Urgent Notification from HMIP

The prison inspector has the option of raising serious concerns about a prison after an inspection direct with the MoJ, and the MoJ has to respond within 4 weeks. This options has only been done once before (on HMP Nottingham).

Return to Exeter

To read the letter with all the attachments and appendices follow the link (click here. (396.93 kB); but the basic letter said;

“Dear Secretary of State

Urgent Notification :HM Prison Exeter

In accordance with the Protocol between HM Chief Inspector of Prisons and the Ministry of Justice dated 30 November 2017, I am writing to you to invoke the Urgent Notification (UN) process in respect of HM Prison Exeter.

An unannounced inspection of HM Prison Exeter took place between 14 and 24 May 2018. This inspection identified a number of significant concerns with regard to the treatment and conditions of prisoners. As required by the process, I am therefore writing to give you formal notification of my decision to invoke it. At this stage I shall also set out an indication of the evidence that underpins that decision, and the rationale for why I believe it is necessary. In addition,  I attach a summary note which details all the main judgements that followed this inspection and includes the priorities addressed in this letter. The summary note is drawn from a similar document provided to the Acting Governor at the end of the inspection last week. He has been informed of my intention to invoke the UN process. I shall, as usual, publish a full inspection report in due course.

The UN process requires me to summarise in this letter the judgements that have led to significant concerns, and to identify those issues that require improvement. A decision to invoke the UN process is determined by my judgement, informed by relevant factors during the inspection that, as set out in the Protocol, may include:

  • Poor healthy prison test assessments (HMI Prisons’ inspection methodology is outlined in the HMI Prisons Inspection Framework);
  • The pattern of the healthy prison test judgements;
  • Repeated poor assessments;
  • The type of prison and the risks presented;
  • The vulnerability of those detained;
  • The failure to achieve recommendations;
  • The Inspectorate’s  confidence  in  the  prison’s    capacity    for    change    and improvement.

The  Protocol  sets  out  that  this  letter  will  be  placed  in  the  public  domain,  and  that  the Secretary of State commits to respond publicly to the concerns raised within 28 calendar days. The  response  will  explain  how  outcomes  for  prisoners  in  the institution  will  be improved in both the immediate and longer term.

The principal reasons I have decided to invoke the UN protocol in respect of HMP Exeter following this most recent inspection are because since the last full inspection in August 2016, safety in the prison has significantly worsened in many respects, and has attracted our lowest possible grading of ‘poor’. There  have  been  six self  inflicted  deaths,  five  of which  were  in  2017. Despite  some  creditable  efforts  to  implement  recommendations from the Prisons and Probation Ombudsman following those deaths, the overall level of safety at HMP Exeter is unequivocally poor.

Self  harm during  the  past six  months is running at  a  higher  rate  than  in any  similar prisons. It has risen by 40% since the last inspection. Assaults against both prisoners and staff  are  among  the  highest  we  have  seen,  and  the  use  of  force  by  staff  is  inadequately governed. Meanwhile, illicit drugs are rife in the prison, nearly a quarter of prisoners are testing positive, and all this is taking place in a prison where the living conditions for too many are unacceptably poor. During the inspection we saw many examples of a lack of care  for  vulnerable  prisoners  which,  given  the  recent  tragic  events  in  the  prison,  were symptomatic  of  a  lack  of  empathy  and  understanding  of  the  factors  that  contribute  to suicide and self harm.

The  last  inspection  of  HMP  Exeter  took  place  in  August  2016. Outcomes  for  prisoners were found to be not sufficiently good in all four of our healthy prison tests. In terms of safety the report noted:

‘Levels of violence were high and many prisoners said that they felt unsafe. The levels  of  self  harm  were  high.There  had  been  10  self  inflicted  deaths  since  the previous inspection.’

At  that  time  we  made 14  recommendations  in  respect  of  safety,  including  two  main recommendations. One  was intended  to  address  the  fact  that  too  many  prisoners  felt unsafe,  and  the other  focused  on  the poor  governance  of  the  use  of  force. During  this latest  inspection  we  found  that  neither  of  these  main  recommendations  had  been achieved, and in fact the situation in both respects had deteriorated. Overall only three out of the 14 safety related recommendations had been fully achieved.

Despite some improvements in monitoring violence, assaults on both staff and prisoners have significantly increased since the last inspection. Many were serious and the use of weapons was a common feature. Assaults against prisoners have gone up by 107% since the last inspection and the rate is now the highest we have seen in local prisons in the last three years. Meanwhile, assaults on staff have risen by 60%, and the number of fights has risen by 46%. During the inspection I was told by a senior member of staff that the reason the figures were so high was because all incidents were properly recorded. I asked whether recording practices had changed since the last inspection and was told that they had not.

A key part of HMI Prisons’ methodology is a survey of prisoners, carried out using fully validated research methods. These survey results are used to inform judgements made by inspectors who also speak to prisoners and staff, observe behaviours and study data and other documents. Our survey suggests that at HMP Exeter the population have high levels of need on arrival at the prison. Fifty five percent told us they felt depressed on arrival, 24% felt suicidal and 38% had problems with drugs or alcohol.

In the context of a prison with significant levels of vulnerability among prisoners, and where suicide and self harm are at such high levels, it was shocking to see the way in which cell call bells were routinely ignored by staff. Given that the prison is now much better staffed, this was inexcusable. Inspectors saw bells going unanswered even when staff were doing nothing else. Even on the first night and induction landings, where  prisoners are likely to be at their most vulnerable, bells were left unanswered for long  periods. The prison’s own recording system showed that it was common place for bells not to be answered within a reasonable time. The system was either not being reviewed by managers, or what it revealed was being ignored.

Care provided to some prisoners during their first night and early days was poor. Some vulnerable prisoners spent their early days on overspill wings where they received a poor regime, abuse from mainstream prisoners and a lack of support from peer workers and  staff. During the inspection we found wing staff who were completely unaware that they had new prisoners located on their wings. We also saw a new prisoner located in a filthy cell with a blocked toilet, and he was only moved after intervention by an inspector. Another vulnerable prisoner who was assessed as being at a heightened risk of suicide and self harm, who should have been located on the dedicated first night unit, was instead placed on C1 wing ,a subterranean unit that was in effect being used as a segregation unit, but without any of the usual safeguards. This prisoner spent three days on this unit before moving to the first night unit where inspectors saw him in a squalid cell without bedding, a television or glass in his window. None of this had been reported by staff who were required to check on him regularly as part of his care plan.

C1 wing was a major cause of concern for inspectors. There were no proper reintegration  plans and no formal reviews. The regime was extremely limited, and record keeping was very poor. I asked to see the record of when one of the men had last had access to exercise, was assured that it would have been recorded, but found that it was not. During my visit the member of staff in the unit could not tell me when the prisoners had access to even basic entitlements such as showers or exercise.

Meanwhile,  in the designated  segregation  unit  (A1)  there was  a  special  cell which  was completely bare and contained no furniture, toilet or bed. Prison and regional managers had approved the use of this cell for those judged to be so vulnerable as to be in need of constant observation, and it had been so used 17 times in the previous six months. There was supposedly an inflatable bed available for use in this cell, but it could not be found by staff  during  the  inspection,  and  inspectors saw  video  of  a  prisoner on constant  watch being located in the cell without it.

Many cells at HMP Exeter were in a very poor state of repair, with many broken windows and  observation  panels,  leaking  lavatories  and  sinks,  and  poorly screened  toilets. I  saw some  cells  that  were  clearly  not  fit  to  be  used,  and  should  have  been  taken  out  of commission. Had  it  not  been  for  the improvement  in  healthcare  in  the  prison  since  the  last  inspection,  it  is  highly  likely  that  the  poor  living  conditions  experienced  by  many would  have resulted in a grading of ‘poor’ for our Respect test.

The   findings   around   safety   and   poor   living   conditions   were   compounded   by   the prevalence of illicit drugs in the prison.In our survey, a very high 60% of prisoners told us it was easy to get hold of drugs, and 14% said they had acquired a drug habit while in the prison. These responses were to an extent confirmed by the results of mandatory drug testing. There  was  a  strong  smell  of  drugs  on  some  of  the  wings,  and  I  saw  prisoners who  were  clearly  under  the  influence  of  drugs. There can  be  little doubt  that  the  ready availability of drugs was contributing to the violence in the prison.

Given the vulnerability of many prisoners, the rise in violence of all kinds, the lack of care in  too  many  cases, the prevalence  of  drugs  and  poor  living  conditions,  it  is  perhaps unsurprising  that  despite  our  main concern  and  linked recommendation  at  the  last inspection, far too many prisoners still felt unsafe. Sixty seven percent told us they had felt  unsafe  at  Exeter  at  some time,  a  significant  increase  since  the  last  inspection, and almost a third said they felt unsafe at the time of our inspection. Sixty percent said they had  been  bullied  or  victimised  by  other  prisoners  and  48%  said  they  had  been  bullied  or victimised by staff.

In light of the high levels of violence at HMP Exeter, it was perhaps to be expected that the  use  of  force  should  have risen  since  the  last  inspection. It  had, by some 39%. However,  it  is extraordinary  that  our  main  recommendation  on  the  governance  of  the use of force has been largely ignored. Since 1 January 2018 there had been 187 recorded incidents of force being used, yet the prison’s own database showed that more than 250 reports relating to those incidents had not been completed by staff, and those that had been  completed  were  not  routinely  reviewed  by  managers. There  had  also  been  39 planned  uses  of  force  between  November  2017  and  April  2018,  but  despite  the  formal requirement to film and review such incidents the prison was only able to provide us with film from three of them. Body -worn cameras  were issued to many staff but these were not used in the majority of incidents and footage was not routinely reviewed.

At  the  last  inspection  I  expressly  mentioned  and  made  allowance  for  the  chronic  staff shortages that HMP Exeter was experiencing at that time. The prison is now significantly better staffed, and there is now a more predictable regime available to many, though not all,   prisoners. There   have   also   been   distinct   improvements   in   health care   and resettlement activity. This latter feature led us to improve the grading for Resettlement and  Release  Planning  from ‘not  sufficiently  good’ to ‘reasonably  good’. This  is  a  real achievement.

Nevertheless,  it  is  of  great  concern that the  response to  our  recommendations  made  in respect  of  safety  issues  at  the  last inspection  has been  so  poor.   Across  the  full breadth of   the   previous   inspection the   number   of recommendations achieved was also disappointingly small. It must be emphasised that a low achievement rate is not in itself an  indicator  of  performance  in  meeting  HMI Prisons’ Expectations. We  make  our judgements  solely  on  the  basis  of the  evidence  gathered  during  the  course  of  the inspection. However,   a  poor   response   to  past   inspections can   and   does   give   an indication  as  to  how  much  confidence  we  can  have  that  the  issues  raised  by  the  Inspectorate  will  be  satisfactorily addressed  in  the  future,  which  is  of  course  a  relevant factor  in  coming to  the  decision  to  invoke  the  UN protocol. The  senior  management team that is currently in place at HMP Exeter is largely the same as at the last inspection in 2016. The failure to address the actual and perceived lack of safety, and the issues that contribute to both, is so serious that is has led me to have significant concerns about the treatment and conditions of prisoners at HMP Exeter and to the inevitable conclusion to invoke the UN protocol.

If  there  is  any  further  information  that  would  be  of  help  to  you  in considering  your response to this Urgent Notification, please do not hesitate to contact me.

Yours sincerely


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