Ministry of Justice

Noted (AI summary) • A common, local protocol for managing those suspected to be under the influence of illicit substances (UTI) at HMP Bedford has been agreed and implemented with the Prison Governor and Head of Safety. • The protocol clearly articulates the roles, responsibilities, and expectations of both healthcare and prison staff in the identification, assessment, and management of those suspected to be UTI. • The protocol makes it clear when prison staff should escalate to healthcare staff and states that healthcare staff are responsible for taking the lead on • HMP Bedford and NHFT carried out a joint review of the UTI policies and protocols in place, resulting in the removal of any previous conflicting guidance and implementation of a single UTI protocol. • The updated protocol has been issued to all prison and healthcare staff through structured briefings, written notices, daily meeting updates, and daily checks. • A newly appointed substance misuse lead carries out daily assurance and visits all suspected UTI cases, ensuring consistency between operational and healthcare colleagues and consistent adherence to the UTI protocol.

Noted (AI summary) The College of Policing outlines existing guidance and practitioner advice for officers and staff regarding suspects of child sexual exploitation and risk assessment processes following release from custody, noting Mr. Brierley declined support offered. The Home Office acknowledges the report and expresses condolences, notes the relevant guidance provided by the College of Policing, and states that a review concluded appropriate support was provided to Mr. Brierley by Border Force. The NPCC is undertaking research to identify commonalities in post-custody suicides to establish a post-release risk assessment process and mandatory referral to support agencies, and has shared the PFD report with all UK custody leads with recommendations for investigative strategies. The Ministry of Justice believes the report should have been directed to the Home Secretary, as it relates to police investigative procedures, bail conditions, and Border Force (Home Office) matters.

Noted (AI summary) HM Inspectorate of Prisons acknowledges the concerns raised and states that the issues are covered in their inspection criteria. They will keep the findings on file for future inspections of HMP Whatton and HMP Hollesley Bay. HMP Whatton will update their Induction policy to include a "late arrivals form" for prisoners when a normal induction cannot be facilitated, and has amended their local safety strategy to ensure prisoners are informed in writing when their CSRA levels change. HMP Hollesley Bay will seek POM attendance at local stability meetings where OCSAs are being discussed wherever possible.

Noted (AI summary) NHS England is undertaking training and upskilling of healthcare and prison staff in the London region. They are also reviewing service specifications and will use learning from the case to strengthen requirements around assessment and management of long-term conditions. HMPPS acknowledges the concerns and refers to ongoing work led by NHS England to improve awareness of sickle cell disease and other long-term conditions, stating their commitment to working collaboratively with healthcare providers.

Noted (AI summary) HMPPS acknowledges concerns about ACCT observations, shower rails, personality disorder training, and cellular confinement, explaining existing policies and planned improvements without committing to specific new actions.

Noted (AI summary) The College has a new Standard Operating Procedure for all referrals received from external agencies. The Trust is developing an organisational approach to investigations as part of the nationally mandated work to implement the Patient Safety Incident Response Framework and is commissioning a training programme that will provide attendees with enhanced skills in reviewing and learning from patient safety incidents; the Executive Director of Quality, Nursing and Health Professionals has also introduced new governance processes. The Trust's safeguarding leads have supported College leads in developing a more robust safeguarding policy for enrolees, provided additional learning sessions to college staff and volunteers, and have a rolling programme of support in place; Additionally, the Executive Director of Quality, Nursing and Health Professionals has introduced new governance processes including a Central Safety Summit with an approved scope and purpose agreed at Board level with reporting into the Trust’s Quality Committee for continuous oversight at a Non-Executive Director level. The Home Office is working with police forces to ensure improvements in effectiveness and efficiency of the system to manage sex offenders and prevent them from committing further harm, and is working with the National Police Chiefs’ Council’s Violence and Public Protection and Violence Against Women and Girls portfolios. The VKPP engages with forces and key partners to identify promising practice and share knowledge to shape future responses to serious crime that exploits vulnerability. HMPPS is developing a new Continuing Professional Development risk learning product to be piloted towards the end of this year before being launched from February 2025, and has identified SEEDS2 as a strategic learning priority for 2024-2025 with Probation Officers required to complete the learning by September 2025 as part of their Continuing Professional Development requirement. No actions or plans described.

Noted (AI summary) NHS England acknowledges concerns about secondary healthcare in prisons, particularly staffing shortages, but focuses its response on NHS England's remit. They have engaged regional colleagues and will consider responses from other Trusts, while also highlighting national work on PFD reports. Berkshire Healthcare has continued developing the One Team model, implemented monthly audits of Community Mental Health Team caseloads, and conducted various training programs (suicide awareness, trauma-informed care). They have also improved VCSE engagement and reinforced MAPPA escalation processes. Oxford Health NHS Foundation Trust will consider introducing guidance for psychological therapy staff about recording when an individual declines treatment in prison, to include guidance that declined offers of treatment are always considered in caseload management supervision. Thames Valley Police details actions taken by both the force and Counter Terrorism Policing South-East, including improvements to intelligence dissemination, Prevent training, MAPPA procedures, and Operation Plato. A multi-agency exercise was conducted to test the effectiveness of the Operation Plato plan. Midlands Partnership NHS Foundation Trust has refreshed the psychology pathway and updated referral criteria, and is standardising practice in regard to psychological care pathways. They have also developed a pilot of the Mental Health & Wellbeing Practitioner role and provide ongoing training for staff. The Ministry of Justice outlines changes to probation and prison procedures, including enhanced risk assessment tools, improved information sharing through MAPPA, and updated training for staff. These changes aim to better manage individuals who pose a terrorism risk. The Home Office describes ongoing improvements to the Prevent programme including reviews, case assurance, and annual statistics. They are implementing improved information sharing practices and conducting assurance reviews of training and processes related to discontinuing impending prosecutions.

Noted (AI summary) Derby City Council has made changes to manage mentally disordered offenders, including working alongside the Forensic Community Mental Health Team and finalizing a Memorandum of Understanding to employ a Senior Social Work Practitioner. They also introduced regular training for social supervisors and a rolling programme of Unconscious Bias training. Derbyshire Healthcare NHS Foundation Trust has invested in a Forensic Community Mental Health Team, which has undertaken shared cultural awareness training with the police and probation. The Trust has adopted Systm1 as its electronic patient record system and conducts ongoing record keeping audits. Derbyshire Constabulary has strengthened the protection offered to vulnerable people via civil orders and Stalking Protection Orders. The force has a comprehensive programme of activity to raise standards and improve record keeping, and all officers and staff now receive training on cultural aspects. Cygnet has reviewed the PFD action plan at Clinical Governance meetings and shared it with relevant teams; all staff complete a report writing and record keeping Skill workbook, and Cygnet audits on triangulation of records are completed 3 monthly. Response is a placeholder document.

Noted (AI summary) HMPPS will revisit recording key dates as it continues to develop the Digital Prison Services (DPS), and it anticipates the ability to search for key words will be available by 2025. It will also issue a Senior Leaders Bulletin on the importance of recognising key dates and encouraging the use of local databases. NHS England describes the Health and Justice Information Service (HJIS) and options for flagging key dates, and refers to NICE guidance on managing medicines. It states that responsibility for cell searches lies with HMPPS. The Ministry of Justice acknowledges the concerns raised and states that HM Prison and Probation Service (HMPPS) will respond to the operational issues; the Minister endorses the HMPPS response.

Noted (AI summary) HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform future risk assessments at HMP Thameside. HM Inspectorate of Prisons acknowledges receipt of the report but states its remit is limited to the inspection process, referring to published inspection reports and stating the information will inform future risk assessments at HMP Thameside. Serco (HMP Thameside) details actions taken, including the introduction of MS Teams folders for data retention, enhanced security strategies with trained analysts, and the implementation of a bodyscanner, with learnings from the inquest shared with senior management. They will also share learnings of the inquest with the senior management team, with advice that where there is a suspected 'swallow' and absence of a positive bodyscanner result, they should re-locate to healthcare. HM Prison and Probation Service acknowledges the concerns regarding record keeping and data retention at HMP Thameside, confirms receipt of the prison director's response, and outlines the contract delivery indicators and monitoring processes in place.

Noted (AI summary) HMPPS emphasizes that the ACCT case management approach is designed to meet the specific needs of the individual by providing multi-disciplinary support. Healthcare staff are always invited to the first case review to consider the need for any additional mental health support.

Noted (AI summary) The Ministry of Justice is working with the Home Office to prioritise commitments in the Tackling Domestic Abuse Plan, including investing over £230 million in tackling domestic abuse. They have also worked to improve probation staff awareness of MARAC and published a draft Victims Bill. The Home Office acknowledges the report and states that officials will provide a full response by the stated deadline. The Home Office highlights the Domestic Abuse Act 2021, its statutory guidance published in July 2022, and the cross-Government Tackling Domestic Abuse Plan published in March. The plan includes funding, model policies, training and awareness packages. The Department of Health and Social Care is working with the Home Office on the Tackling Domestic Abuse Plan and will include measures to tackle domestic abuse in the national suicide prevention strategy. Integrated care boards are required to set out how they will address the needs of victims of abuse and NHS England is developing guidance to assist them.