Giuseppe Tabone and Andrew Evans

Dear Mr Spencer,

Thank you for your Regulation 28 report of 12 March 2024 addressed to HM Prisons and Probation Service (HMPPS) following the inquest into the deaths of Giuseppe Tabone and Andrew Evans at HMP Lewes on 28 June 2022. I am responding as Director General of Operations for HMPPS.

I know that you will share a copy of this response with the families of Mr Tabone and Mr Evans, and I would 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.

Following evidence heard at the inquest you have raised concerns around staff completing roll checks and the measures in place to ensure that the required checks are being carried out. I am grateful to you for bringing your concerns to my attention.

Roll checks are a fundamental part of ensuring the security and safety of those in our care. Whilst the primary purpose of roll checks is to ensure that all prisoners are accounted for, staff are required to take any necessary action if there are any immediate concerns for a prisoner’s welfare.

All prisons are required to have a local security strategy in place which includes a local operating procedure (LOP) that covers what security checks need to be carried out by staff. These include roll checks and any other mandatory checks, such as ACCT observations. The duties and expectations of all staff are clearly communicated and staff receive training and shadowing before working on the wings. For OSGs who work alone during the night state, these duties include carrying out a roll check at the beginning and end of each shift which must be reported to the control room and signed for.

The Governor of HMP Lewes has informed me that the prison’s LOP on roll checks was reviewed in August 2023 and clearly sets out the times that roll checks are required to be carried out and where staff must sign to confirm that the checks have been completed. The LOP provides guidance on checks during the week, on weekends and during the night state so that staff understand what their duties are at all times.

I am also informed that the prison has published notices to staff highlighting the importance of carrying out roll checks in line with expectations. A notice to staff was issued in August 2023 which prompts staff to consider three points when carrying out roll checks:

• Is the cell door secured?
• Are the correct number of occupants in the cell?
• Have you observed signs of life with all occupying the cell?

Following the inquest into the deaths of Mr Tabone and Mr Evans, the prison is reviewing roll checks to ensure that processes are in line with new staffing profiles and regime planning which is currently being reviewed and updated. Once this work is complete, a new notice to staff will be issued setting out learning from the inquest around roll checks.

There is a quality assurance process in place whereby the Orderly Officer (a Custodial Manager grade working during the night) or the Duty Governor carry out a check to satisfy themselves that the roll check has been completed and recorded. If roll checks are found to be incomplete, the member of staff is reminded of the importance of completing roll checks fully and warned that undertaking roll checks are part of their duties and that a failure to complete these may lead to disciplinary action being taken.

I understand that evidence was given at the inquest on the assurance measures in place for roll checks at the prison but that you remain concerned that the measures are insufficient. Whilst I am also concerned to learn of instances where staff have not carried out their duties in line with clear expectations, we must be able to trust staff to carry out the required tasks that are fundamental to their role. HMP Lewes hold a daily briefing which provides an opportunity to update and remind staff of the duties to be carried out as well as to convey any other important information.

Staff are aware that CCTV is in use around the establishment and that their actions may be scrutinised following an incident such as a death in custody. If staff are found to have failed to carry out the required tasks or when there is a question over their performance and ability there will be a thorough investigation to determine what has happened and to ensure that staff who fail to uphold the values of HMPPS by putting prisoner’s safety at risk are held to account through disciplinary procedures. Staff are aware that failure to carry out the duties entrusted to them will result in disciplinary action, and that, depending on the circumstances, the outcome may range from advice and guidance in order to support them to perform better, to dismissal from the service. As you are aware, in this case, the prison investigated and disciplined the staff members who failed to carry out the roll checks.

It is important that staff understand the importance of their duties, and the consequences of not fulfilling them properly, so we will continue to ensure that appropriate action is taken where staff fail to meet expectations.

I can confirm that HMP Lewes has planned further sessions of ‘bite size’ training on roll checks. The two members of staff who gave evidence that they had not received the training will be required to attend as a priority. Additionally, the prison has received support from the standards coaching team, a national resource, which consisted of a team of experienced prison staff shadowing officers at HMP Lewes to provide support and on-the- job training. The team covered roll checks as part of the support.

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 that you have raised.