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Prison deaths: Recent reports show prisoner safety is being compromised whilst the authorities fail time and again to learn lessons from preventable deaths in custody

This summer saw the publication of two key reports dealing with conditions in our prisons. The HM Chief Inspector of Prisons for England and Wales Annual Report 2014 – 2015, and the Harris Review, Changing Prisons, Saving Lives – Report of the Independent Review into Self-Inflicted Deaths in Custody of 18-24 year olds. Both have raised major concerns about prisoner safety, with worrying statistics showing that staff shortages and overcrowding are contributing to a rise in violence and self-harm.

HM Inspectorate of Prisons’ Annual Report

The role of the HM Chief Inspector of Prisons is to ensure that there are independent inspections of places of detention and to report on conditions and treatment. Four tests are used to determine a healthy establishment; safety, respect, purposeful activity and resettlement. Nick Hardwick, HM Chief Inspector of Prisons since July 2010, published his final annual report this year.

It found that an average of four to five prisoners died each week in England and Wales during 2014 – 2015, 239 prisoners in total. This figure was 6% higher than the previous year. Half of these deaths were self-inflicted. In 2014, there were 18,995 incidents of self-harm and the report found that prisoners were more likely to die in prison than they were five years ago with more killing themselves, self-harming, being murdered or assaulted than five years ago.

There has been an increase in violence towards both staff and other prisoners. At HMP Elmley in Kent during April 2014 there were 60% more fights and assaults than in April the previous year. There was a rise in the proportion of prisoners who said they felt unsafe compared to previous inspections with almost 50% of prisoners at HMP Ranby in Nottinghamshire asked saying they felt unsafe.

Whilst violence has increased, staffing has seen sharp falls. Between March 2010 and December 2014 there has been a 29% reduction in the number of full time equivalent staff in public sector prisons. Whilst prison governors stated staffing levels were adequate, they noted they couldn’t manage with high levels of additional vacancies and absences.

Population pressures meant that some prisoners were placed in prisons a long way from home and the courts where their case had been heard. Distances involved and delays in leaving court meant they had long journeys and arrived late at establishments. This compromised their safe reception into the prison and reduced the opportunities for prison staff to identify those at risk before they were locked up for their first night in prison.

Overcrowding was in evidence at some prisons. At HMP Leicester 387 prisoners were living in cells designed to accommodate 214. Dorms were being used to increase capacity with one 16ft by 12ft room housing three double bunk beds. Overcrowding was sometimes exacerbated by squalid conditions. One member of staff at HMP Wormwood Scrubs in referring to a cell noted ‘I wouldn’t keep a dog in there’. Many cells were filthy, covered in graffiti, with furniture missing or broken, windows smashed and on one wing in HMP Wormwood Scrubs cockroaches were found.

20% of prisoners told the inspectors that they spent less than two hours per day out of their cells. In a number of prisons 50% were locked in their cells during the working day. Exercise in the fresh air was limited to 30 minutes a day in most closed prisons. Less than 40% of the men’s prisons inspected during the year had sufficient activity places for their population and in just over two thirds of the prisons inspected the standard of teaching was rated as requiring improvement or inadequate.

Generally the report found that that staff shortages, overcrowding and wider policy changes have had a significant impact on prison safety. They concurred with the conclusion of the Justice Committee that ‘significant numbers of prisons have been operating at staffing levels below what is necessary to maintain reasonable, safe and rehabilitative regimes’. With overcrowding remaining a significant problem this in turn leads to pressure on the number of activity places, the support mechanisms available to prisoners and rehabilitative programmes.

The Harris Review

In February 2014, the Justice Secretary announced an independent review into self-inflicted deaths in custody of 18-24 year olds. The Review was led by Lord Toby Harris, the Chair of the Independent Advisory Panel on Deaths in Custody and he was supported by other members of the Independent Advisory Panel. The Review was asked to examine whether appropriate lessons had been learnt from the self-inflicted deaths in custody of 18-24 year olds since April 2007, and if not, what lessons should be learnt and what action taken to prevent further deaths.

The review reported that harsh environments and impoverished regimes in prisons, particularly when combined with current staff shortages, make the experience of being in custody particularly damaging to developing young adults.
It was clear that young people in prison were not sufficiently engaged in purposeful activity and that their time was not spent in a constructive way. They did not have sufficient education or work which would enable them to go on to lead purposeful lives.

Whilst the policies NOMS (National Offender Management Service) promote through Prison Service Instructions would deliver good practise if they were properly implemented it was found there were no effective processes in place to monitor their implementation across the prison estate. There are, for example, no proper means of assessing whether minimum standards are being met. This is particularly important in the context of the rules meant to ensure ‘Safer Custody’. As a result there was a disconnect between what those in charge thought should be happening and what was actually happening in individual prisons.

Concern was also expressed about the effectiveness of staff training, and the problem of inadequate levels of staffing was a recurrent theme in the evidence collected. The panel were struck by how difficult prisons found it to recruit staff into their many existing vacancies.

Both reports provide worrying reading, particularly in relation to their shared concerns that lessons are not being learnt. This includes from recommendations made by the Prisons and Probation Ombudsman following deaths in custody and concerns raised by Coroners in Prevention of Future Death Reports.

The Harris Review looked at the recommendations made in 87 deaths of 18-24 year olds over six and a half years and found;

  • 145 recommendations were made in relation to ACCTs (self-harm and suicide prevention measures);
  • 33 recommendations concerned the transfer of information between bodies responsible for the care of these young adults;
  • 30 recommendations were in relation to internal communications within establishments; and
  • 135 recommendations relating to staff training and improving skills or knowledge.

Recommendations concerning mandatory actions within the Safer Custody Prison Service Instruction were regularly not adhered to. The Harris Review ultimately concluded that there was insufficient rigour, accountability or transparency in the follow-up procedures following a death in custody. Many of its findings echoed the criticisms and recommendations made consistently and repeatedly over the last 15 years or so. Lessons haven’t been learnt and not enough had been done to bring about substantive change. The HM Inspectorate of Prisons Annual Report noted for example that its’ review of the recommendations of the inquiry into the racist murder of Zahid Mubarek at HMP Feltham in 2000 found that the significant concerns which were found to be a factor in his death, still existed.

This certainly echoes the experience of those of us who represent families at the inquests into the deaths of their loved ones in custody. It is shocking that despite countless reviews, reports and inspections as well as all the work undertaken by those tasked with uncovering the facts around each prison deaths, the recommendations made to prevent future deaths are so often disregarded. Ultimately ‘those who ignore the lessons of past failures are condemned to repeat them’. We must ensure that action is taken to compel our prisons and detention centres to respond and make the changes that are needed to improve prison safety and ultimately save lives.