Sarah Boyle

Dear Ms Davies,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MS SARAH BOYLE

Thank you for your Regulation 28 report of 2 May 2025 following the inquest into the death of Ms Boyle. The report is addressed to the Governor of HMP/YOI Styal, the Minister of State for Prisons, Probation and Reducing Reoffending, and the Ministry of Justice. I am responding as the interim HMPPS Director General of Operations on behalf of all three recipients.

I know that you will share a copy of this response with Ms Boyle’s family, and I would first like to express my condolences for her death. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

You have expressed a number of concerns about safety at the prison, including the operation of the Assessment, Care in Custody, and Teamwork (ACCT) case management process for those at risk of self-harm or suicide. Your report also touches more broadly on the extent of imported risk amongst the population at Styal, including the presence of women who have been remanded for their own safety on ‘warrants of concern’, and the pressure that this puts on both the prison and the provider of their mental health services.

I recognise your concerns that Styal has had a higher number of self-inflicted deaths than other establishments in the women’s estate, and would like to reassure you that following the cluster of self-inflicted deaths, support has been provided to the prison from the national safety team as part of the HMPPS cluster death support process. This has included assistance with delivering a local safety summit and upskilling for staff on a range of issues, including awareness of risks, triggers and protective factors for suicide and self-harm.

The purpose of the ACCT process is to provide a person-centred approach for prisoners at risk of suicide and/or self-harm, and I take very seriously your concern that it is not doing so effectively at Styal. The process is designed to ensure that support is responsive to the specific needs and circumstances of the individual, such as mental health concerns, which are discussed during multi-disciplinary case reviews. Care plans are then developed which use a range of support mechanisms, including specific support actions, observations and conversations, to ensure that there is holistic support for the individual to reduce their risk of suicide and/or self-harm.

In the light of your concerns and on the basis of other feedback and learning, the Governor of Styal is taking further steps to ensure meaningful support actions are identified at each case review and implemented. Case reviews are subject to quality assurance processes, and any case coordinators identified as needing additional support receive weekly one-to-one upskilling sessions. Furthermore, through the support of the group safety team, learning and best practice identified from other cases within the women’s estate is shared and applied at to facilitate continuous improvement.

As you have identified, the primary purpose of an ACCT observation is to ensure the safety and welfare of the prisoner. However, staff are also encouraged to engage with the prisoner during these observations where appropriate, to establish and build relationships. Additionally, the ACCT case co-ordinator sets the expected frequency of meaningful conversations throughout the day, in addition to the observations. These interactions are designed to allow prisoners to raise any concerns and to express how they are feeling, offering a valuable opportunity for emotional support to be provided by staff themselves, or for a referral to be made to other sources of such support, including Listeners.

All prisoners at Styal who are subject to ACCT case management and have observation levels set at more than one every two hours are located on the residential wings, as opposed to the dormitories, where there are more staff available to conduct the observations. Additionally, women who are being supported through the ACCT process are discussed during the Senior Management Team morning meeting, and where appropriate more staff are deployed to areas in which more such individuals are located to ensure that there is time for meaningful interactions with them. In support of this the local safety team is being expanded with the introduction of a safety analyst and a second safety hub manager, who will assist in the ACCT quality assurance process and provide any necessary upskilling for staff.

You have expressed particular concern about the contribution of mental health staff to the ACCT process. As you are aware, all new prisoners are assessed by healthcare colleagues and any mental health concerns are passed to the mental health team. Additionally, prison staff can contact the daily duty mental health worker during the core day if they have concerns about a prisoner. Every effort is made to ensure mental health colleagues attend the initial ACCT case review if there are concerns about a prisoner’s mental health, and if these continue mental health colleagues will be invited to attend subsequent reviews. In

response to your concerns, the Governor of Styal and the mental healthcare provider will be reviewing the current process for involving mental health services in such cases.

As you have pointed out the prison currently receives a number of women under what is known as a “warrant of concern”. This term is used to describe any warrants that cite mental health issues, vulnerabilities or own protection as a reason to refuse bail. Currently, any warrants of concern are reported to the Prison Group Director for the women’s estate who is monitoring their prevalence across the estate. As you have noted the presence of prisoners remanded for this reason, who frequently have complex needs, adds to the challenges faced by prison and healthcare staff.

I am pleased to report that the Government is committed to ending the use of remand for own protection where the court’s sole concern is a defendant’s mental health through the Mental Health Bill which is currently going through Parliament. Instead, courts will be directed to bail the defendant and work with local health services to put in place appropriate support and care to address risks to their safety.

I am aware that both you and the Senior Coroner for Cheshire are intending to visit Styal in September. I am pleased to hear this and hope you will be able to see the benefits of these actions and the broader programme of work to improve safety at HMP/YOI Styal.

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 matters identified.