SR — HMP Durham
The report of the independent investigation conducted by Andy Smith into the serious assault on ‘SR’ at HMP Durham on 16 April 2015 is published here. Also published is the response to the investigation from His Majesty’s Prison and Probation Service (HMPPS). On 16 April 2015, ‘SR’ was seriously assaulted by another prisoner in a shower area at HMP Durham, sustaining serious injuries that have left him requiring some assistance with daily living. The incident was referred to the police and the perpetrator was found guilty of grievous bodily harm with intent. He received a sentence of 12 years and six months, to be served consecutive to his original sentence.
Key findings
Learning points
In order to reduce the risk of harm posed by prisoners to other prisoners’ Cell Sharing Risk Assessments should be better recorded and steps to mitigate risk of harm clearly stated. In addition, there should be a system for retrieval of the document upon request.
In order to reduce the risk of violence to prisoners the Violence Reduction Strategy should be monitored by managers to ensure that all prisoners to whom it applies are included and steps taken to reduce their likelihood of potential violence.
Since the incident, a new national system for Head of Safety Completed In order to reduce the risk of managing those prisoners who are violent or pose a HMPPS violence to prisoners the raised risk of harming others through violent Violence Reduction Strategy behaviours has been introduced. The Challenging and should be monitored by Supporting Intervention Plan (CSiP) process is managers to ensure that all opened for every prisoner involved in a violent prisoners to whom it applies incident or displaying volatile behaviours, an are included and steps investigation takes place and an individual plan is taken to reduce their implemented to provide appropriate challenge, likelihood of potential support and monitoring. The prison holds a bi-weekly meeting to review all violence prisoners with a CSIP plan and those who may have been involved in violence but who are considered suitable to be managed via other processes. This meeting takes a multi-disciplinary approach with information being widely shared and a management plan agreed involving relevant partner agencies.
In order to reduce congestion in and around showers and make observation easier HMP Durham should introduce a prisoner reservation booking system for the use of showers.
HMP Durham is committed to improving prisoner Governing Governor In order to reduce accepted safety, however, this recommendation cannot be HMPPS congestion in and around implemented at this time. Staffing levels have been showers and make amended under the national benchmarking process observation easier HMP and the capacity to monitor the showers in the fashion Durham should introduce a requested is currently unachievable based on the prisoner reservation booking regime requirements, prison layout, and staffing system for the use of levels. Separately, CSRA is also used to manage prisoners’ Safety Group July 2024 movements and mixing, and the new policy framework HMPPS will include improved advice on the management of “unsupervised areas” and will require prisons to devise the best measures for their sites. Once the new framework has been published, HMP Durham will be able to consider the advice provided to reassess whether any further measures can be introduced in relation to the management of prisoners showers.
HMP Durham should review the minimum staffing level needed to safely oversee prisoners taking part in association.
HMP Durham no longer offers general association Governing Completed HMP Durham should review applicable periods. Periods of unlock are regime specific and are Governor the minimum staffing level staffed according to the benchmarking and Regime HMPPS needed to safely oversee Management Plan (RMP) levels. A RMP meeting prisoners taking part in takes place weekly to monitor levels and the regime is association. adjusted according to staff availability.
As a considerable time may pass before an Article 2 investigation is commissioned, HMPPS should clarify whether the prison is responsible for completing a full investigation where serious harm to an individual has been sustained.
In April 2023, HMPPS circulated a Safety Learning Safety Group, Completed As a considerable time may Bulletin to remind senior managers to consider HMPPS pass before an Article 2 whether a formal investigation is required in line with investigation is PSO 1300 ‘Investigations’ following incidents of commissioned, HMPPS serious self-harm and assaults. It set out that where it should clarify whether the becomes clear (either immediately, or on completion prison is responsible for of the fact-finding template) that an incident has major completing a full consequences such as disorder, damage, injury etc or investigation where serious there was serious harm to a person, a formal harm to an individual has investigation should be commissioned to allow a been sustained. broader scrutiny into the facts to gather wider learning, which will result in a more detailed report. Additionally, HMPPS has amended the fact-finding report template annexed to PSI 15/2014 ‘Investigating incidents of serious self-harm or assault’ requiring the Governor or the Deputy Governor to sign off the report and to consider whether a formal investigation is required. A new health and injuries section of the template will assist Governors/Directors to consider whether a formal investigation is required in line with PSO 1300 ‘Investigations’.
As the impact on staff well-being of traumatic incidents may not be immediately apparent, all staff should be actively encouraged by their managers to access staff care services following such incidents.
Trauma Risk Management (TRiM) is now available in Safety Group Completed As the impact on staff well- all establishments and is offered to any staff who have HMPPS being of traumatic incidents witnessed a potentially traumatic experience. All may not be immediately establishments have peer support teams such as apparent, all staff should be Care Teams and TRiM teams and if staff agree to actively encouraged by their participate in a TRiM assessment, trained TRiM managers to access staff practitioners will signpost to any relevant services care services following such required to ensure the individuals receive appropriate incidents. care and support. All staff within HMPPS have been made aware of these services and are encouraged and empowered to request appropriate support when required. This is in addition to the Post Incident (Hot) Debrief held immediately following any serious incident. The purpose of a post-incident debrief is to acknowledge what happened and the roles of the staff involved, normalise the situation and ensure that the immediate needs of the staff have been met. The post-incident debrief provides an opportunity to understand and deal with chaotic and distressing thoughts and feelings to help prevent psychological damage. The manager in charge of the incident or the line managers of employees exposed to a traumatic incident are also required to carry out active monitoring, which means maintaining contact with the staff members involved in the incident. If there is any cause for concern during this active monitoring period, or beyond, that individually or as a group, staff are having troublesome feelings or symptoms that are extreme, are not going away and/or are getting worse, and it is considered that professional support is, or may be, required, signposting or referral to appropriate services should be carried out.
HMPPS takes steps to reduce the time between incidents and the commission of Article 2 Investigations.
The nature of the injuries to the individual informs the Safety Group, Completed HMPPS takes steps to decision to commission an Article 2 investigation. In HMPPS reduce the time between order to assess this, HMPPS requests relevant incidents and the information from external organisations and is reliant commission of Article 2 on issues around consent being resolved quickly and Investigations. this information being provided in a timely fashion. HMPPS has taken action to reduce the time it takes to commission an Article 2 investigation following an incident. This has included using electronic communication, updating and strengthening letters requesting health reports and regularly chasing up where no responses are received. HMPPS will continue to review where changes can be made to improve the speed in which decisions can be made. In order to ensure documents are retained in cases where an incident is identified as a potential Article 2 case, the Safety Group shares with the prison a detailed list of documents that investigators are likely to request so that they can be collated and stored securely.
HMPPS should ensure that liaison between Article 2 investigators and prisons is improved by ensuring that the member of staff in an establishment appointed to liaise: a) understands the nature of the Article 2 process, and b) is of sufficient seniority to direct staff and resources to facilitate the investigation.
HMPPS has reviewed the guidance it provides to the Safety Group, Completed HMPPS should ensure that Governor and prison liaison point when an Article 2 HMPPS liaison between Article 2 investigation is commissioned to ensure that sufficient investigators and prisons is background information is provided about the Article 2 improved by ensuring that process. the member of staff in an establishment appointed to The guidance explains that the Governor should liaise: a) understands the appoint as the liaison point a member of staff with nature of the Article 2 sufficient seniority to direct staff and resources to process, and b) is of facilitate the investigation. sufficient seniority to direct staff and resources to facilitate the investigation.
Case details
| Establishment | HMP Durham |
| Responsible body | HMP Durham |
| Incident date | 16 April 2015 |
| Incident type | Serious Assault |
| Investigator | Andy Smith |
| Learning points | 8 |