Source · Prevention of Future Deaths

Haik Nikolyan

Ref: 2023-0340 Date: 15 Aug 2023 Coroner: Crispin Butler Area: Buckinghamshire Responses identified: 1 / 1 View PDF

HMP Aylesbury's transition to a Category C prison is challenged by recruitment and retention issues among experienced staff, impacting daily operations, training, incident response, and the management of vulnerable prisoners.

Date 15 Aug 2023

56-day deadline 17 Nov 2023 est.

Responses identified 1 of 1

State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

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HMP Aylesbury transitioned from a High Security Young Offenders Institution (a role it had undertaken for many years) into a Category C Training Prison after the time in which Haik Nikolyan had been an inmate. This has led to a quite different cohort of prisoners with different and additional issues to be addressed in their management and healthcare needs. Staffing changes have also occurred over the period, although the physical prison infrastructure is largely the same with some wing refurbishments being undertaken from time to time. Healthcare provision is also being undertaken by different providers today. Following the conclusion in March this year of an Inquest into the death of another young prisoner, Anthony McNally, at Aylesbury (which occurred in January 2021), a letter was written by me to the Governor in which I noted, inter alia, that the evolution to Category C status required time and resources and was not without significant challenges going forward. I was then (as now) interested to hear that appropriate resources continued to be sought and deployed by the prison to continue the work, from prison and healthcare perspectives, adapting to the Category C status, ensuring the safety and wellbeing of prisoners, staff and those with cause to visit the prison going forward. Some three months further on, my concerns are heightened to the extent that a death may result in a variety of circumstances through the continuing significant issues HMP Aylesbury is encountering in recruitment and retention of experienced prison staff, particularly Grade 3 officers. Although initial steps are being taken towards implementation of a new neurodiversity plan, including the management of prisoners with autistic traits (pertinent to the circumstances of the death of Haik Nikolyan in 2019) and some recruitment has just taken place, without appropriate resources specifically in this area and within the broader staff cohort, there will be difficulties in maintaining this important work. The evidence heard at this Inquest in July 2023 indicates that general staffing levels are likely to impact upon the operation of the daily regime, training and reaction to individual incidents, against a background of increasing levels of violence and access to illicit substances, resulting from the changing cohort of longer-term and older prisoners within this Category C institution. The indication in evidence was that addressing these issues and continuing to address these issues is a matter for His Majesty's Prisons and Probation Service, working with HMP Aylesbury.

Responses

1 respondent

HM Prison and Probation Service Central Government

19 Oct 2023 PDF

Action Taken

HMP Aylesbury has improved staffing levels, expanded key work provision, appointed a Neurodiversity support manager, reviewed the adjudication tariff for drug-related incidents, and reconfigured the safety team. Nationally, a TV and radio advert has been launched to support recruitment. (AI summary)

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Dear Mr Butler,

Thank you for your Regulation 28 report of 15 August 2023, addressed to . I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.

I know that you will share a copy of this response with Mr Nikolyan’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 expressed concerns regarding the recruitment and retention of prison officers at HMP Aylesbury.

To support Aylesbury’s function as a category C trainer prison, a review of all staffing requirements was undertaken which has enabled Governors to review and distribute the resources available more effectively. The staffing position at HMP Aylesbury has notably improved and the now small number of vacancies for Band 3 Officers includes some staff who are currently undergoing training. A number of recruitment initiatives have taken place, with more planned for the coming months, to continue to fill vacancies in other key posts, such as instructors and probation POMs.

This increase in staffing has allowed an improved regime to be offered to all prisoners, and has enabled the expansion of the key work provision, which gives enhanced support to prisoners. HMP Aylesbury have appointed a Band 6 Neurodiversity support manager to raise awareness of neurodiversity among all staff, and to provide training using the neurodiversity toolkit. The reception and induction will also be adapted to make them more accessible for neurodivergent prisoners.

Considerable work continues to be undertaken to reduce the availability and use of drugs within HMP Aylesbury. A National and Group Drug Strategy support visit has included a review of the adjudication tariff and process for drug related incidents including positive MDT results, and a review of county lines and criminal exploitation. Conversations are additionally underway with Public Health and Commissioners to support the strategy of improving staff and prisoner

awareness around the impact of substance misuse, in order to restrict supply, reduce demand and build recovery.

While levels of violence at the establishment remain low, the safety team has been reconfigured to offer more support to prisoners, adding an operational Band 5, Band 4 Analyst and an extra officer to this team.

At national level we are taking all necessary steps to improve the staffing position across the country, and we are seeing the impact of that work. Substantial levels of support has been provided to HMP Aylesbury as one of the highest priority prisons for recruitment marketing. In addition, the Prison Resourcing Communications team are working closely with the establishment to improve their staff engagement channels, including their staff newsletter, to increase staff pride and morale to help reduce attrition.

In September 2023, the Ministry of Justice launched its first ever large-scale TV and radio advert to support recruitment across England and Wales, aiming to attract new recruits to a career in HMPPS, while getting the public to rethink what working in the prison and probation service involves, all under the slogan “An extraordinary job done by someone like you”.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.

Report sections

Investigation and inquest

On 15 March 2019 I commenced an investigation into the death of Haik Patrick NIKOLYAN aged 21. The investigation concluded at the end of the inquest on 12 July 2023. The jury recorded a narrative conclusion which stated: Haik was a vulnerable person with Autism Spectrum Disorder, who committed suicide following failures by those organisations who had responsibility to protect him from harm. He had a documented history of mental health difficulties, self-harm, depression, anxiety, suicidal thoughts and suicide attempts. The decision to withdraw prescription medications managing his depression without a documented risk assessment or enhanced monitoring was not in his best interest and led to him experiencing psychological withdrawal symptoms, exacerbating his anxiety and depression. The insufficient security at the prison allowed illegal drugs to circulate which contributed to his bullying and exploitation and created a barrier to accessing prescription medication. The prolific bullying, exploitation and humiliation that Haik experienced in prison contributed to his declining mental health. Policies, procedures and interventions put in place to safeguard him were ineffective, ill-advised and at times absent. This resulted in ineffective communication, between the Prison, Health and Mental Health services which meant information was recorded but inconsistently shared and acted upon effectively. Furthermore, the absence of a process for escalating concerns put him at heightened risk. Due consideration for the complexities that Austism Spectrum Disorder can present were not appropriately addressed. Due to a lack of adequate training and the absence of a clinical psychologist, some of his behaviours were interpreted to be dangerous rather than the presentation of Autism Spectrum Disorder. This resulted in the interventions that were in place being ineffective, and incompatible with Haik's needs and therefore this was an unsuitable custodial environment for him.

Circumstances of the death

Haik committed suicide and was found unresponsive in his cell in the early hours of 11th March 2019 at HMYOI Aylesbury (as it then was).

Copies sent to

2. Ministry of Justice3. Practice Plus Group (formerly Care UK)4. Barnet, Enfield & Haringey Mental Health NHS Trust6. Governor , HMP Aylesbury

Similar PFD reports

Shared signals

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Billy Wright Inquiry HMP Maghaberry lessons learned

Report details

Reference: 2023-0340
Date of report: 15 August 2023
Coroner: Crispin Butler
Coroner area: Buckinghamshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 17 Nov 2023 (estimated).

Sent to

Prison and Probation Service

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.