HMP Nottingham: 'one of the most disturbing inspection reports in recent years'

Peter Clarke, HM Chief Inspector of Prisons, has asked whether prisoners in HMP and YOI Nottingham took their own lives because they could no longer face life in the violent, drug-ridden jail.

In one of the most disturbing inspection reports in recent years, Mr Clarke posed the question in relation to eight apparent self-inflicted deaths between inspections in February 2016 and January 2018, part of an “appalling and tragic” picture of suicide and self-harm in Nottingham.

The formal cause of death in those cases will be decided by inquests but Mr Clarke said: “For too long prisoners have been held in a dangerous, disrespectful, drug-ridden jail. My fear, which may prove to be unfounded, is that some could face it no longer and took their own lives.”

HM Inspectorate of Prisons (HMIP) inspected the East Midlands jail in 2014. That was, like the vast majority of inspections, an unannounced visit. Safety then was assessed as poor, the lowest grade. The following inspections in 2016 and 2018 were, unusually, announced in advance. Despite this, safety was yet again found to have remained at a poor assessment. This spurred Mr Clarke to invoke the first ever use of a new ‘Urgent Notification’ protocol, which requires the Secretary of State for Justice, publicly, to take personal responsibility for improving a jail with significant problems. This centred on a “dramatic decline” at Nottingham and a “persistent and fundamental lack of safety”.

Mr Clarke said: “This prison will not become fit for purpose until it is made safe. It was clear from our evidence that many prisoners at Nottingham did not feel safe.” Inspectors identified disturbing findings:

• Forty per cent of prisoners in the inspection survey said they felt unsafe on their first night in the jail; 67 per cent that they had felt unsafe at some point during their stay; and 35 per cent that they felt unsafe at the time of the inspection. Well over half reported bullying or victimisation.
• Reported violence had not reduced since 2016, with 103 assaults against staff in the six months before the inspection. In the same period, there were nearly 200 incidents of prisoners climbing on the safety netting between landings. Inspectors said the overall level of disorder “contributed to a tense atmosphere at the prison.”
• Well over half of prisoners said drugs were easily available and 15 per cent had acquired a drug problem since entering the prison.
• Use of force by staff had increased considerably since 2016 with nearly 500 incidents in the six-month period prior to the inspection, yet governance and supervision of such interventions were weak.
• Just under half of prisoners had mental health needs and a “very high” 25 per cent – 116 prisoners – were under psychiatric care. A quarter of prisoners said they felt suicidal on arrival in Nottingham.
• Levels of self-harm were far too high, with 344 occurrences recorded in the six months up to the inspection.

Not surprisingly, Mr Clarke said, “in a prison which could be defined by the prevalence of drugs and violence, the level of suicide and self-harm was both tragic and appalling. Since our previous visit, eight prisoners had taken their own lives, with four of these tragedies occurring over a four-week period during the autumn of 2017.  Just a few short weeks after this inspection, a ninth prisoner was believed to have taken his own life.

“We were concerned that some repeated criticisms related to these deaths made by the Prisons and Probation Ombudsman (PPO) (which investigates prison deaths) had not been adequately addressed. For example, cell call bells were still not being answered promptly.”

Mr Clarke added: “We do not claim that the prison had been completely inactive in the face of these challenges. A new violence reduction strategy had been prepared in late 2017… However, this work was fitful and had yet to have an impact.” The prison also had a drug supply reduction policy, though it was not embedded and was not effective.

Inspectors also acknowledged an increase in staff numbers in recent months, though they noted that “too many staff were passive, lacked confidence in dealing with issues or in confronting poor behaviour, and prisoners did not yet see them as reliable or able to deal with the many daily frustrations they faced.”

Health care was reasonably good, and there were plans to improve mental health provision. Daily routines were more predictable and more activities were available for prisoners. There were also “some creditable efforts to prepare men for release”.

The prison governor assured inspectors they had understood the scale of the problems. Mr Clarke said: “I am hopeful that the Urgent Notification will galvanise Her Majesty’s Prison and Probation Service (HMPPS) to provide the support the prison needs to make it an acceptable environment in which to hold prisoners. If this is to happen, there will need to be levels of supervision, support and accountability that have been absent in the past.” The HMPPS action plan drawn in response to the Urgent Notification in January 2018 promised “much that is welcome in terms of review, audit and analysis. However, this must all be translated into tangible action to improve the day-to-day experience, safety and well-being of prisoners. Unless this happens, I fear that progress will be neither substantial nor sustainable.”

Overall, Mr Clarke said: “This was yet again a very poor inspection at Nottingham that left me with no alternative but to bring matters directly to the attention of the Secretary of State by invoking the urgent notification procedure. The record of failure, as set out in this report, cannot be allowed to continue.”

Michael Spurr, Chief Executive of Her Majesty’s Prison and Probation Service, said: “We published an immediate response to the Chief Inspector’s concerns on 14 February and have today published a comprehensive plan setting out the practical actions we are taking to improve conditions at HMP Nottingham. Drug testing has been increased, specialist staff are working with vulnerable prisoners and safety is the absolute priority for the Governor and staff every day. We have strengthened management arrangements, are providing external support and will monitor progress closely over the coming months.”

The Prisons and Probation Ombudsman (PPO), who investigates deaths and complaints in prisons, echoed the findings of the Chief Inspector of Prisons’ report.  

The Acting PPO, Elizabeth Moody, said: “It is highly troubling that HMP  Nottingham has a history of failing to implement recommendations from our  investigations into deaths at the prison”.   

The PPO makes recommendations following investigations into deaths in  prisons so that the prison service can learn from mistakes and prevent them  being made in the future.  

Elizabeth Moody added: “It is a matter of great concern that we found some similarities, not only between the deaths of the five prisoners who took their own lives last autumn, but also with deaths which happened earlier in the year and before. The Chief Inspector is right to highlight the apparent inability of  the prison to learn lessons and I agree that until it can demonstrate progress in  this critical area the risk of future deaths will remain high.”

She also said: “Complaints from prisoners frequently indicate poor custodial  care.  I am troubled that my office upheld proportionately more complaints from prisoners at HMP Nottingham, than in other similar prisons.  This is consistent with the findings of the Chief Inspector and should be a source of concern to the management of HMPPS.”   

At the same time as the Chief Inspector's letter to David Gauke, Elizabeth Moody raised key concerns with the Ministry of Justice which had been identified in her investigations into recent deaths at the prison:

• The importance of initial identification in prisoners of risk of suicide or self-harm. 
• Assessment and management of those individuals, particularly applying multi-disciplinary assessment rather than relying on the way the prisoner presents and talks on arrival in the jail. 
• Referring mental health concerns and issues to healthcare or other experts.
• The importance of staff responding, in line with HMIP expectations, when prisoners press their cell call bells and of staff entering cells promptly when prisoners are found unresponsive. 
• Keeping proper medical records.
• Effective emergency response. 

Elizabeth Moody said: “HMPPS is preparing an Action Plan to address the  urgent concerns raised by the Chief Inspector, particularly in relation to suicide  and self-harm at HMP Nottingham. It is vital that, this time, HMPSS fully incorporates PPO recommendations into the Action Plan. That will help HMP Nottingham create a new culture of safety and protection for vulnerable prisoners. Put simply, it will help save lives and prevent a repetition of the tragedies we saw in 2017.”

* The urgent notification protocol with the Ministry of Justice states that if, during the inspection of prisons, young offender institutions and secure training centres, HM Chief Inspector of Prisons (HMCIP) identifies significant concerns regarding the treatment and conditions of those detained, HMCIP will write to the Secretary of State within seven calendar days of the end of the inspection, providing notification of and reasons for those concerns. The Secretary of State must then publish an action plan within 28 days.

* Read the protocol and the HMP and YOI Nottingham urgent notification letter here

* Read the inspection report on HMP and YOI Nottingham here

* HM Inspectorate of Prisons https://www.justiceinspectorates.gov.uk/hmiprisons/

* Prisons and Probation Ombudsman https://www.ppo.gov.uk/

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