The MATTER OF CONCERN is as follows: While the evidence called at the inquest predominantly related specifically to matters at HMP Swaleside, I did hear some evidence that relates more widely to the prison estate. Matters of a more localised nature have been addressed, under cover of a separate report, to the Governor of HMP Swaleside. This report relates only to matters relating to the wider prison estate.

(1) The evidence was that in November 2024, up to (and possibly more than) 90% of prison officers at HMP Swaleside were new in post and still in their probationary period. I was told in evidence by a Supervising Officer (SO) that on 16 November 2024, he 'possibly did not have the right mix of staff in terms of skills and experience to keep the wing safe'. In this inquest, the jury found that, "the communication between prison staff was insufficient and lacked clarity". I was told that the level of officers still in their probationary period has now reduced. I was also made aware of the 'Urgent Notification' (UN) from HM Chief Inspector of Prisons in relation to HMP Swaleside (December 2025), which included in the rationale, "Staff, many of whom lacked experience, were not confident in challenging poor behaviour and there was a lack of order and control." This suggests to me that the issue is ongoing. When exploring the evidence further, I was told that issues relating to the recruitment and retention of prison officers were significant and that this is not something that it is confined only to HMP Swaleside. There was evidence that this is a much wider issue. Without sufficient numbers of experienced prison officers across the prison estate, the staffing issues seen in this particular inquest are likely not isolated. I highlight to you my concern that high levels of inexperienced staff will undoubtedly contribute to future deaths of those in custody.