First of the new HMI ‘Independent Review of Progress’ Reports shows “Too Little Too Late” at HMP Exeter

“A thoroughly depressing report”
Mark Leech, Editor:  The Prisons Handbook
for England and Wales

Work to address key failings at HMP Exeter, a troubled prison found last year to suffer high levels of drug-fuelled violence, has lacked urgency, according to HM Inspectorate of Prisons.

In the first of its new ‘Independent Reviews of Progress’ (IRPs) – in Exeter in April 2019 – HMIP tested progress against key recommendations from a full inspection in May last year. Peter Clarke, HM Chief Inspector of Prisons, was so concerned by the conditions in Exeter at that time that he issued a rarely-used ‘Urgent Notification’ requiring the Secretary of State to respond with plans for improvement within 28 days.

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The IRP visit presented a mixed picture. One of the most troubling findings was ‘no meaningful progress’ in understanding the factors underlying high levels of illicit drug use.

Mr Clarke said that while there had been progress on some aspects, “the lack of progress in over half the 13 recommendations that we reviewed could be characterised by the statement ‘too little too late’.

“The purpose of the Urgent Notification Protocol, which is only used where I have serious concerns about the treatment of and conditions for prisoners, is to initiate immediate remedial action.

“At Exeter, in too many critical areas, this simply had not happened. It was not clear whether this was as a result of a conscious decision not to prioritise our recommendations, bureaucratic inertia, or whether managers were simply overwhelmed or uncertain as to how to set about making the much-needed improvements. 

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“Whatever the reason, there had not been a sufficient sense of urgency in the prison’s response to a number of key recommendations.”

In the May 2018 inspection, inspectors found there had been six self-inflicted deaths between 2016 and 2018 and self-harm had risen by 40%. Despite these levels of vulnerability, self-harm and suicide, cell call bells were routinely ignored by staff. The rate of assaults between prisoners was then the highest inspectors had seen in a local prison in recent years.

In April 2019, the IRP found that overall levels of violence had decreased, though they remained higher than in similar prisons. Mr Clarke said: “A number of actions had been taken to reduce violence and the strategy to reduce violence further in the future was promising.” The use of unregulated segregation had been eradicated, and governance of the use of force by staff was improving.

“However, despite a rise in the already high use of illicit drugs in the establishment, there had been an inexplicable failure to develop a comprehensive drug strategy which, if properly implemented, would certainly contribute to a reduction in violence. A draft strategy was being put together and it is essential that this is now treated as a priority.”

Relationships between staff and prisoners were found to be improving and improvement processes were in place to monitor cell bell responses. There was progress on prisoner applications and complaints, though equality and diversity work had not been prioritised at all. Similarly, attendance at education and work, some of which remained mundane, had not been prioritised.

Mr Clarke said that after the Urgent Notification the prison was required to produce an action plan for the Secretary of State but a number of the deadlines in this plan had not been met on time.

“Nevertheless, there had been a proactive response to some recommendations in critical areas and there are now credible plans to make further improvements in the future. It is unfortunate that the prison had not devised and implemented some of these plans earlier as they would no doubt have led to a more positive assessment at this review of progress.”

Mark Leech, Editor of The Prisons Handbook for England and Wales called the report ‘thoroughly depressing’.

Mr Leech said: “We all had high hopes that the Urgent Notification process would lead to real and lasting improvements in those prisons which have been subject to it – HMP Exeter was the first such prison to benefit from a post Urgent Notification IRP and this review of progress is a thoroughly depressing report that demonstrates that not even the Justice Secretary’s public undertakings of progress can be relied upon.”

The report is available here:

HMP ONLEY: A chaotic, fundamentally unsafe, prison locked in a battle with drugs and violence.

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“This is a truly shocking report of a prison in complete chaos and in danger of flipping into self-destruct – the lack of Urgent Notification from the Prisons Inspectorate is frankly bewildering.”
Mark Leech

UPDATE:  Mark Leech: Following publication of this post today, and my comments at the bottom of it, I received a juvenile email from the Chief Communications Officer at The Prisons Inspectorate – you can read it, and my reply, here

HMP Onley, a training prison in Warwickshire with 80% of its population from London, is “fundamentally unsafe” with high levels of drugs and violence.

When the Prisons Inspectorate last inspected HMP Onley in 2016 they made 70 recommendations overall. The prison fully accepted 53 of the recommendations and partially (or subject to resources) accepted 16. It rejected one of the recommendations.

At this follow-up inspection in November 2018 – two years later – the Prison Inspectorate found that the prison had achieved 24 of those recommendations, and not achieved 46 recommendations.

Peter Clarke, HM Chief Inspector of Prisons, said the prison had been assessed as ‘poor’ for safety – the lowest assessment – at the previous inspection in 2016.

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When inspectors visited in November 2018, Mr Clarke added, it was “particularly disappointing” to find Onley was still fundamentally unsafe.   “Time and again we find that prisons which are unsafe will struggle to make progress in other areas, and HMP Onley was no exception.”

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The lack of safety was “all too obvious”. The report noted that the reception wing was chaotic and “new arrivals, still carrying their property and stood in the busy corridor, were approached and faced predation by more experienced prisoners.”

 Mr Clarke added: “Perhaps it is not surprising that in our survey only 62% of prisoners said they felt safe on the first night. Sadly, their feelings were an all too accurate reflection of what life in Onley would be like during their time there.”

The prevalence of illicit drugs played a major role in causing destabilising factors such as violence, debt, bullying and health emergencies. During the previous three months there had been 200 emergency health calls related to the use of new psychoactive substances (NPS). “Despite this, we found that far too little was being done to obstruct the flow of drugs into the jail.”

Violence was higher than at similar category C prisons and although prisoner-on-prisoner assaults had decreased since 2016, assaults on staff had more than doubled. Far too many prisoners were self-isolating – refusing to come out of their cells or to go to education, work and training. The prison believed much of the violence was gang-related.

Mr Clarke said: “HMP Onley was a clear example of where the failure to deal with drugs and violence undermined many other aspects of prison life. There was a vicious circle where fear, frustration and boredom increased the demand for drugs, which in turn fuelled the violence.

“In order for Onley to break out of this circle, there must obviously be more effective action taken to reduce violence and the availability of drugs. But at the same time, more can be done in other areas.”

Rubbish was consistently thrown from cells windows and, the report noted, “there were problems with rats, and recent attempts to control the infestation had left some dying in wall cavities and vents, leaving an intolerable smell in some cells.” Accommodation on Onley’s newer wings was better than on its “shabby, cramped” older wings.

Onley was a training prison without enough activity places for the population, and during the inspection only 50% of prisoners were engaged in purposeful activity at any one time. Some 39% of prisoners were locked in their cells during the working day – far too high a proportion for a training prison. Extensive PE facilities were underused by the prison population, which was predominantly young, with around 60% from a black and minority ethnic background.

Inspectors noted that the prison had run a restricted daily regime for more than four years because of chronic staff shortages, though this was gradually being addressed.

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Mr Clarke said: “There can also be little doubt that doing more to support family relationships would help prisoners rehabilitate and prepare for their eventual release.” The report noted that Onley was in a remote location but there was no transport for families from local stations.

Overall, Mr Clarke said:

“I would not wish to detract from the many good things being delivered by dedicated and skilful staff. Health care, education, training, industry and offender management leading to release were all areas where there was some very good provision. Sadly, Onley will fail to fulfil its role as a training and resettlement prison until it can deal with the inextricably linked blights of drugs and violence.”

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

“Tackling drugs and violence at Onley is our top priority and, while challenging, significant efforts have been made to drive improvement. These have included a major recruitment drive, with 30% more officers soon to be in place compared to 2018, along with additional security measures such as mail scanners, while a new drug recovery unit is due to open this spring. As the Chief Inspector makes clear, despite the difficulties there is good work going on at Onley to help prisoners turn their lives around and reduce the risk of reoffending on release.”

Mark Leech, Editor of The Prisons Handbook for England and Wales said the report showed “a prison in complete chaos”.

Mr Leech writes:

This is a truly shocking report of a prison in complete chaos and in danger of flipping into self-destruct – the lack of Urgent Notification from the Prisons Inspectorate at Onley is frankly bewildering.

Onley is a fundamentally unsafe prison, previous recommendations on safety, decency, and respect have been ignored wholescale.

Drugs and violence have taken control, and Onley ticks all the Urgent Notification boxes – yet the Prisons Inspectorate has failed yet again to activate a procedure designed for exactly these kind of situations.

I have heard it suggested elsewhere that political pressure was placed on the Prisons Inspectorate to ‘give it a rest’ and not to activate the Urgent Notification procedure ‘for a while’, after four in a row were bowled stump high at the Justice Secretary last year – true or not, if Onley doesn’t meet the test for the Urgent Notification procedure, then I’d like someone to tell me exactly what does.

Mark Leech is the Editor of The Prisons Handbook for England and Wales

The Prisons Inspectorate ‘Urgent Notification Protocol’: Does It Work?

By Mark Leech FRSA. Editor: The Prisons Handbook.


Like many who know a thing or two about prisons I was really encouraged last November when HM Chief Inspector of Prisons (HMCIP), Peter Clarke, announced details of the ‘Urgent Notification Protocol’ (UNP) he had signed with the Justice Secretary.

Privately, while praying it would work, I was also cynically sceptical; it happens after 20 years in this field – and its healthy too.

The UNP allowed HMCIP to give the Justice Secretary urgent notification of significant concerns with regard to the treatment and conditions of those detained’ in establishments the Inspectorate had visited.

More than that, in a break with tradition, the urgent notification was itself to be made public by HMCIP – and the Justice Secretary agreed to reply publicly too, within 28 days, by setting out an Action Plan bringing focus and delivering resources to what urgently needed to be put right.

No other Chief Inspector of Prisons had ever managed to achieve anything like the degree of public accountability the UNP promised from a Justice Secretary; but could it really work in practice?

It seemed a tall order, time would tell, and as it turned out I didn’t have long to wait.

On 17th January 2018, six weeks after the UNP was agreed, HMCIP signed the first urgent notification in respect of appalling conditions he found at HMP Nottingham.

Peter Clarke wrote:

“The principal reason I have decided to issue an Urgent Notification in respect of HMP Nottingham following this most recent inspection is because for the third time in a row HMI Prisons has found the prison to be fundamentally unsafe.

“Most seriously, in the two years since our last inspection, levels of self-harm have risen very significantly and eight prisoners are understood to have taken their own lives (some cases are still subject to a coroner’s inquest). Despite these shocking facts, there have been repeated failures to achieve or embed improvements following previous recommendations made by the Prisons and Probation Ombudsman (PPO).

“Irrefutable evidence of the failure to respond to HMI Prisons’ inspection findings at Nottingham can be seen not only in the gradings given as a result of the latest inspection, but also in the progress made in implementing previous recommendations.

“Following the February 2016 inspection we made a total of 48 recommendations, 13 of which were in the crucial area of Safety. Of those 13, a mere 2 had been fully achieved, and 2 partially achieved. Overall, 12 of the 48 recommendations were fully achieved, 23 were not achieved and 13 partially achieved.

“As the last two inspections have been announced in advance, to give the prison the opportunity to focus on the areas where improvement was urgently needed before the inspections took place, it is extraordinary that there has not been a more robust response. An action plan was drawn up to guide the implementation of recommendations, but has obviously not received consistent focused attention nor close monitoring from HMPPS senior leadership.”

True to his word the Justice Secretary prepared an Action Plan, with specific time deadlines by which improvements at HMP Nottingham had to be made – but Clarke wasn’t finished yet.

In May 2018, while the Action Plan at Nottingham was underway, the Chief Inspector fired off his second incendiary urgent notification – which this time landed squarely on HMP Exeter.

Peter Clarke wrote:

“The principal reasons I have decided to invoke the UN protocol in respect of HMP Exeter following this most recent inspection are because since the last full inspection in August 2016, safety in the prison has significantly worsened in many respects, and has attracted our lowest possible grading of ‘poor’.

“There have been six self inflicted deaths, five of which were in 2017.

“Despite some creditable efforts to implement recommendations from the Prisons and Probation Ombudsman following those deaths, the overall level of safety at HMP Exeter is unequivocally poor.

“Self harm during the past six months is running at a higher rate than in any similar prisons. It has risen by 40% since the last inspection. Assaults against both prisoners and staff are among the highest we have seen, and the use of force by staff is inadequately governed.

“Meanwhile, illicit drugs are rife in the prison, nearly a quarter of prisoners are testing positive, and all this is taking place in a prison where the living conditions for too many are unacceptably poor.

“During the inspection we saw many examples of a lack of care for vulnerable prisoners which, given the recent tragic events in the prison, were symptomatic of a lack of empathy and understanding of the factors that contribute to suicide and self harm.”

Again the Justice Secretary responded with an Action Plan with time deadlines for improvements to be made. It was while David Gauke was reeling from both the Nottingham and Exeter notifications that, in August 2018, the Chief Inspector bowled his most devastating urgent notification at the Justice Secretary stump high – this time about HMP Birmingham.

Peter Clarke wrote witheringly:

“The first priority of any prison should be to keep those who are held or work there safe. In this regard, HMP Birmingham had completely failed.

“Levels of violence had increased and, when measured over the last 12 months, were the highest for any local prison in the country. Many of the assaults were serious and the number was rising. Prisoners and staff frequently required hospital treatment.

“In our survey, 71% of prisoners told us they had felt unsafe at some time in Birmingham, an extraordinarily high figure.

“Thirty-seven per cent felt unsafe at the time of the inspection and many reported being bullied and victimised by other prisoners. The prison’s response to this was wholly inadequate.

“Most violent incidents were not investigated. There was inadequate analysis or understanding of the violence. In short, the prison’s strategy for confronting violence was completely ineffective. It did not, for example, even address the potential impact that the widespread availability of drugs had on the violence.”

The Justice Secretary’s response and publication of the Action Plan for Birmingham prison are due imminently as I write this, but it was immediately apparent how seriously the Ministry of Justice took the urgent notification on Birmingham because for only the second time since prison privatisation came to the UK almost 30 years ago, the Government stepped in, removed the private prisons contractor (G4S) and put in place a public sector Governing Governor to restore order.

[As an aside, this weekend, in our national prisons monthly newspaper Converse, we publish a powerful article by the only other Governing Governor ever to ‘step in’ to a private prison after it had been taken back into public sector control – an article in which the difficulties and dangers of such a task are laid bare.]

How did we get here, how could these prisons have failed so seriously – and would this UNP even work?

How did we get here lol?

In a word: ignorance.

It was almost exactly a year ago now, following a damning prisons Inspectorate report on HMYOI Aylesbury that revealed of the 74 recommendations made to improve conditions at the prison two years before, only 14 had actually been implemented, that I decided to delve a little deeper into the effectiveness of the Prisons Inspectorate.

The research I carried out (published in The Independent) showed that of over 1,800 recommendations the Inspectorate made to improve safety and conditions last time they visited the 28 prisons they had inspected in the year to August 2017 – well over 60% of those recommendations had never been implemented, despite three and five years that had passed between those inspections having taken place.

No-one, from the very top down, batted an eyelid at the shameful implementation figures; ignoring HMIP recommendations had become dangerously routine and where, as a consequence, little if anything changed.

The Chief Inspector continued to tour the country finding exactly the same failings, in exactly the same prisons, and where he was ignored in exactly the same way, time after time.

I wrote at the time that what we needed was a Prisons Inspectorate that was ‘bold and forceful, one that publicly held Ministers to account’ or what, I asked, was the point of it all?

It would be wrong of me to imply my Independent article was responsible for the UNP that was signed three months after my article appeared, HMCIP had himself been privately complaining bitterly that his recommendations were being ignored, but if nothing else the Urgent Notification Protocol that followed it was a welcome by-product.

But does the UNP work?

On 14th August 2018, I submitted a FOIA request to the MOJ, looking at the Action Plans devised after the Urgent Notifications at HMP Nottingham and HMP Exeter. I asked whether the timescales for completion of all the remedial tasks set out in the Plans had been met.

I was both relieved and pleasantly surprised to learn that although there had been a time slippage of a couple of weeks on one or two tasks, the action plan tasks at both Nottingham and Exeter had all been completed – you can view the full request and response at the bottom of this editorial.

Without doubt the UNP is a massive professional accomplishment for Peter Clarke, one the prison system will derive benefits from for years to come, and one in which he has succeeded where so many others before him have failed.

But equally Clarke still has much more to do – ridding the Inspectorate of their ridiculous ‘partially achieved’ assessments would be a good start.

Instead of just assessing whether a previous HMIP recommendation has been achieved or not, HMCIP allows Inspectors – without any guiding criteria at all – to mark them as ‘partially achieved’; but what on earth does that even mean?

I asked the Chief Inspector to explain – he couldn’t do so – and its also unclear where ‘partially achieved’ even comes from; the words don’t appear once in the whole of the Expectations documentation that underpins all inspections.

But that is something for the future, right now the danger is that with the passage of time an ‘urgent notification’ will cease to have its current media effect – and with it, the political resolve to put things right.

Do things really have to reach the dreadful, dangerous, demeaning Dickensian conditions found at Nottingham, Exeter and Birmingham before the MOJ swings into action?

Surely not.

The lesson (and the danger) of the UNP though is an old one: a stitch in time saves nine.

Unless we view every single recommendation of HMCIP, in all of their Inspection Reports, as an ‘urgent notification’ about which action needs to be taken, then the danger is the ‘urgent notifications’ will become less urgent as they become increasingly frequent – and as quantity increases quality and effect inevitably decline.

For the moment, however, we can be content to know that it is working as it should – but that must not stop the huge underlying mindset change that is needed in our prison system, if ever urgent notifications are to be the isolated examples they were designed to be, rather than the tip of an iceberg that they seemingly currently appear to represent.

You can view the FOI request and response here.

Mark Leech is the Editor of The Prisons Handbook for England and Wales and other books about the prison system. Twitter @prisonsorguk. Download our App!

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.