Dear Mr Short,

Pre – Inquest reviews into the death of Sean Plumstead

Thank you for your Regulation 28 Report addressed to The Governor, HMP Winchester, dated 9 August 2017, following the pre-inquest review hearings into the death of Sean Plumstead in September 2016.

Your report has been passed to Safer Custody and Public Protection Group (SCPPG), which has responsibility for the policy on suicide prevention and self-harm management and for sharing learning from deaths in custody.

The Governor takes her responsibility towards preventing future deaths very seriously and wishes to assure you that the concerns you raise have been addressed.

Her responses are laid out below.

1) HMP Winchester does have recordings of all telephone calls made by Mr Plumstead and will provide you with a copy as directed. HMP Winchester have always had copies of the calls but the system on which calls are accessed to be listened to is encrypted.

HMP Winchester does not have a dedicated typing resource. The prison have taken on a temporary member of staff to access the encrypted PIN system, which has just the one point of listening, to transcribe the calls. Once completed, copies will be made available to all interested parties.

They will be catalogued and stored within a secure storage facility.

In addition HMP Winchester have implemented a new protocol for information and evidence gathering from prison departments within specified timeframes. If these are not adhered to, matters will be escalated to the Governor.

The Governor is clear that these processes should prevent HMP Winchester from being in a similar position again.

2) The recordings of interviews with the two staff members have been located. The interview discs had been left unsecured and the Governor’s secretary had secured them. Now the discs have been sourced, they have been transcribed and the transcripts have been shared with Government Legal Department and will be forwarded to yourself.

The Governor accepts that the discs should not have been left unsecured and apologises for the delay in sending you the transcripts of them.

As a result of this, the Head of Business Assurance at the prison is carrying out a review of accounting systems and storage of internal investigation material at HMP Winchester with a view to identifying and rectifying areas of weakness.

3) A secure storage facility for documentation regarding any death in custody was not previously available. This has now been ordered and it’s security handling will be written into the current contingency plan for deaths in custody and managed by the Safer Custody team.

All material will be catalogued as evidence prior to its storage.

I hope that this response provides you with reassurance that HMP Winchester recognises the concerns you have raised and has addressed them.

The Governor confirms that she is happy to answer any further questions that may arise either from yourself, or from Mr Plumsteads’ family.

Dear Mr Short

Sean Patrick Plumstead Deceased Regulation 28 Report to Prevent Future Deaths

Thank you for your Regulation 28 report dated 19 October 2017 following the inquest touching the death of Mr Plumstead. We note the areas of concern you have highlighted and that there is a risk that future deaths may occur unless action is taken. I am now in a position to respond to you on behalf of Carillion and do so specifically in respect of the areas that touch Carillion’s work under its facilities management contracts with Her Majesty’s Prison and Probation Service (HMPPS). You raised the following areas of concern:

1. ‘In the 18 months before Mr Plumstead’s death in September 2016 at least two Carillion staff were employed in prisoner facing roles at the prison (in CES) without any training in self- harm/suicide prevention (in apparent contradiction to the national policy – The PSI 64/2011 in its latest version). Further, one of those staff members was expected to make entries in an (ACCT) support document without having had relevant training. As of October 2017, one of those staff members has still to be trained in self-harm suicide prevention’.

2. ‘There is a risk arising that there was and continues to be a gap in training which Carillion is either unaware or unconcerned with – a gap that may continue here and elsewhere. I understand that Carillion has a contractual obligation to ensure that staff provided to the prison will be appropriately trained, but I cannot identify any requirement for self- harm/suicide management training by the prison as necessary’.

3. ‘I have also heard evidence that the prison do not hold training records for Carillion staff’.

4. ‘I am also concerned of a risk in other prisons where Carillion staff are directly engaging with prisoners without adequate or appropriate training in suicide and self-harm management. I consider Carillion has the power to take action to remedy these shortcomings and that in collaboration with the Ministry of justice both can address these concerns and clarify responsibilities’.

PSI64/2011 I set out below the relevant extracts from PSI64/2011

Relevant sections within Safer Custody PSI 64/2011 state: Page 8 Specification Outputs -clause 27 ‘Contract/Service Level Agreements with third party providers reflect the need for multi-disciplinary working in relation to at risk prisoners. It is important that service providers are encouraged to contribute to the identification of risk procedures and multi-disciplinary case management reviews, either in person or in writing. Where appropriate contracts or SLAs must include this as a business requirement and key deliverable’. Page 10 Roles and responsibilities -paragraph 1

Making tomorrow a better place Registered in England and Wales no 3782379 Registered Office Carillion House 84 Salop Street Wolverhampton WV3 0SR CARILLION and the logo are trademarks of Carillion plc A Carillion Company

Carillion plc

2nd Floor Lynton House 7-12 Tavistock Square London WC1H 9LT ‘All staff in contact with prisoners must be trained to at least ACCT Foundation Level. ACCT refresher training must be provided according to local training needs’.

CARILLION’S CONTRACTS WITH HMPPS I wish to clarify an apparent misunderstanding about our contractual obligations that you appear to be under following evidence that you heard during the inquest. By contract, Carillion provides a range of hard and soft facilities management services to HMPPS in public prisons throughout the country. However, having carefully reviewed our contracts with HMPPS, and contrary to the view that you formed during the inquest, there is in fact no contractual requirement upon Carillion and its staff to undergo SASH training, either as a business requirement, key deliverable or at all. Accordingly, prior to the inquest touching the death of Mr Plumstead, Carillion was unaware of the requirement for its staff to undergo SASH training. We are accordingly grateful for having had this issue drawn to our attention and immediately upon receipt of your Regulation 28 report set about investigating the matter and how we might work with HMPPS on it, the obligation to train all prisoner facing staff, being theirs.

ACTION TAKEN/TO BE TAKEN
1. We have familiarised ourselves fully with PSI64/2011 and its updates so as to ensure compliance with HMPPS policies and procedures.
2. We have identified that SASH training is highly specialist and specific to a custodial setting and as such is not job specific in terms of the training we would ordinarily expect our staff to undertake within facilities management. Accordingly, it is not training that we are able to provide to our staff as employers.
3. Notwithstanding the contractual arrangements referred to above, we have made contact with colleagues at HMPPS and indicated our willingness and motivation to support Prison Governors to ensure that across our custodial contracts our staff are properly trained and supported in their work - in line with PSI 64/2011.
4. We have proposed to them that they provide us with a formal instruction under the contractual arrangements for our staff to undergo SASH training and confirm which categories of staff should undergo training. Our client has confirmed this week that it considers all Carillion prisoner facing staff should be required to undergo training.
5. We have proposed that as soon as we have that formal instruction to proceed on this basis, we issue a notice to all our site managers to make staff available to attend SASH training and we have suggested that HMPPS issues a notice in parallel to the People Hubs and Safer Custody Managers in each prison to provide SASH training to Carillion staff in line with PSI 64/21011.
6. We have also suggested that the People Hubs in each prison maintain a training record for all Carillion and agency staff within the facilities management contract and that there is an agreed mechanism whereby Carillion can receive management information on a monthly or quarterly basis on staff training planned and achieved across the contract.

I trust you are assured of our intention to work with HMPPS on this issue and that our action plan is appropriate in the circumstances.

Making tomorrow a better place Registered in England and Wales no 3782379 Registered Office Carillion House 84 Salop Street Wolverhampton WV3 0SR CARILLION and the logo are trademarks of Carillion plc A Carillion Company

Carillion plc

2nd Floor Lynton House 7-12 Tavistock Square London WC1H 9LT

Dear Mr Short,

Inquest into the death of Sean Plumstead

Thank you for your Regulation 28 report of 19 October 2017 following the conclusion of the inquest into the death of Sean Plumstead.

I know that you will share a copy of this response with Sean’s mother and I would like first to express my condolences for her loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

I am grateful to you for bringing these matters of concern to my attention, and I will address them in the order in which they appear in your report.

ACCT Training Your first concern is that targets for suicide and self-harm training at HMP Winchester are not being met, and that as a result there is a growing proportion of

staff who have not been trained and may not recognise prisoners at risk of suicide and self-harm.

I note that you have been given information about training in evidence at this and other inquests, and in response to previous Regulation 28 reports. There have recently been some changes in the training that is being delivered on this subject, and I think it will be helpful for me to explain these changes before moving on to address your point about targets.

PSI 64/2011 Safer Custody states that: “All staff in contact with prisoners must be trained to at least ACCT Foundation level. From January 2012 ACCT Foundation will be replaced by Introduction to Safer Custody and new staff must be trained in this. ACCT refresher training must be provided according to local training needs.”

The Introduction to Safer Custody course to which this refers was replaced by the Introduction to Suicide and Self-Harm Prevention course, known as SASH, in May
2017. Like its predecessor courses, the SASH course is being delivered to all new prison officers as part of their entry level training, and to all new staff in other prisoner-facing roles. It has also been developed in modular form so that it can be delivered as refresher training to existing staff.

The ACCT training at Winchester about which you have previously been informed was a two hour course, provided locally as refresher training, in accordance with the PSI above. This has now been replaced by the SASH training, which consists of six modules, including one on mental health awareness, totalling one and a half days in duration.

The targets for the programme of refresher training have been revised to reflect the fact that the new training takes much longer to complete. This, together with the resourcing challenges that the Prison faced during the summer months, and the lack of availability of trainers equipped to deliver the new course means that it is now projected that the new course will have been delivered to all existing staff who have contact with prisoners by the end of September 2018. Additional staff will be trained as trainers in early 2018 in order to facilitate this.

Crucially, this does not mean that untrained staff who are unable to recognise prisoners at risk are being deployed in the prison. The training targets relate to the completion of the local refresher training. So, whilst the figures that you quote show a temporary reduction in the proportion of staff who are “in date” in terms of the local requirement to have undertaken such training within the last three years, this does not mean that there are staff in prisoner-facing roles who have never been trained. Moreover, the refresher training that the staff are now undertaking is much more extensive, and contains more detailed information about risk, than the ACCT training that was previously available. For this reason I am confident that the changes that have been made to the training programme will have the effect of improving staff awareness and capacity to identify and address risk.

You may also be interested to know that HMPPS has worked with Samaritans to develop a Suicide Prevention Learning Tool that is now available on the HMPPS

intranet. This consists of a series of short films that communicate important messages about suicide prevention through interviews with staff who share their own experiences. They tackle some of the myths about suicide, explain how to identify and help somebody at risk and describe the sources of support available for staff who are affected by issues related to suicide and self-harm. Since the films were released in October, feedback has been that staff find them engaging and inspiring, as they recognise the important role that staff play, intervening every day to support men and women at risk, whilst acknowledging that approaching a prisoner who appears distressed can be difficult and providing useful tips about how to do so.

Training of all prisoner-facing staff Your next concern relates to the fact that prisoner-facing staff who were employed by Carillion had not received any ACCT training and that the Prison did not hold training records for these staff.

I can confirm that a number of Carillion staff in prisoner-facing roles at HMP Winchester have been trained, and that records of training delivered to all staff, including those who are not directly employed, are now held. These records do not, however, include information about the internal training programmes of other employers.

I accept that the requirement for prisoner-facing staff to undertake suicide and self- harm prevention training was not specifically brought to the attention of Carillion when their contract began, and I can confirm that a Service Manager’s Instruction will be issued imminently to ensure that Carillion, and our other contractors, are made aware of the requirement and their contractual obligation to comply with it. Both HMPPS and Carillion are committed to ensuring that all relevant staff are trained as soon as possible.

Emergency Cell Bells Your final concern relates to the effectiveness or otherwise of emergency call bells (ECBs), the expected response times and the widespread misuse of ECBs by prisoners.

All staff at Winchester have been issued with individual notices about the importance of answering ECBs promptly within the required time. Prisoners have again been issued with information about the risks caused to themselves and others by misuse of ECBs. In addition, the ECB response times are now checked every day in order to improve accountability, and the Governor is preparing a bid for funding to upgrade the ECB system. The range of sanctions available for prisoners misusing ECBs will increase following the rollout of digital in-cell equipment in 2018, as abuse of the ECB system may result in the removal of this equipment.

At national level a learning bulletin for staff on the importance of responding promptly to ECBs, and tackling abuse of them by prisoners, will be issued early in
2018.

Thank you again for bringing these matters of concern to my attention. Please be assured that as well as driving the actions described above at Winchester, learning from the circumstances of Mr Plumstead’s tragic death will be shared widely across the prison estate.