HM Prison and Probation Service
Central Government
Action Planned
HMPPS is undertaking a cell design review to explore different materials that meet fire safety and anti-ligature requirements for bedding, expected to conclude at the end of 2026. To improve first-on-scene care, HMPPS have with St John Ambulance created a set of bespoke first-on-scene videos for Prison Officers and frontline staff. (AI summary)
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Dear Mr Brownhill, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR AZROY DAWES- CLARKE Thank you for your Regulation 28 report of 29 July 2025, addressed to His Majesty’s Prison and Probation Service (HMPPS). I am responding as the Interim Director General of Operations. I know that you will share a copy of this response with Mr Dawes-Clarke’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. You have raised several concerns which I will address in turn. Your first concern relates to the material from which the mattress and pillow covers are made. This is an ongoing challenge for HMPPS and an area of continual improvement to source products that meet both durability and fire safety standards. It is important to note that, as prisons are classified as ‘very high fire hazards’ (compared to hospitals which are ‘medium hazard’ and residential care homes ‘high hazard’), they are required to comply with stringent regulations when selecting beds, mattresses, and bedding to ensure the safety of both prisoners and staff. Prison Service Instruction (PSI 11/2015) Fire Safety in Prison Establishments sets out the fire-retardancy standards for furniture and upholstery in prisons. HMPPS are currently undertaking a cell design review which is looking at all aspects of cell design, including furniture and fittings, to ensure it takes account of developments in how prisoners are accommodated and improvements in what is currently available on the market. As part of this review, we will explore the possibility of using different materials which meet the stringent fire safety requirements and can also function as anti-ligature for bedding. The review is expected to conclude at the end of 2026.
You raised that staff at inquest described different levels of familiarity and training in respect of the Assessment, Care in Custody and Teamwork (ACCT) process. HMP Elmley is committed to providing appropriate local training to upskill both operational and non- operational staff. This includes reinforcement of ACCT procedures through the ongoing rollout of Suicide and Self-Harm (SASH) training and “speed training” for bite-sized learning. Since Mr Dawes-Clarke’s death much work has been undertaken to help increase awareness and recognition of risk factors that increase the possibility of suicide and/or self- harm. A focus on continuing to upskill and support better case management as well as ACCT training for all staff working with prisoners is ongoing. The quality of ACCT management and compliance with policy is routinely assured, as per the nationally mandated quality assurance process, and findings from this assurance is fed back to staff to enable ongoing awareness and improvement. Additionally, Elmley’s safety team have devised an action plan to support improving case management including ACCT upskill training, attending case reviews to share experience and guidance and developing an improved booking system to enable better multi-disciplinary attendance and consistency of case co-ordinators. You also raised that during the inquest it became clear that not all staff had recent training in first aid or basic life support. The first aid policy framework was re-issued nationally in August 2023. It outlines the requirements for emergency first aid and first aid at work, emphasising the responsibility of Governors to always ensure adequate first aid cover. This is achieved by conducting a detailed local risk assessment to establish the number of trained first aiders at work (FAW) and emergency first aiders at Work (EFAW) needed for each establishment. Emergency first aid is mandatory and forms part of the foundation training for all new officers and is valid for three years. At HMP Elmley, 44 officers currently hold in-date first aid qualifications, with an additional 152 staff trained in EFAW. Alongside this provision, healthcare staff are available 24 hours a day 7 days a week to provide emergency assistance. To further improve our emergency contingency arrangements and to better equip employees to provide first-on-scene care (before medical assistance arrives), HMPPS have with St John Ambulance created a set of bespoke first-on-scene videos for Prison Officers and frontline staff. These provide practical guidance on what to do in several potential scenarios staff may come across in the course of their duties. Finally, you raised that none of the officers who completed the Use of Force paperwork appeared to have any basic understanding of the circumstances when the Mental Capacity Act may apply in a custodial setting. The Mental Capacity Act (MCA) is referenced within both the Use of Force (UoF) Policy Framework and UoF training, particularly regarding circumstances where officers may need to restrain a prisoner lacking capacity to ensure their safety or to facilitate medical treatment. The framework emphasises that any intervention must be proportionate, use the minimum necessary force, and last only as long as required.
Officers are not expected to assess a prisoner’s mental capacity; this responsibility lies with healthcare professionals. Where staff have concerns about a prisoner’s mental capacity, they are directed to seek healthcare input. Staff are instead required to act in accordance with policy, supported by appropriate de-escalation techniques, and to apply use-of-force measures only when strictly necessary and in a proportionate and sensitive manner. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the issues identified.
You raised that staff at inquest described different levels of familiarity and training in respect of the Assessment, Care in Custody and Teamwork (ACCT) process. HMP Elmley is committed to providing appropriate local training to upskill both operational and non- operational staff. This includes reinforcement of ACCT procedures through the ongoing rollout of Suicide and Self-Harm (SASH) training and “speed training” for bite-sized learning. Since Mr Dawes-Clarke’s death much work has been undertaken to help increase awareness and recognition of risk factors that increase the possibility of suicide and/or self- harm. A focus on continuing to upskill and support better case management as well as ACCT training for all staff working with prisoners is ongoing. The quality of ACCT management and compliance with policy is routinely assured, as per the nationally mandated quality assurance process, and findings from this assurance is fed back to staff to enable ongoing awareness and improvement. Additionally, Elmley’s safety team have devised an action plan to support improving case management including ACCT upskill training, attending case reviews to share experience and guidance and developing an improved booking system to enable better multi-disciplinary attendance and consistency of case co-ordinators. You also raised that during the inquest it became clear that not all staff had recent training in first aid or basic life support. The first aid policy framework was re-issued nationally in August 2023. It outlines the requirements for emergency first aid and first aid at work, emphasising the responsibility of Governors to always ensure adequate first aid cover. This is achieved by conducting a detailed local risk assessment to establish the number of trained first aiders at work (FAW) and emergency first aiders at Work (EFAW) needed for each establishment. Emergency first aid is mandatory and forms part of the foundation training for all new officers and is valid for three years. At HMP Elmley, 44 officers currently hold in-date first aid qualifications, with an additional 152 staff trained in EFAW. Alongside this provision, healthcare staff are available 24 hours a day 7 days a week to provide emergency assistance. To further improve our emergency contingency arrangements and to better equip employees to provide first-on-scene care (before medical assistance arrives), HMPPS have with St John Ambulance created a set of bespoke first-on-scene videos for Prison Officers and frontline staff. These provide practical guidance on what to do in several potential scenarios staff may come across in the course of their duties. Finally, you raised that none of the officers who completed the Use of Force paperwork appeared to have any basic understanding of the circumstances when the Mental Capacity Act may apply in a custodial setting. The Mental Capacity Act (MCA) is referenced within both the Use of Force (UoF) Policy Framework and UoF training, particularly regarding circumstances where officers may need to restrain a prisoner lacking capacity to ensure their safety or to facilitate medical treatment. The framework emphasises that any intervention must be proportionate, use the minimum necessary force, and last only as long as required.
Officers are not expected to assess a prisoner’s mental capacity; this responsibility lies with healthcare professionals. Where staff have concerns about a prisoner’s mental capacity, they are directed to seek healthcare input. Staff are instead required to act in accordance with policy, supported by appropriate de-escalation techniques, and to apply use-of-force measures only when strictly necessary and in a proportionate and sensitive manner. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the issues identified.