on a young and short-term population.

In our survey, significantly more prisoners than at other local prisons reported they needed help around finance, benefit and debt. Support from the CRC overall was too limited, but prisoners could now open bank accounts, which was an improvement.

There was high demand for help with accommodation. Despite the best efforts of the CRC, a third of prisoners with an identified accommodation need were released homeless. Remand prisoners who made up half of the population were not helped to find accommodation at all.

Release planning

Demand for resettlement services was very high, with about 90 prisoners released each month. Many prisoners stayed for a very short time – about 60% of the population had been at Bedford for three months or less.

CRC provision remained too limited. While initial resettlement plans were completed on time and appropriately identified need, too many prisoners did not have their plan reviewed prior to release to ensure that referrals and actions were completed.

The pre-release board, which was potentially extremely useful, was poorly attended and was not given sufficient priority by the prison.


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Related articles:

13/9/2018 Urgent Notification HMP Bedford

16/8/2018: Urgent Notification HMP Birmingham

30/5/2018: Urgent Notification HMP Exeter

17/1/2018: Urgent Notification HMP Nottingham

All Urgent Notifications, Responses & Action Plans

HMP Bedford Latest IMB Report (June 2017)

HMP Bedford: Ministerial Response (13 November 2017)

Chief prisons inspector demands urgent government action to tackle appalling violence and squalor at HMP Birmingham

HM Chief Inspector of Prisons has called on the Justice Secretary to launch an urgent and independent enquiry to understand how the privately run HMP Birmingham, one of Britain’s biggest jails, has “slipped into crisis” in only 18 months.

Inspectors found the prison in “an appalling state” with high violence, widespread bullying, squalid living conditions and poor control by fearful staff, who suffered an arson attack on their supposedly secure car park during the inspection. It is only the second jail ever to be assessed by HM Inspectorate of Prisons (HMIP) as poor, its lowest assessment, across all key aspects of prison life.

Peter Clarke told David Gauke that the prison had suffered a “dramatic deterioration” since the last inspection in early 2017, when inspectors found it was still shocked after disturbances at the end of 2016 but was showing a determination to improve. Just 18 months later it was assessed as poor in HMIP’s four ‘healthy prison tests’ – safety, respect, purposeful activity and rehabilitation and release planning.

HMP Birmingham is managed by the private contractor G4S, in a contract with the Ministry of Justice (MoJ) and HM Prison and Probation Service (HMPPS). Mr Clarke said he believed no long-term progress could be achieved until the reasons for such a swift and dramatic decline in Birmingham were fully understood. However, he stressed, an enquiry into what had gone wrong with the contract management and delivery must not be allowed to stand in the way of the “urgent and pressing need to address the squalor, violence, prevalence of drugs and looming lack of control that currently afflict HMP Birmingham.”

Mr Clarke has invoked the Urgent Notification protocol, signed in November 2017 and designed to enable the Chief Inspector to put the Secretary of State publicly on notice that urgent action is needed to address significant concerns at a jail. The protocol has only been used twice before, at HMP Exeter and HMP Nottingham. Mr Clarke today published the letter he sent on 16 August to Mr Gauke, with a briefing note drawn closely from the debrief for the Director of the prison at the end of the inspection. The letter and note depict some of the most disturbing evidence that inspectors, who visited Birmingham between 30 July and 9 August 2018, have seen in any prison:

  • Over the last year, Birmingham was the most violent local prison in England and Wales. Those perpetrating the violence “could do so with near impunity.”
  • Inspectors saw many prisoners under the influence of drugs and blatant drug use went largely unchallenged.
  • Control across the prison was tenuous, with staff often not knowing where their prisoners were and “a general lack of order on some wings.”
  • Many staff were inexperienced, lacking confidence and skills, and were poorly led. Many, also, were fearful. During the inspection, criminals launched an arson attack on the supposedly secure staff car park.
  • Communal areas were filthy, with cockroaches, vermin, blood and vomit left uncleaned. Staff and managers appeared to have become inured to these conditions, some of the worst inspectors had seen. In older wings, virtually every window was damaged and many were missing.
  • Education, work and training were ‘inadequate’ and measures to protect the public from high-risk men – while in prison and on release – were very poor.

Concluding his letter, Mr Clarke wrote:

“I was astounded that HMP Birmingham had been allowed to deteriorate so dramatically over the 18 months since the previous inspection. A factor in my decision to invoke the Urgent Notification protocol is that at present I can have no confidence in the ability of the prison to make improvements. There has clearly been an abject failure of contract management and delivery…The inertia that seems to have gripped both those monitoring the contract and delivering it on the ground has led to one of Britain’s leading jails slipping into a state of crisis.”


  1. Mr Clarke’s Urgent Notification letter to Mr Gauke, and the accompanying note, can be found here.
  2. On 30 November 2017, Mr Clarke and David Lidington, then Justice Secretary, signed the Urgent Notification protocol – an extension of the existing working protocol between HMI Prisons and the Ministry of Justice. Mr Clarke said at the time: “The Secretary of State has accepted that he and his successors will be held publicly accountable for delivering an urgent, robust and effective response when HMI Prisons assesses that treatment or conditions in a jail raise such significant concerns that urgent action is required. The protocol requires the Secretary of State to respond to an Urgent Notification letter from HM Chief Inspector of Prisons within 28 days. The Chief Inspector’s notification and the Secretary of State’s response will both be published.
  3. The most recent two-week inspection of HMP Birmingham began on 30 July 2018 and ended on 9 August. The inspection was unannounced.
  4. The debriefing note accompanying the Urgent Notification letter to the Secretary of State is drawn from the initial HMI Prisons findings shared with the Director of HMP Birmingham. As is the case with all HMI Prisons inspections, these early findings are indicative and may be changed at the discretion of the Chief Inspector, after due consideration or following the emergence of new evidence (all HMI Prisons evidence and conclusions are subject to a rigorous fact-checking process). However, it was the view of the Chief Inspector that the initial findings at HMP Birmingham were clear and concerning enough to warrant his decision to invoke the Urgent Notification protocol.
  5. A full report on HMP Birmingham will be published in due course, around 18 weeks after the end of the inspection.