Downview

Safety statistics

Incidents during reporting year

Indicator	This year	Previous
Deaths in custody	2	—
Self-harm incidents	728	1,171
Prisoner assaults	30	26
Assaults on staff	36	48
Use of force	119	310

Positive findings

Staffing levels remained healthy, and many officers demonstrated effectiveness, fostering positive relationships with prisoners. The reducing reoffending team secured post-release employment, and the prison kitchen maintained its five-star rating. CSU staff displayed exceptional professionalism and compassion, and the Board noted a positive refresh of the induction process and the value of the Gladragz prison shop. The prison also re-engaged with the Zahid Mubarek Trust for DIRF scrutiny.

Key concerns

31 items

Mental Health Repeated We continued to observe numerous acutely mentally unwell prisoners segregated in the care and separation unit (CSU), some of whom were awaiting to be transferred to a psychiatric facility... CSU staff exhibit extraordinary patience, professionalism and compassion, but they are not trained to support such unwell prisoners.

Other Repeated As in previous years, we have seen a significant number of applications relating to property being lost or delayed when prisoners are transferred to Downview from other prisons.

Staffing Often, prisoners’ basic requirements are not dealt with in a timely and proactive way by staff.

Overcrowding Repeated Population pressure cited across the prison estate continues to impact on prisoners’ outcomes. For example, safety in the prison, timely healthcare appointments and efficient daily medication distribution, the availability of purposeful activity, release on temporary licence (ROTL) and access to family support networks.

Mental Health Repeated Acutely mentally unwell prisoners are still waiting far too long for transfer to secure psychiatric units following assessment and referral.

Safety A number of prisoners were transferred to Downview from other prisons who were not in a safe or stable condition for transfer.

Healthcare Limited dementia care is provided at Downview, but there remain challenges in accessing memory assessments for those who need a dementia diagnosis.

Resettlement/Release Repeated The number of prisoners working on release on temporary licence (ROTL) from the prison has, again, remained alarmingly low. The lack of clarity regarding ROTL opportunities at the prison, which we reported on last year, has continued.

Education/Purposeful Activity There has been an ongoing focus on recording and increasing attendance at education and activities, but attendance remains variable.

Resettlement/Release Repeated Despite acknowledgement by the Ministry of Justice that prisoners who have experienced ROTL have better outcomes, the prison has only a very small number of prisoners accessing ROTL... This seems to be a waste of the excellent employment links at the prison and an example of cited population pressure providing obstacles to progression.

Equality/Diversity Repeated Last year, the Minister provided reassurance to the Board in the response to our previous annual report that allocation decisions for transgender prisoners would be made “in the quickest time possible to reduce the anxiety and uncertainty experienced whilst they await the outcome”. However, we have, again, seen a significant delay in a prisoner’s allocation by the Lord Chancellor.

Other Repeated The HMPPS Prisoners’ Property Policy Framework states: “How HMPPS looks after prisoners’ possessions may be symbolic of how we look after the people in our care”. We continue to see extremely high levels of property loss for prisoners when transferring in from other prisons... It is unconscionable that, in 2025, HMPPS has not been able to create or manage a system that takes the transfer of prisoners’ belongings seriously. It is a disgrace.

Resettlement/Release Repeated We have, again, seen examples of prisoners who were transferred to Downview from prisons across the country, often with just a few weeks to serve and with apparently no consideration of family networks.

Staffing Can the Governor please comment on the issues raised earlier in this report regarding the effectiveness of certain staff in resolving prisoners’ basic issues, and on operational oversight in the prison generally?

Resettlement/Release How is it expected that the ongoing mixed messages regarding the future viability of working ROTL at the prison will be resolved?

Regime/Time Out of Cell Repeated Gladragz (the prison shop) is a valuable resource for prisoners. It would be a positive development if it could be adequately stocked and managed.

Staffing Repeated Management of, and attendance at, some meetings by staff at times remains poor.

Safety Can the Governor comment on the lack of enhanced gate security in the prison?

Regime/Time Out of Cell There were limited wing activities and unexplained delays with accessing some off-wing activities. At various times, the atmosphere on the wing was challenging for various prisoners - with frequent conflict, bullying, exclusion and flashpoints in prisoner relationships. It was often described by prisoners and staff as “toxic” and “full of drama”.

Other The prison’s Business Hub appeared to the Board to be inadequately staffed for much of the period. As from late 2024, it appeared incapable of functioning and was repeatedly closed for responses to staff and prisoner queries.

Other The transfer of monies process appears particularly inefficient for transfers from HMPs Bronzefield and Peterborough (private prisons). Their financial systems are not compatible with Downview, which means that cheques need to be sent, rather than an automated bank transfer taking place.

Substance Misuse The rising number of illicit drugs brought into the prison in the reporting period was of concern to the security department, with the first appearance of synthetic opioids amongst them in early 2025. There was a reported rise also in early 2025 in ‘street drugs’ (e.g. spice, heroin and cannabis) in the prison, with an impact on debt and violence.

Safety There is no routine enhanced security on the gate for visitors or staff. It is notable that most of the Board’s members... have not been searched on entering the prison. People attending for social visits often commented on the relaxed searching process for visitors

Regime/Time Out of Cell Repeated Last year, we reported our concerns regarding rule 39 breaches in the prison. There was a rule 39 breach late in 2024.

Safety Repeated We continue to have ongoing concerns regarding a perceived failure by relevant staff to appropriately communicate with prisoners when managing certain individual outcomes arising from security intelligence.

Staffing Repeated The delivery of the key worker scheme has, again, been below target and the quality of entries has also been a focus for staff development. The average of sessions delivered for this reporting period was 39.99%

Equality/Diversity The Board’s perception remains that equality and diversity work has a low priority with staff outside of the function.

Equality/Diversity Foreign national prisoners: as of the end of the reporting period, there were 49 foreign nationals in the prison, 15% of the population. We regularly monitored new arrivals who did not speak any English. They struggled with the limited translation support from HMPPS and instead relied on other prisoners and staff on an informal basis.

Complaints/Property The prison introduced a phone-based applications process for prisoners in late 2024... Their answering service was usually full and prisoners were unable to leave a message. There is no way of a prisoner keeping a record of when a phone application has been made... the new system has been unpopular with prisoners.

Complaints/Property Whenever overdue complaints increase, pressure is applied by governors, which often succeeds in reducing them. As a result, there has been a modest increase in the number of complaints answered within the recommended time frame: 67% compared with 64% last year. The worst offenders for overdue complaints remain other prisons, where the overdue period can exceed 100 days.

Other Repeated It is often not possible to judge whether the transferring prison simply failed to send the property or if the transfer subcontractor failed or refused to take it. But the outcome is a considerable amount of additional work for staff and distress for the prisoners.

Recommendations

15 items · 8 repeated

#	Recommendation	Addressee	Status
1	Acutely mentally unwell prisoners continue to arrive at the prison. They often face long delays in transfer to secure psychiatric units, following assessment and referral (6.1). How confident is the Minister that the statutory 28-day time limit for transfer from prison to hospital, envisaged by the Mental Health Bill, will be achievable, given the low number of suitable beds for female prisoners? Repeated Response It is regrettable that mentally unwell prisoners continue to arrive at HMP/YOI Downview and across our prisons, and then often face delays in transfer to suitable secure units. This Government is committed to ensuring that people in contact with the criminal justice system can access appropriate and timely support. The Mental Health Bill has recently completed Committee Stage in the House of Commons. The Bill’s reforms include introducing a new statutory time limit of 28-days for the transfer of patients with a mental disorder from prison and other places of detention to hospital. This time limit, together with operational improvements, aims to reduce unnecessary delays and deliver swifter access to treatment. NHS England’s national team have now completed the initial scoping work to ensure there is clinical leadership throughout the pathway to and from prison and secure hospital. The recently launched Mental Health and Justice Strategic Advisory Group will assure the 28-day transfer process. The group is chaired by NHS England’s National Medical Director for Mental Health and Neurodiversity, who will report regularly to Ministers and be responsible for agreeing a joint workplan to support implementation of the statutory time limit, identifying solutions to common barriers to timely transfers and holding relevant parties to account.	Ministry of Justice	In progress
2	Despite acknowledgement by the Ministry of Justice that prisoners who have experienced ROTL have better outcomes, the prison has only a very small number of prisoners accessing ROTL. This was described by HMPPS in the response to our previous annual report as a “significant reduction… due to capacity pressures”. This seems to be a waste of the excellent employment links at the prison and an example of cited population pressure providing obstacles to progression (7.3). The Minister’s view on this is welcomed. Repeated Response Prioritising progression and positive outcomes for women and all prisoners is essential, and I therefore fully understand the Board’s continued concerns about access to Release on Temporary License (ROTL). HMP/YOI Downview, as a closed training establishment, plays a vital role in supporting the operation of the wider prison estate so there is sufficient capacity to meet court demand. While it continues to provide valuable opportunities for women to access paid employment through Release on Temporary Licence (ROTL), this must be balanced against the operational need to manage population flow through the system. Women assessed as suitable for open conditions are encouraged to transfer to open prisons, which offer stronger ROTL and employment pathways and better outcomes for women on release. This supports the effective use of closed estate capacity and enables reception prisons to fulfil their core function. Prioritising recategorisation is essential to unlock these opportunities, support ROTL activity, and enable appropriate progression to open conditions.	Ministry of Justice	Noted
3	Last year, the Minister provided reassurance to the Board in the response to our previous annual report that allocation decisions for transgender prisoners would be made “in the quickest time possible to reduce the anxiety and uncertainty experienced whilst they await the outcome”. However, we have, again, seen a significant delay in a prisoner’s allocation by the Lord Chancellor (7.3). Does the Minister agree that this delay, regarding the location of a transgender prisoner, was unfair and inhumane? It appears to the Board that the prisoner is being caught in the crossfire of a politically sensitive issue. Repeated Response I note your concerns about the amount of time it took to inform a transgender individual of a Ministerial exemption decision. The Complex Case Board (CCB) and the staff at HMP/YOI Downview took steps to keep the individual updated and provided close support whilst the exemption process was ongoing. CCBs will continue to do all they can to ensure that their actions are completed at the earliest opportunity within this process and they inform individuals of Ministers' final decisions in the quickest time possible once that information is available. Whilst a decision is awaited, a range of evidence-based support and services is available to mitigate against anxiety and uncertainty including the Women’s Estate Psychology Service team which provides forensic psychologists within HMP/YOI Downview.	Ministry of Justice	In progress
4	We have, again, seen that population pressure impacts significantly on prisoners’ outcomes. These include increased self-harm and violence, healthcare pressures, a decrease in working ROTL opportunities and prisoners being transferred in a seemingly random fashion across the estate, away from families and other support networks. The Board is hopeful of the outcomes from the Sentencing Review and the Women’s Justice Board in better managing the population in the female estate. The Minister’s view on this is welcomed. Repeated Response I recognise the Board’s concerns about the effects of population pressures on prisoners’ outcomes. That is why the Women’s Justice Board (WJB), chaired by myself, is setting the vision and direction for improving the Criminal Justice System’s response to women. The Board has a clear goal of advising on how to reduce the number of women in prison. The WJB is supported by the Women’s Justice Partnership Delivery Group, which has cross-government and delivery partner representation, and also external subject experts. We also welcome the recent Independent Sentencing Review’s consideration of the particular needs of women, and the recommendations that will help address these. The reforms to suspended and short sentences will support our goal to reduce the number of women in custody.	Ministry of Justice	In progress
5	There is no mention of ROTL in the Women’s Group Deliverables for 2025-202615. There were only three prisoners accessing working ROTL from the prison as of the end of our reporting period. This seems to be a waste of the excellent work by the prison employment lead, industries and community engagement manager, and the Employment Advisory Board in securing training partners and employment links at the prison (7.3). We understand that HMP/YOI East Sutton Park may need to be filled up, but this should not necessarily mean that working ROTL opportunities cannot also develop further at Downview, with its opportunities and local transport links. Response Prioritising progression and positive outcomes for women and all prisoners is essential, and I therefore fully understand the Board’s continued concerns about access to Release on Temporary License (ROTL). HMP/YOI Downview, as a closed training establishment, plays a vital role in supporting the operation of the wider prison estate so there is sufficient capacity to meet court demand. While it continues to provide valuable opportunities for women to access paid employment through Release on Temporary Licence (ROTL), this must be balanced against the operational need to manage population flow through the system. Women assessed as suitable for open conditions are encouraged to transfer to open prisons, which offer stronger ROTL and employment pathways and better outcomes for women on release. This supports the effective use of closed estate capacity and enables reception prisons to fulfil their core function. Prioritising recategorisation is essential to unlock these opportunities, support ROTL activity, and enable appropriate progression to open conditions.	HMPPS	Noted
6	The HMPPS Prisoners’ Property Policy Framework16 states: “How HMPPS looks after prisoners’ possessions may be symbolic of how we look after the people in our care”. We continue to see extremely high levels of property loss for prisoners when transferring in from other prisons (5.6). The much-heralded Prisoners’ Property Policy Framework appears to have had no impact in managing the issue. The process remains labour-intensive and paper-based, and there is no system at Downview for recording how property loss and delay is followed up with other prisons. Much of the operational performance of a prison is audited and managed by various metrics and key performance indicators, yet there is no attempt to hold prisons accountable for property management. It is unconscionable that, in 2025, HMPPS has not been able to create or manage a system that takes the transfer of prisoners’ belongings seriously. How does HMPPS intend to improve this dire situation? It is a disgrace. Repeated Response HMPPS note the Board’s concerns about the handling of prisoners’ property and this is an area to which HMPPS is currently giving further attention. Careful consideration is being given to the findings in the IMB national thematic report on how property loss impacts on prisoners, as well as those received from Independent Prisoner Complaint Investigations following a thematic review of the property complaints they have received in the last five years. Since receiving the reports, Governors and other senior leaders have been reminded of the most important property handling points. This includes the need to ensure compliance with volumetric control limits; this is important since any property within those limits transfers with prisoners when they move establishments. Consultation is taking place with prisons on further areas raised in the reports. HMPPS also note the Board’s concerns about the lack of digital improvements on property handling. Whilst it is recognised this will be disappointing, other pressures around digital changes mean that it is not anticipated that an electronic property card will be in place in the immediate future. At HMP/YOI Downview, a more structured approach to tracking property issues with sending establishments has recently been introduced. This includes the implementation of an “Outstanding Property Tracker,” a shared spreadsheet where staff manually log follow-up actions. The tracker enhances visibility and accountability across teams and represents a move towards greater consistency in managing property-related concerns. Although the system is still in its early stages, it is intended to support quicker resolution of property issues. The Head of Operations is overseeing implementation of this process and improvements in this area have already been noted.	HMPPS	In progress
7	We have, again, seen examples of prisoners who were transferred to Downview from prisons across the country, often with just a few weeks to serve and with apparently no consideration of family networks (4.1, 7.4). We were informed by HMPPS in the response to our previous annual report that such transfers were a necessary response to cited population pressure (“every bed matters”). These transfers are, however, entirely at odds with HMPPS’ own research17 regarding the importance of family ties as a significant factor in rehabilitation. Given that population pressure appears likely to continue in the women’s estate for the foreseeable future, how can prisoner moves be managed in a more compassionate and rehabilitative way? Repeated Response The primary function of the seven Reception prisons is to serve the courts and as such they need to routinely transfer women to other prisons, such as HMP/YOI Downview, to ensure there is space to meet the court function. When women are transferred, wherever possible, their needs and distance from home are considered when determining where they will be transferred to. Work to draft and confirm Offender Flows for the Women’s Estate is underway. This work will take into account population pressures and impacts from the Independent Sentencing Review, whilst aiming to ensure women are held in the right place at the right time of the sentence.	HMPPS	In progress
8	Can the Governor please comment on the issues raised earlier in this report regarding the effectiveness of certain staff in resolving prisoners’ basic issues, and on operational oversight in the prison generally? Response I note you have raised a number of local issues of concern in your report which the Governor will continue to keep you aware of progress as work continues.	Governor / Director	Noted
9	The Board is hopeful that the latest recent positive refresh of the prisoner induction process receives the staff support it needs for ongoing implementation (4.1).	Governor / Director
10	How is it expected that the ongoing mixed messages regarding the future viability of working ROTL at the prison will be resolved? (7.3) Response Prioritising progression and positive outcomes for women and all prisoners is essential, and I therefore fully understand the Board’s continued concerns about access to Release on Temporary License (ROTL). HMP/YOI Downview, as a closed training establishment, plays a vital role in supporting the operation of the wider prison estate so there is sufficient capacity to meet court demand. While it continues to provide valuable opportunities for women to access paid employment through Release on Temporary Licence (ROTL), this must be balanced against the operational need to manage population flow through the system. Women assessed as suitable for open conditions are encouraged to transfer to open prisons, which offer stronger ROTL and employment pathways and better outcomes for women on release. This supports the effective use of closed estate capacity and enables reception prisons to fulfil their core function. Prioritising recategorisation is essential to unlock these opportunities, support ROTL activity, and enable appropriate progression to open conditions.	Governor / Director	Noted
11	The Board hopes that the successful HMPPS audit carried out in the reporting year may be a catalyst for more ambition and creativity with family engagement at Downview. How does the prison intend to sustain the focus on families and significant others (7.4)?	Governor / Director
12	Which measures recently utilised to encourage and record attendance at purposeful activity are seen as effective and will be retained going forward (7.3)? Response I was therefore encouraged to note the significant reduction in self-harm incidents, a resolution to the longstanding transfer of funds issues, and the success of the pilot IT system for allocation and attendance monitoring of purposeful activity.	Governor / Director	Implemented
13	Gladragz (the prison shop) is a valuable resource for prisoners. It would be a positive development if it could be adequately stocked and managed (5.1). Repeated Response I note you have raised a number of local issues of concern in your report which the Governor will continue to keep you aware of progress as work continues.	Governor / Director	Noted
14	Management of, and attendance at, some meetings by staff at times remains poor. Will the significant investment and support from the Enable Programme also provide encouragement to staff in this area? Repeated Response I am also optimistic about the outcomes of the Enable programme at HMP/YOI Downview.	Governor / Director	Noted
15	Can the Governor comment on the lack of enhanced gate security in the prison (4.5)? Response I note you have raised a number of local issues of concern in your report which the Governor will continue to keep you aware of progress as work continues.	Governor / Director	Noted

Applications to the IMB

Category	Current	Previous
Property lost or damaged during transfer (H2)	50	47
Property within Downview (H1)	29	31

Related inspections & investigations

— PPO fatal incident Lee-Ann Stent · Other non-natural

— PPO fatal incident Fay Newman · Natural causes

29 Jun 2024 PPO fatal incident Susan Simpson · Natural causes

24 May 2023 PPO fatal incident Kirsten Hocking · Other non-natural

— PPO fatal incident Niarena Ryan-Harriott

27 Oct 2014 PFD Cherylin Norrell-Goldsmith · State Custody related deaths

Other reports for Downview

2024 Published 3 Sep 2024 Population 324 · Self-harm 1,171 · Concerns

2023 Published 1 Sep 2023 · Self-harm 1,153 · Concerns

2022 Published 10 Oct 2022 Population 265 · Self-harm 752 · Concerns

2021 Published 29 Sep 2021 Population 219 · Self-harm 369 · Concerns

2020 Published 19 Oct 2020 Population 287 · Self-harm 659 · Concerns

Population	319
Operational capacity	356

Safety statistics

Positive findings

Key concerns

Recommendations

Applications to the IMB

Related inspections & investigations

Other reports for Downview

Report details

Population

Source links