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).
To read the letter with all the attachments and appendices follow the link (click here.; 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.