Preventing Deaths in Prison

 

Last August, after the inquest into the self-inflicted death of a prisoner serving an IPP sentence at HMP Swaleside, a Ministry of Justice spokesperson said: “Our thoughts remain with the family and friends of Sean Davies.”

They did not remain long it seems. The Prevention of Future Deaths Report (PFD) issued by the Mid Kent and Medway coroner about Mr Davies’ case is one of seven such reports relating to people who’ve died in prison which did not receive a timely response from the authorities last year.

Coroners issue PFD reports when they hear evidence of matters giving rise to concern and form the view that there is a risk that future deaths could occur unless action is taken. Recommendations can be directed at the Prison Governor, HMPPS and/or the Ministry of Justice- and private prison companies where appropriate.  

They are under a duty to respond within 56 days (though the date may be extended) with details of action taken or proposed to be taken, setting out the timetable for action- or explain why no action is proposed.

As well as the seven prison cases, the total of 60 “non-responses to PDF reports” published today include two cases where people died shortly after leaving prison and one where a person was serving a community sentence.

Among the issues raised in the prison cases are the inadequacy of staff training in first aid and on the suicide prevention scheme; a lack of national specification in respect of prison healthcare units; and shortcomings in how welfare checks are conducted on vulnerable prisoners.

One of the most far reaching recommendations concerns how the duty of candour after a death in custody applies to the prison service and those individuals working for it whether employed directly or through a private provider.   

It is disappointing that responses have not been made about these important matters on time, all the more so given the Ministry of Justice's responsibility for the Coroner system. 

In a letter to the Justice Committee last month, Justice Minister Alex Davies-Jones said the Government believes that "Prevention of Future Death reports are vital in contributing to public safety by ensuring that lessons are learned. Our expectation is that recipients will have systems in place to consider the reports they receive, and that they will take very seriously what those responses say about actions that will be taken".

She needs to speak to her colleague Lord Timpson to ensure that the Ministry's own house is in order and that necessary action is taken to keep people safe in prison and after release. 

From Kent to Kenya - The Changing Shape of Youth Custody

 

Earlier this year, as part of an evaluation project in Kenya, I visited Shikusa Borstal Institution, home to more than 150 boys aged 15-21. Its eight dormitories, each led by a house master or mistress, the School Captain, prefects and assistants replicate closely the model of an English boarding school.  

While Borstal training as a sentence was abolished in England and Wales in 1982, the approach is still going strong in a number of former British colonies and even here several former borstals are in use as youth and adult prisons.

Meanwhile, less than two miles down the road from the Kent village which gave Borstals their name in 1902, the first of a new generation of custodial facilities finally opened its doors in August this year. Oasis Restore, the first Secure School is promising a revolution in youth justice, by placing therapeutic, integrated education, health, and care at the heart of the secure estate.

What will its influence be on the shape of youth custody?

In the short term, it’s already giving the Youth Custody Service an additional and welcome option to place some children deprived of their liberty outside an increasingly unsuitable prison system. Latest data shows 366 children and young people in prison run Young Offender Institutions (YOI) at the end of October- the smallest ever number.  That should fall further as the Secure School ramps up its capacity. According to the Oasis Restore accounts published last month, the full capacity of 49 children and 223 staff should be in place by September 2025.

How’s the School going? It’s difficult to know for sure as there has not yet been any independent inspection and no data published for example about the extent to which Oasis has exercised its right to pick and choose its residents. The Justice Secretary has told MPs it is making good progress. 

Prior to opening the school published a set of policies, including on physical interventions which have proved one of the most problematic issues in the secure estate. The Oasis approach is commendably honest about the risks to staff and children in using physical restraint. But of course it remains to be seen whether staff adhere to the policies.    

Thankfully the school does not seem to have experienced the turbulence and disorder which marked the first few months of Medway Secure Training Centre when it opened on the same site back in 1998- and to an alarming extent characterises life in YOI’s today.

An otherwise highly optimistic Times article admitted that the school has not been able to avoid violence and self-harm entirely, “although the levels have been far lower than in a conventional YOI”.

But is this the right comparator? A recent inspection rated a Secure Childrens Home (SCH) as outstanding with children making “remarkable progress”. Children said that they feel very safe living at the home and have a trusted adult who they can speak to. On the rare occasion that there is an incident of bullying, the staff are quick to address this in a way that is non blaming to the child.

Quite why we needed a new model of secure care when we already have one that by and large works well has always escaped me. Wouldn’t expanding the SCH sector have been a better bet?

So I have my doubts as to whether Secure Schools will have the longevity or reach of borstals. The Justice Secretary told MPs she wants to see more evidence on outcomes at Oasis Restore before committing to rolling out Secure Schools. Fully understanding the long term impact the Secure School has on violence among its young residents will  surely take many years, although Shabana Mahmood promised to write to MPs about what they can expect by way of evaluation in 2025.   . 

In the immediate future there must be some concern that the Principal who set up the first school has left only three months after it opened. Interviews to appoint his successor are planned for the end of January so depending on any notice period for the successful candidate, there may be a vacancy for several months. 

That will hopefully prove just a hiccup. The Oasis Restore accounts suggest that the Secure School’s land and buildings have been transferred to them on a 125 year lease. They may well be in for the long haul in Kent – but will they change the overall  shape of youth custody? 

Much too early to tell.

What a Waste!

 

There’d always been a hope against hope that the new Labour government might change course on penal policy. Up until yesterday's statement and strategy on prison capacity.

To their credit, they’ve commissioned a comprehensive re-evaluation of the sentencing framework designed to make greater use of punishment outside prison.

But just as the Independent Sentencing Review led by David Gauke has started work, the Ministry of Justice has anyway pledged to continue with the last government’s prison building programme. It’s a match made in haste they may well repent at leisure.

While the rate of imprisonment in England and Wales is already twice as high as in Germany and the Netherlands, the government has decided that yet more people should be locked up for longer, regardless of the financial, social and ethical costs.

So much for an administration that promises a test and learn culture to tackle the biggest challenges; or a Finance Ministry that will take an Iron Fist against waste.

Before signing off the spending, has anyone there asked if this is the best way of protecting the public and reducing reoffending? Last month three former Lord Chief Justices told the Howard League that the answer was a resounding no. 

Surely at least some of the money earmarked for new prison places would be better used to make existing ones decent; or better to strengthen alternatives to prison- through more hospital beds, drug treatment or probation hostels.

Or better still to fund properly activities which can prevent serious youth violence - like mentoring and therapy – or those which can deal more constructively with crime- like restorative justice.

Even if Mr Gauke recommends more approaches like this, the government won’t be able to fund them.

Older readers may know Ian Dury and the Blockheads’ 1978 hit “What a Waste.”  I was reminded of the lines

“I could be the catalyst that sparks the revolution,
 I could be an inmate in a long-term institution”.

More of the latter than the former in these disappointing announcements.

 

 

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Health and Safety in Prison : Time for a New Approach?

 

 

 

Given the parlous state of the prisons – evidenced most recently in reports from the Independent Monitoring Boards (IMB) and the National Audit Office (NAO), it seems odd how little interest is taken in them by the Health and Safety Executive (HSE).

The HSE is the national regulator for workplace health and safety, dedicated, they say, to protecting people and places, and helping everyone lead safer and healthier lives. According to their website the HSE works to ensure people feel safe where they live, where they work and, in their environment. Presumably this includes people in prison- prisoners, staff and visitors. 

The HSE say that they will not intervene “if another regulator has specific responsibility for that area.” But the Prison Inspectorate, IMB's and the Ombudsman are not regulators. Prisons are subject to the enforcement powers of the Crown Premises Fire Safety Inspectorate and the Care Quality Commission, the regulator of health and social care. But there's a gap in the regulation of other aspects of prison environments and processes. 

It's true that the HSE has played a role in investigating the levels of Radon gas in Dartmoor prison, which led to the prisoners and staff being transferred out four months ago.  But this was the culmination of a shambolic sequence of events dating back four years.

The prison’s local IMB has published a troubling timeline in their annual report detailing how fluctuating decisions from the Prison Service and HSE led to “the repeated decanting and recanting of prisoners” after the potentially dangerous substance was first detected in 2020. There is no record of any formal enforcement notice having being served by the HSE at Dartmoor or indeed any other prison.

In fact their register shows only one improvement notice in the prison sector. This relates to the Prison Service’s National Tactical Response Group (NTRG), a group of trained staff deployed to deal with incidents of violence and disorder which cannot be handled locally. 

The HSE notice served in June this year says that the NTRG’s “system of work for Close Control Techniques in Operational (live) Interventions does not reduce the risk of harm so far as reasonably practicable”. 

The Prison Service must comply with the notice by 7^th December 2024. I am not sure what specifically needs attention or what gave rise to the notice. But it may be significant.

NTRG was deployed more than twice a day last year . When the sharply increased figures were announced, the Shadow Justice Secretary said: “These squads are trained to deal with the most serious disorder and violence in the prison estate. The shocking rise in the number of deployments is a damning testament to the failure to manage our prisons and the miserable impact of 14 years of Tory rule on our criminal justice system”.

Now Ms Mahmood is in charge of the system, she will need to ensure that the NTRG has taken any necessary remedial action.

But there is a broader issue. In his relaunch speech, the Prime Minister included regulators in his list of "naysayers" who will no longer have an upper hand, (whatever that means). 

In prisons, they have hardly had a hand at all. They should do more not less.    

Throwing Good Money After Bad

 

The Wellcome Collection exhibition Hard Graft: Work, Health and Rights has among an eclectic mix of items on display an elaborate slide rule used to set daily targets for the number of steps on the treadmill each prisoner should take per hour. 

While no doubt useful to standardise the diverse working practices across the mid-19^th century prison estate, I wondered whether any of the administrators who created the device or the Governors who applied it stopped to ask themselves: What is the fundamental point of what we are doing here?

A similar thought struck me reading the National Audit Office Report Increasing the Capacity of the Prison Estate to Meet Demand. Of course there are benefits to charting forensically what turn out to have been woeful and often wasteful attempts by Government to deliver a prison estate fit for purpose.

Failures to maintain existing prisons, unbridled optimism bias about timescales for building new ones and the expensive short term fixes dreamt up to stave off total collapse all provide lessons, I suppose. Whether they will be learned is another matter. The most important of the NAO’s recommendations could have been cut and pasted from their 2020 report on Improving the Prison Estate.

What’s missing though is any engagement with the bigger questions. Why on earth are we spending what’s now £10 billion on more than 20,000 new prison places? And in what universe is this considered good value for money?

The NAO’s job is to tell us if resources have been used economically, efficiently and effectively to achieve intended outcomes. Sure, their role is not to question government policy objectives. But in the case of the Ministry of Justice, their relevant objectives have been protecting the public and reducing reoffending. Should the NAO not have at least raised a question about whether the biggest prison building programme since Victorian times is the best way of meeting those objectives?

Last week three former Lord Chief Justices not only asked the question but answered it with a resounding “no”.   One told the Howard League that the relentless rise in the length of prison terms had led to an “appalling” and unnecessary use of money and the prison population should be about 50,000 not the 85,000 we have today let alone the 100,000 we may end up with. Another described the increasing numbers of people recalled to prison as “completely insane”.

Not the language of auditors perhaps but not normally of judges either.  If leading judicial figures conclude that funds spent on prison would be better used in other ways, the body charged with assessing value for money should at least engage with the argument.  

Had they done so they could have looked at whether at least some of the money earmarked to lock up more people for longer might be better used to strengthen the range and quality of alternatives to prison- through more hospital beds, drug treatment or probation hostels. Or to fund properly activities which can prevent serious youth violence - like mentoring and therapy – or those which can deal more constructively with crime- like restorative justice.

But they didn’t.  Perhaps David Gauke and his colleagues undertaking the sentencing review will do so. We know from the NAO report that there is a need to cut demand for prison places by 12,000 because the MoJ does not have any contingency plans to increase prison capacity beyond the current target “as it views it has limited options left to do this”. Let’s hope Gauke doesn’t simply get a slide rule out but takes the opportunity to fashion a genuinely more effective response to crime and justice.

Confidence and Supply

 

Much of the focus on prison reform in recent months has been on managing burgeoning demand for places. The newly formed JusticeSelect Committee started their examination of Prisons Minister Lord Timpson this week by asking how long the space freed up by the SDS 40 early release scheme might last.

The answer it seems is next Autumn or maybe a bit longer. That’s hoped to be enough time to create longer term sustainability in the system by putting in place whatever legislative changes are recommended by the David Gauke Sentencing Review.

But is that realistic? Even if Gauke manages to report in the Spring, his proposals are likely to be controversial. Getting them on to the statute book and then implemented could easily take another year.

The MoJ handily has a couple of further demand reduction measures up its sleeve- a change to the process of recalling released prisoners to jail in April and extending to a year the period of release on a Home Detention Curfew for eligible prisoners, from June. So they may muddle through.

But what about the supply of new prison places?

MPs heard that the new all electric Millsike Prison in North Yorkshire is on track to open in April, (although like all new prisons will surely need time to reach its full capacity of 1500). A new houseblock at Rye Hill in Warwickshire will also be ready early next year which should add 450 additional places. Timpson also said that HMP Dartmoor - closed in the Summer because of high levels of Radon- will re-open when safe, making more than 600 places available.

Prison Service Chief Amy Rees told the Committee that planning permission had now been granted for 17,000 of the 20,000 proposed new prison places. (The outstanding decision on the one remaining new build prison near Wymott and Garth in Lancashire is due to be made by mid-December).

Planning delays have added between 18 months and 3 years to the original timelines according to Ms Rees. In future, planning for prisons will be treated as Crown development with urgent procedures for reaching decisions and more in the way of permitted development on existing sites.  

On the downside, Timpson revealed that 100 projects in courts and prisons were affected when construction company ISG filed for administration in September. 79 will require re-procurement.

He also acknowledged the significant shortcomings in the physical condition of the existing estate although did not put a financial cost on the backlog of maintenance. It was £1 billion in 2021 and seemed to suggest it has doubled since then.

What we do know is that there are still 23,000 cells which require fire safety upgrades. According to my calculations, the necessary work has been progressing at the rate of about 3,000 cells a year- far too few to meet the commitment to complete the work by 2027.  The latest HMPPS Annual report, published last week but curiously unmentioned in the Select Committee, says reaching the target is “finely balanced in terms of the future headroom position and we are likely to require additional places out of use in future years to achieve this aim.”

More broadly, inspection and monitoring reports have drawn repeated attention to often shocking failings in infrastructure. These aren’t limited to the 25 odd prisons dating from the Victorian era. The HMPPS Annual Report revealed that in May 2024, eight sites were confirmed as containing RAAC.

HMPPS have undertaken a comprehensive survey of conditions in the prisons. I was pleased to hear Ms Rees tell the committee that the report of the survey would be published shortly particularly as the MoJ had refused my FOI request to see it.  

But then according to the HMPPS Annual Report, the Final Report of the Survey was published in June 2024. It wasn’t.  I have asked the Justice Committee to try to clarify the position.

A Secure Future?

 

In 2016, Charlie Taylor’s Review of Youth Justice concluded that “fundamental change is needed to the current youth custody system”. He found children spending too much time in their cells; inadequate education and rehabilitation; and increasing violence both among children and towards staff.

This week Taylor- now Chief Inspector of Prisons-reported that Young Offender Institutions (YOIs) are still “dominated by violence and disorder and weak education”. If anything, eight years on, things are worse.

It’s not surprising that children’s experiences in YOI’s are as dismal as they are given the fundamental unsuitability of prison establishments for their care.

 At Feltham in West London, over the summer two serious incidents of violence led to 34 members of staff being injured.

“Inspectors saw children trying to get to each other through locked gates as they were returning from education.”

But most “simply did not attend enough education to make substantial progress.”

Compare this to a Secure Childrens Home (SCH) in Nottingham where inspectors found a much more positive setting. When children are at risk of hurting themselves or others, staff intervene with physical holds which are used safely, proportionately, and for a short length of time. When children do not get on with each other, appropriate action is taken to prevent potential bullying. Staff work with children to repair relationships whenever possible.  

School attendance is very high. Some children achieve GCSEs in core subjects, others study vocational options in line with their career ambitions.

SCH’s are much smaller facilities than YOIs with better trained staff and a greater ability to choose which children they take. And they cost a lot more.

So while they probably cannot replace YOIs altogether, it’s always puzzled me why Taylor’s Review did not recommend their expansion. They consistently provide high quality care and education, but the numbers of places have reduced substantially in recent years

Instead Taylor arguably overcomplicated matters by inventing a new hybrid institution -the Secure School- which is both a SCH and a 16-19 Academy. After a protracted and expensive development of the old Medway Secure Training Centre, Oasis Restore took its first children in August.

We learned this week that the Secure School’s Principal Director and Responsible Individual, Andrew Willetts will start a new job in January, as Chief Executive Officer at The Orpheus Trust. The Director of Care and Wellbeing left Oasis Restore in June before the first children were even placed there.

I don’t know exactly what lies behind these moves, but it cannot help the stability of any institution if the leader who’s spent three years preparing it to open departs so soon after it does. Despite misgivings about the need for a new model of custody, I hope Oasis Restore proves successful.

In 2016 the government agreed with the Taylor Review’s vision that YOIs and STCs should be replaced in the longer term by smaller secure schools situated in the regions that they serve.  

This week’s bleak inspection reports on youth custody confirm the need for change- but whether by more Secure Schools or Secure Childrens Homes remains open to debate.