Poor prisoner suicide risk assessment

HMP Send is a closed prison for adult women with an operational capacity of 191, holding 182 prisoners at the end of the reporting year, including 63 ISPs. The Board considers Send a safe prison but highlights a significant increase in self-harm incidents (837) and one death in custody. Key concerns include the need for specialist mental health provision for prolific self-harmers, slow progress on digital in-cell technology, and persistent staffing shortages.

HMP Lowdham Grange, a Category B training prison, experienced a challenging year marked by the continued impact of Covid-19 restrictions, which limited board visits and significantly affected the regime. The prison leadership was successful in controlling infections, and healthcare provision was largely efficient despite severe staffing shortages. However, the report highlights a significant increase in prisoner-on-prisoner assaults and self-harm, alongside critical concerns regarding delayed inquests, inadequate mental health transfers, and a persistent lack of resolution for property management issues during transfers.

HMP/YOI Norwich faced significant challenges in 2021-2022 due to ongoing Covid-19 restrictions and chronic staff shortages, impacting regime, safety, and humane treatment. Despite dedicated local leadership and staff efforts, the prison grappled with high self-harm incidents, violence, and inadequate ACCT management. Key issues highlighted include overcrowding, dilapidated facilities, insufficient rehabilitative programmes for long-term prisoners, and concerns regarding the detention of individuals with severe mental health needs and foreign nationals past their sentences.

HMP New Hall operated under significant Covid-19 restrictions, with staff commended for their professionalism in maintaining safety. While safety metrics showed a notable increase in self-harm and use of force incidents, many were attributed to a small number of individuals and Covid-related confinement. Key areas for development include estate maintenance on Rivendell Unit and improving the quality of CSIP investigations, alongside addressing consistent prisoner complaints regarding healthcare and property.

HMP Manchester navigated a challenging year with ongoing Covid-19 restrictions and its transition to a Category B training prison. While commendations were noted for efforts in safety and equality, persistent staffing shortages severely impacted regime consistency, prisoner treatment, and access to services. Key concerns highlighted delays in vital estate improvements, an unacceptable wait for dental care, and significant issues with prisoner property and escorts to healthcare appointments.

The CFMT monitored 12 charter removal and relocation operations in 2022, finding that returnees were generally treated kindly but experienced significant issues. Key concerns included prolonged confinement in vehicles, inconsistent use of force, and inadequate interpreting services, often exacerbating detainee distress. Despite some positive changes in escorting practice, the Board raised recommendations for HOIE and its contractor, particularly regarding vulnerability, financial preparation, and transit times.

HMP Erlestoke, a Category C training prison, held 467 prisoners with an operational capacity of 468 during the reporting year ending March 2023. The prison experienced a reduction in self-harm incidents to 215 and violent incidents to 102 (65 prisoner-on-prisoner, 37 prisoner-on-staff), with no deaths in custody. Key improvements included enhanced gate security and the introduction of in-cell laptops for prisoners. However, significant challenges persist, notably chronic staff shortages across healthcare, education, and key working, persistent issues with illicit substances, and an inadequate constant watch cell. Delays in essential building works and national issues like parole restrictions for IPP prisoners continue to impede progression and resettlement efforts.

HMP/YOI Downview experienced a challenging reporting year marked by significant operational changes and an increase in prisoners with complex mental health needs, leading to increased self-harm and use of force incidents. While staff demonstrated compassion, issues like delayed mental health transfers, inconsistent medication distribution, and an un-embedded key worker scheme persisted. The Board expressed concerns about population pressures, property loss during transfers, and a reactive approach to the new transgender policy.

The IMB report for HMP Leeds covering 2021-2022 found the prison to be generally safe, although expressing concern over 24 deaths in custody and incidents of unsecured doors. While staff-prisoner relationships were mostly satisfactory, issues with staff conduct and an inability to deliver key worker sessions due to shortages were noted. Accommodation remains unsatisfactory, particularly due to cell sharing, and the lack of external mental health places means many prisoners with severe needs are held inappropriately. Positive aspects included healthcare provision, commended catering staff, and successful prisoner engagement in projects like the Lock-In cafe and bird of prey care.

HMP Bedford, a Category B reception and resettlement prison, continues to face significant challenges, particularly high levels of violence and self-harm, overcrowding, and an inconsistent regime with prisoners spending excessive time locked in cells. While education and family visits have seen improvements, the mental health team remains under-resourced, and staffing issues impede purposeful activity and the full implementation of the key worker scheme. The IMB raises concerns about the dilapidated infrastructure, poor property management, and calls for HMPPS and the Governor to address these long-standing issues.

HMP Dovegate, a Category B training prison managed by Serco, reported a generally calm and settled environment with good staff-prisoner relationships. Key challenges include persistent long waiting times for mental health transfers and dental appointments, along with concerns about lost prisoner property during transfers and staffing shortages affecting healthcare and education. The Board highlighted the need for improved strategies for IPP prisoners and more secure mental health spaces.

HMP/YOI Eastwood Park, a closed local prison for women, faced significant challenges in staffing, self-harm, and the management of complex mental health needs during the reporting year. Despite positive recruitment efforts and a new regime increasing time out of cell, the Board highlighted concerns regarding delays in mental health transfers, a substantial rise in use of force, and the under-utilisation of new facilities. The report also commended improvements in social visits and property management, while calling for better support for remand and short-sentence prisoners and more reliable resettlement data.

Drake Hall continues to provide a largely safe and humane environment, with commendable support for vulnerable women and effective management of challenging behaviours, although self-harm and violence have increased. Key concerns persist regarding the poor condition of Richmond and Plymouth houses, systemic issues with property, and healthcare resources being outstripped by the increasing complexity of the population's needs. The Board also highlights issues around staffing, regime restrictions, and the halting of planned capacity improvements.

HMP Exeter faced another challenging year, operating under an Urgent Notification due to high levels of violence and self-harm, alongside significant staffing instability, particularly in healthcare. Major refurbishment projects continued, impacting operational capacity and regimes, compounded by persistent overcrowding and unsuitable conditions in the temporary Care and Separation Unit. While improvements were noted in induction processes and use of force governance, critical issues like security vulnerabilities, challenges in purposeful activity due to high turnover, and deficiencies in property management remained key concerns.

The Independent Monitoring Board's Charter Flight Monitoring Team observed nine charter operations to Albania, primarily involving individuals transferred from prisons to immigration detention before removal. The report highlights significant concerns regarding the humane treatment of returnees, particularly excessive in-vehicle confinement during night operations, and issues with interpretation provision and the handling of vulnerable individuals. While positive engagement from escorts was noted, the Board raised concerns about medical confidentiality, increasing use of restraint, and some coach safety incidents.

HMP Coldingley, a Category C training prison, maintains a relatively open regime and positive staff-prisoner relationships, contributing to low self-harm levels. However, the Board notes a concerning rise in violence, use of force, and illicit substances, often linked to population pressures and insufficient new arrival checks. Significant challenges remain, including dilapidated older wings lacking in-cell sanitation, a struggling kitchen, and persistent issues with lost property and perceived disproportionality in treatment for some ethnic minority groups.

HMP Bullingdon continues to grapple with chronic overcrowding and persistent staff shortages, impacting regime delivery, purposeful activity, and key worker provision. While self-harm, violence, and use of force incidents remain high, the prison has made some progress in healthcare provision and reducing outstanding OASys plans. Education and resettlement efforts are hampered by prisoner churn and staffing, but new initiatives like the Employment Hub show potential for improvement.

HMP Bure, a Category C prison primarily for older prisoners, maintains a calm and safe environment with good staff-prisoner relationships and effective healthcare, including a fully staffed mental health team. Key concerns include insufficient purposeful activity, inconsistent key worker engagement, and the significant impact of not having formal medical care on-site at night. Persistent estate maintenance issues and a call for the re-sentencing of IPP prisoners highlight areas requiring urgent attention from both the prison and the Ministry of Justice.

HMP Channings Wood, a Category C prison, faces significant challenges due to overcrowding, impacting safety, regime stability, and the delivery of purposeful activity. Self-harm and assaults have risen, and the Board remains concerned about drug availability and the inappropriate use of segregation for mental health cases. Persistent issues with property loss on transfer and delays in estate repairs further exacerbate prisoner conditions, alongside ongoing staffing shortages that hinder key work and offender management.

HMP Chelmsford is a Category B local prison that faces significant challenges, particularly with overcrowding where 49% of prisoners share single cells, and an increasing use of force attributed to inexperienced staff. While positive developments include improved staff-prisoner interactions and an increase in key worker sessions, persistent issues like inadequate property safeguarding, frequent missed healthcare appointments due to officer shortages, and difficulties in transferring mentally ill prisoners require urgent attention. The IMB highlights these concerns and makes recommendations to the Minister, Prison Service, and Governor to address systemic failings.

HMP Cardiff, a Category B local training prison, maintained a relatively safe environment with one death in custody and 374 self-harm incidents, matching the previous year. However, it faced increasing population pressures and a rise in illicit substance use. The Board noted positive developments in healthcare staffing, family services, and education provision, alongside the opening of a Neurodiversity Hub and an Incentivised Substance-Free Living unit. Key concerns include ongoing staffing shortages in offender management, the impact of old infrastructure on living conditions, and significant delays in visits booking and mental health transfers.

The Board would like to see more targeted understanding of the triggers to self-harm.

The Board is concerned at the number of self-harm incidents in the reporting year (4.8), and we would like assurances about the actions being taken.

Initiate a fundamental review of the assessment, care in custody and teamwork (ACCT; the care planning process for prisoners identified as being at risk of suicide or self-harm) process – is it ‘fit for purpose’?

The IMB is concerned about: the continued high level of self-harm

The number of self-harm incidents has escalated to an average of 220 incidents each month in the reporting year. How is the prison service supporting the prison to manage this high level of risk on an urgent and long-term basis?

What action is being taken to reduce the exceptionally high levels of self-harm in the prison?

What plans does the Governor have to address the continuing high number of cases of self-harm in the prison?

The number of self-harm incidents has continued to rise to an average of 238 incidents a month. Given that a few prolific self-harmers account for a high proportion of these incidents, how does the Prison Service plan to provide support to the prison to manage these extremely challenging prisoners? (See section 4.2.)

Self-harm. What further measures can be to be taken to reduce self-harm?

To consider what further steps can be taken to address the increase in self-harm.

Can the Governor advise what is happening in response to the increased level of prisoner self-harm?

The number of self-harm incidents increased this year, from 803 to 881. While the Board acknowledges that some of this increase derives from a small number of prisoners repeatedly self-harming, it commends the efforts of staff supporting these prisoners. The Board welcomes regular updates on new initiatives to reduce the extent of self-harm and their impact and would like to …

Although it is noted that there was no further increase in the number of self-harm incidents reported in 2019, the Board remains concerned about the high level of self-harm (see paragraph 4.5).

ensure that plans are in place to prevent a return to the levels of self-harm over the first three months of the year, when a normal regime is resumed (see section 4.2)

Will the Governor take all measures necessary to reduce the levels of violence, self-harm, bullying, drug taking and drug smuggling, including adequate staffing and resource continued being allocated to the safer custody team?

While the Board very much welcomes the continued downward trend in many key safety indicators, progress in reducing levels of self-harm and the use of psychoactive substances is slower. What steps are planned to further reduce the number of prisoners self-harming at Channings Wood? Despite successes in the interception of drugs, can even more effective measures be taken to reduce …

In the review of the ACCT process, consider the two main drivers: (a) clinical need; and (b) achievement of personal goals or redress of perceived procedural injustice. Can these be addressed separately?

Ensure that Listeners and the Samaritans services are available at all times of the day and night, including ensuring all staff understand that access to these services should be allowed, following occasions where prisoners have not been able to access them at night.

While there is a steady decrease in self-harm incidents, we feel that a better system of investigation of incidents, to understand the causal links, would lead to further improvements.

Wellbeing checks for all prisoners must be increased and maintained regularly to prevent self-harm.

In respect of self-inflicted deaths in custody, is there more that could be done to reduce the likelihood of such incidents happening again?

Delivery of staff training e.g. suicide and self-harm (SASH) (4.2.6).

The prison was designated a ‘cluster death site’ in October 2021 but no additional support/training was forthcoming from the centre which would have been helpful in identifying any areas for development.

Self-harm levels continue to be high. What more can be done to support prisoners who harm themselves?

The Board has noticed an increase in self-harm and this needs to be investigated by the prison.

The number of prisoners at Bristol has risen and alongside this there has been an increase in self-harm, violence and deaths in custody. Can the prison roll be reduced to enable the prison to address this effectively?

Continue to undertake trend analysis and proactive work to reduce self-harm and violent incidents (prisoner on prisoner and assaults on staff).

How will the prison improve its management of ACCT cases to reduce the frequency of self-harm incidents?

The prison was, again, designated as a cluster death site in July. What urgent steps will the Prison Service take to prevent deaths in custody?

The Board has noticed an increase in self-harm and this needs to be investigated by the prison.

The Board shares the concerns expressed by the senior leadership team (SLT) that there have, again, been deaths in custody during the year, especially as only two were, apparently, due to natural causes. What specific, actions are being taken to prevent further fatalities and improve prisoner safety?

The ACCT documentation (revised in 2022) remains overly complicated and cumbersome. When will HMPPS revise this essential documentation, given its potentially life-saving importance?

Will the governor renew efforts to reduce incidents of self-harm, which have gone up by around one third over the past two years?

What steps will the prison take to reduce the frequency of self-harm incidents?

What steps will the prison take to reduce the frequency of self-harm incidents?

The prison was, again, designated as a cluster death site in July. What urgent steps will the Prison Service take to prevent deaths in custody?

What will you do to improve the quality assurance of assessment, care in custody and teamwork (ACCT) processes, as highlighted in the HMIP IRP report, and ensure that all relevant participants are included in reviews?

What measures are being introduced to reduce the risk of violence in the prison and support those prisoners at risk of self-harm?

We applaud the establishment in its efforts to maintain key worker sessions during the restricted regime but would ask that consideration be given to whether the cross-deployment of key workers affected the incidence of self-harm (see paragraph 5.3.1).

How will the governor set out to address the changes in culture and practice that are required if assessment, care in custody and teamwork (ACCT) and associated procedures are to be used more effectively (see below, 4.2.5)?

Improve implementation of the current ACCT process.

There should be greater, more formal analysis of self-harm. The assessment, care in custody and teamwork (ACCT) documents are valuable for recording such events and their possible triggers, but the underlying causes seem never to be identified in their relation to the prison environment, which could be modified.

The Board is concerned about the high levels of self-harm, assaults and use of force.

We echo the concerns of Her Majesty’s Inspectorate of Prisons (HMIP) regarding the implementation of the assessment, care in custody and teamwork (ACCT) process and would hope that the new version might lead to improvements. We can also see real value in involving prisoners in assessing the effectiveness of the ACCT system.

Address Listener call-out issues across the houseblocks (see section 4.2).

The continued high level of self-harm (see paragraph 4.2.1)

To continue to reduce the levels of violence, self-harm, bullying, drug use and drug smuggling.

We believe that the formulation of ACCT care plans should begin by asking prisoners about their coping strategies and preferred sources of help. The care plan should proceed from there.

The Board remains concerned regarding the mental health of prisoners who have suffered long-term lockdown. This is evidenced by the high number of ACCT cases, self-harm cases and violent incidents. The first indications from the recent improvement in regime are positive. However, the necessity for increased psychology and psychiatric services still needs to be assessed.

The number of inappropriate transfers has risen over the last year. This includes prisoners who are transferred on open assessment, care in custody and teamwork (ACCT) documents and prisoners who have only been in prison for a few days or weeks. Hence, prisoner flow is still not working as it should.