Stewart Stanley
PFD Report
All Responded
Ref: 2023-0341
All 1 response received
· Deadline: 14 Nov 2023
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
14 Nov 2023
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) The evidence revealed that there was an inconsistent approach taken by staff when conducting and recording observations on prisoners subject to the Prison Service suicide and self-harm prevention procedures (known as ACCT).
(2) The evidence also revealed that some Officers had a different interpretation of the requirements of set out in PSI 64/2011 in respect of the timing of observations.
(3) The evidence also revealed that precise times of such observations were not routinely being recorded accurately.
(4) During the evidence it became apparent that a prison officer worked 23 hours out of 24, he was asked if this was normal and he replied, “yes, to make the regime work.”
(2) The evidence also revealed that some Officers had a different interpretation of the requirements of set out in PSI 64/2011 in respect of the timing of observations.
(3) The evidence also revealed that precise times of such observations were not routinely being recorded accurately.
(4) During the evidence it became apparent that a prison officer worked 23 hours out of 24, he was asked if this was normal and he replied, “yes, to make the regime work.”
Responses
Response received
View full response
Dear Mr Spinney
Thank you for your Regulation 28 report of 19 September 2023 addressed to the Governor of HMP Exeter. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.
I know that you will share a copy of this response with Mr Stanley’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have raised some concerns regarding the management of the Assessment, Care in Custody and Teamwork (ACCT) process and staffing levels, recruitment and retention at HMP Exeter. Thank you for bringing your concern to my attention.
HMP Exeter have reviewed the management of the ACCT process and have introduced an assurance procedure to ensure there is consistency and effective completion of all ACCT documents including observations. All ACCT are now allocated to a supervising officer who is responsible for conducting daily checks to ensure all set observations for the previous 24 hours have been completed. Any discrepancies are highlighted with the safety team for prompt action.
Since February 2023, the Prison Performance Support Programme (PPSP) have provided funding for 12 months for two Band 4 ACCT safety ‘Floorwalkers’ who are responsible for conducting regular upskilling sessions which include the need for accurate completion of observations. Further to this, ACCT V6 observation posters have been displayed in all wing offices and guides have been produced for staff.
With regards to your second concern, we remain committed to ensuring prisons are sufficiently resourced to deliver quality outcomes and ensure staff and prisoner safety, as well as improving our regime offering. Staffing has been an ongoing challenge at HMP Exeter, but from June 2020 to June 2023, the total number of operational staff increased by 12% (from 199 to 222), with Band 3-5 officers specifically increasing by 7% (from 165 to 176).
Nationally, we continue to monitor staffing levels across the estate, and when staffing levels affect stability or the regime, there are a number of ways establishments can maximise the use of their own resources and seek support from other establishments to address staffing shortfalls. HMP Exeter have previously received support with additional marketing activity to bolster the recruitment pipeline. Further to this, we have introduced a retention toolkit to help Governors identify the drivers of attrition in their prisons.
Following the Urgent Notification received by the prison in November 2022, additional action was taken to address concerns relating to leadership and staffing, this included a review of staff profiles and the core day regime. HMP Exeter remains classed as a ‘standard plus’ site, which reflects its complexity. A business case to uplift managerial grades has been approved to attract and retain experienced managers, and therefore improve stability of the leadership team for the Governor, Deputy Governor and Head of Safety grades.
More widely, there is ongoing work within HMPPS to examine the overall staffing model for Public sector prisons. The project aims to improve our analysis of resource allocation across the system and ensure that we have prioritized our staff resources to address key business.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address.
Thank you for your Regulation 28 report of 19 September 2023 addressed to the Governor of HMP Exeter. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.
I know that you will share a copy of this response with Mr Stanley’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have raised some concerns regarding the management of the Assessment, Care in Custody and Teamwork (ACCT) process and staffing levels, recruitment and retention at HMP Exeter. Thank you for bringing your concern to my attention.
HMP Exeter have reviewed the management of the ACCT process and have introduced an assurance procedure to ensure there is consistency and effective completion of all ACCT documents including observations. All ACCT are now allocated to a supervising officer who is responsible for conducting daily checks to ensure all set observations for the previous 24 hours have been completed. Any discrepancies are highlighted with the safety team for prompt action.
Since February 2023, the Prison Performance Support Programme (PPSP) have provided funding for 12 months for two Band 4 ACCT safety ‘Floorwalkers’ who are responsible for conducting regular upskilling sessions which include the need for accurate completion of observations. Further to this, ACCT V6 observation posters have been displayed in all wing offices and guides have been produced for staff.
With regards to your second concern, we remain committed to ensuring prisons are sufficiently resourced to deliver quality outcomes and ensure staff and prisoner safety, as well as improving our regime offering. Staffing has been an ongoing challenge at HMP Exeter, but from June 2020 to June 2023, the total number of operational staff increased by 12% (from 199 to 222), with Band 3-5 officers specifically increasing by 7% (from 165 to 176).
Nationally, we continue to monitor staffing levels across the estate, and when staffing levels affect stability or the regime, there are a number of ways establishments can maximise the use of their own resources and seek support from other establishments to address staffing shortfalls. HMP Exeter have previously received support with additional marketing activity to bolster the recruitment pipeline. Further to this, we have introduced a retention toolkit to help Governors identify the drivers of attrition in their prisons.
Following the Urgent Notification received by the prison in November 2022, additional action was taken to address concerns relating to leadership and staffing, this included a review of staff profiles and the core day regime. HMP Exeter remains classed as a ‘standard plus’ site, which reflects its complexity. A business case to uplift managerial grades has been approved to attract and retain experienced managers, and therefore improve stability of the leadership team for the Governor, Deputy Governor and Head of Safety grades.
More widely, there is ongoing work within HMPPS to examine the overall staffing model for Public sector prisons. The project aims to improve our analysis of resource allocation across the system and ensure that we have prioritized our staff resources to address key business.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address.
Action Should Be Taken
(1) Consideration should be given to reviewing the process of conducting and recording ACCT observations to ensure accuracy and compliance with relevant policy and guidance.
(2) Consideration should be given to reviewing staffing levels, retention, and recruitment to ensure the efficient and safe running of the prison.
(2) Consideration should be given to reviewing staffing levels, retention, and recruitment to ensure the efficient and safe running of the prison.
Report Sections
Investigation and Inquest
On 15 July 2020 an investigation was commenced into the death of Stewart Stanley. The investigation concluded at the end of the inquest held on 17 -27 July 2023. The conclusion of the inquest was Suicide in addition the Jury answered a series of questions raised by me.
In summary, the Jury concluded that Mr Stanley’s death was probably caused or contributed to by a failure to follow the processes resulting in the staff best qualified to appreciate Stewart’s risk to himself being excluded from the decision to remove him from constant watch. In the addition the Jury concluded that the multi-disciplinary processes in place were adequate however they were not fully complied with in this case.
In summary, the Jury concluded that Mr Stanley’s death was probably caused or contributed to by a failure to follow the processes resulting in the staff best qualified to appreciate Stewart’s risk to himself being excluded from the decision to remove him from constant watch. In the addition the Jury concluded that the multi-disciplinary processes in place were adequate however they were not fully complied with in this case.
Circumstances of the Death
On 23 June 2020 Mr Stanley was remanded in custody to HMP Exeter.
On the night of 9 to 10 July, Mr Stanley’s cellmate found him seemingly trying to hang himself. He alerted prison staff, who started Prison Service suicide and self-harm prevention procedures (known as ACCT). The staff placed Mr Stanley under constant supervision and moved him to a special cell that allowed an officer to observe him continuously. On 11 July, after a case review it was decided that constant supervision should end and directed that Mr Stanley should now be observed at least once every half an hour during the evening. At around 1.20am on 12 July, the night patrol officer, found Mr Stanley hanging. She called for staff assistance and, when it arrived, they opened the cell, removed the ligature and began chest compressions. Paramedics arrived and took Mr Stanley to hospital, where he died on 14 July.
On the night of 9 to 10 July, Mr Stanley’s cellmate found him seemingly trying to hang himself. He alerted prison staff, who started Prison Service suicide and self-harm prevention procedures (known as ACCT). The staff placed Mr Stanley under constant supervision and moved him to a special cell that allowed an officer to observe him continuously. On 11 July, after a case review it was decided that constant supervision should end and directed that Mr Stanley should now be observed at least once every half an hour during the evening. At around 1.20am on 12 July, the night patrol officer, found Mr Stanley hanging. She called for staff assistance and, when it arrived, they opened the cell, removed the ligature and began chest compressions. Paramedics arrived and took Mr Stanley to hospital, where he died on 14 July.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.