Mr North — HMP Whitemoor

Serious Assault 6 September 2008
The independent investigation conducted by Kevin Bradford into the serious assault on ‘Mr North’ at HMP Whitemoor on 6 September 2008 is published.  Also published is the HM Prison and Probation Service (HMPPS) response to the investigation. On 6 September 2008 ‘Mr North’ was found in his cell with injuries suggesting that he had been assaulted.  He was taken to hospital, where he received treatment for a head injury, and returned the same day to the healthcare centre at HMP Whitemoor.
Key Findings
The investigation identified significant systemic and operational failures at HMP Whitemoor in 2008, particularly in the management and investigation of two serious assaults on Mr North. These failures included a lack of proper internal investigations, inadequate preservation of evidence, and delayed reporting of serious crimes to the Police. While Mr North's non-cooperation and misleading information complicated matters, the prison's command structure and adherence to safety protocols were found to be severely lacking.
Learning Points (10)
Learning Point 1
If it has not already done so, HMP Whitemoor may wish to consider the benefits to be obtained from reviewing internal procedures and guidance for the management, recording and investigation under PSOs 1300, 2700 and 2750 of both prisoner on prisoner assaults and unexplained injuries. It may also be considered appropriate to reinforce any guidance with staff at the establishment in order to ensure an appropriate level of compliance.
HMP Whitemoor policy Accepted
HMPPS Response
All assaults at HMP Whitemoor are immediately reported to the Orderly Officer and the majority, including all serious assaults, are then referred to the police. Prison managers are briefed on any assaults at the daily operational meeting. The prison has robust systems in place to ensure that incident reports, Mercury intelligence reports and injury to prisoner forms are completed following the incident. Every violent incident at HMP Whitemoor, including unexplained injuries, is the subject of a simple investigation by the custodial manager in charge of the respective area. The reports of these investigation are considered at the monthly Safer Custody meeting to identify learning. Wing managers and officers attend these meetings and provide feedback to staff in their respective functions. A weekly check of the residential units by the Safer Prisons Manager ensures compliance with these processes. Where the incident is particularly serious, or where the simple investigation identifies issues that require further exploration, the prison Governor will commission a further investigation in accordance with PSO 1300. Since the incident HMPPS has issued Prison Service Instruction (PSI) 15/2014 Investigations and learning following incidents of serious self-harm or serious assaults, which reinforces the requirement for prisons to conduct investigations in these circumstances.
Learning Point 10
If it has not already done so, HMP Whitemoor may wish to consider reviewing current arrangements in relation to prisoners’ access to razor blades. The prison should be satisfied that any arrangements for access also provides for an appropriate level of protection from harm for both staff and other prisoners.
HMP Whitemoor safety Accepted
HMPPS Response
HMP Whitemoor conducted a review of the effectiveness of the system for providing prisoners with access to razor blades. HMP Whitemoor manages prisoners’ access to razor blades according to the location of the prisoner: for example in the segregation unit prisoners are allowed razor blades in possession when in patrol state, and staff control the issuing of them on a one for one basis. In other areas of the prison, prisoners may be permitted two razors in possession at any time. HMP Whitemoor has also introduced enhanced searching to reduce the opportunity for bladed weapons to be carried out of the residential wings. At national level, HMPPS has instructed the Governors of all closed prisons to ensure that an appropriate local risk assessment has been conducted on the process for managing razor blades.
Learning Point 2
If they have not already done so, NOMS and HMP Whitemoor should consider if current procedures and staff training provide for the full and accurate completion of official prison documents. Adequate audit and storage arrangements should also be considered as part of any subsequent review. The investigation highlighted a high number of either incomplete, or missing, official prison records. HMP Whitemoor should consider the policy on retaining both draft and final copies of letters and ensure that a process is in place to readily differentiate between draft and final versions of documents.
NOMS and HMP Whitemoor policy Accepted
HMPPS Response
HMPPS issues Prison Service Instructions setting out the key features of operational policies. It is not possible or desirable for staff these to include detailed guidance on the completion of related documents, and Governors are required to ensure that staff are aware of their responsibilities in this regard. This is achieved through staff induction and training, for the most part delivered locally at establishments. At national level, the Prison Officer Entry Level Training (POELT) is provided to all new entrant prison officers and includes material on the writing of reports and the use of official documents including: Assessment, Care in Custody and Teamwork (ACCT) documents, used to manage those at risk of self-harm or suicide; adjudication forms, injury to prisoner forms; use of force forms, Mercury intelligence reports and corruption prevention reports, prisoner property records and Person Escort Records (PERs). HMP Whitemoor conducted a health check on the completion of F213s, gym observation books, segregation unit daily diary sheets, the recording of use of force in observation books, high security estate pre-transfer documents and control room logs for incidents. The completion of these documents continues to be reviewed through internal audit procedures. Since the incident HMPPS has issued PSI 35/2014 Records, archiving, retention and disposal, which provides a framework for prisons to ensure that: records are retained for the right length of time and regularly reviewed; the destruction of records is properly documented; and historical records are preserved and transferred to the appropriate repository. HMP Whitemoor now has an established document archive system. The processes in place are reviewed as part of the internal review procedure so the prison will identify any shortcomings and take remedial action. . A review of the central filing system for public correspondence was undertaken at HMP Whitemoor to ensure that it is clear which versions of letters are draft and which are final. No changes were identified to the already established processes for the business hub. However, it resulted in the arrangements for storing archived correspondence/documentation in the muniments store room being tightened up. New members of the business hub team are trained in public correspondence processes to ensure that they are aware of the importance of distinguishing between draft and final versions of letters. All managers have been reminded that the business hub holds copies of the official responses to all public correspondence, and that they should label their own files clearly to distinguish between draft and final versions. Routine reminders continue to be given at the morning operational meetings and at senior management team meetings.
Learning Point 3
If it has not already done so, NOMS should consider the requirement, and benefits to be gained, by reviewing how it responds to managing serious prisoner on prisoner assaults or indeed other critical incidents. Whilst not necessarily exclusive, this review should consider including issues such as command structure, scene and evidence preservation, offender identification and management, plus timely investigations and referral to the Police. There should be absolute clarity at any given time as to who is in command of the prison should a critical incident arise.
NOMS safety Accepted
HMPPS Response
Since the incident, HMPPS has issued PSI 9/2014 Incident Management, which clarifies the command structure during serious incidents and provides guidance on resolving serious incidents with the minimum risk of harm to staff, prisoners, visitors and the public. National Operations Unit provides contingency plan templates to establishments to use as a guide for formulating local contingency plans. These templates cover the issues identified, including scene and evidence preservation and police referrals. Both the PSI and the contingency plan templates are subject to continuous review, and prisons are required to review their local contingency plans as part of the debrief process following any serious incident.
Learning Point 4
If it has not already done so, NOMS should consider the requirement to review, at both national and local levels, protocols and procedures for referring crimes that take place within prisons to the Police, so that all organisations are clear around what is expected of them and the service that will be provided in return.
NOMS communication Accepted
HMPPS Response
A joint national protocol between NOMS (now HMPPS), the police and the CPS on the handling of crimes committed in prison was published in February 2015. It provides guidelines for joint working between prisons, police and the CPS to ensure that, wherever possible and appropriate, those who commit acts of violence or commit other serious crimes in prison are punished through the courts rather than by the internal prison disciplinary system. An inter-departmental Crime in Prison Board has been established to monitor the implementation of the protocol, to set priorities for further work and to commission the development of guidance to assist local police/prison/CPS in prioritising and managing crime in prison.
Learning Point 5
If it has not already done so, NOMS should consider reviewing PSO 1700 relating to segregation. Any such review should consider including policy, procedural guidance and a risk assessment matrix for the occasions when prisoners return to main wings from Segregation outside of the main Segregation Review Board process.
NOMS policy Accepted
HMPPS Response
PSO 1700 Segregation provides that a prisoner will be returned to normal location on the basis of a decision by a segregation board which will determine whether the prisoner can go directly to normal location, whether there should be a phased return to normal location or whether the prisoner should transfer from segregation to a High Supervision Unit. Revised guidance on the review and authorisation of segregation was issued in September 2015 in response to the findings of a Supreme Court Judgment. This recommendation will be considered as part of a comprehensive review of segregation policy which commenced in late 2017.
Learning Point 6
If it has not already done so, NOMS may wish to consider reviewing its policies and procedures relating to the seizure, recording, retention and continuity of seized items, particularly in respect of critical incidents or where items are likely to be used as evidence in subsequent criminal proceedings.
NOMS policy Accepted
HMPPS Response
HMPPS, with the support of the Crime in Prison Board, is reviewing internal policies and processes for preserving evidence. This includes working closely with other parts of the criminal justice system to develop better training for our staff who are collecting evidence.
Learning Point 7
NOMS may wish to consider whether the introduction and use of bespoke bound notebooks would be appropriate for use by personnel engaged in the management of serious or critical incidents. Similar documents are in use in other organisations for the purpose of recording, in one place, notes, thought processes and subsequent decisions.
NOMS communication Accepted
HMPPS Response
An exercise is under way to provide costings for appropriately sized notebooks, with a view to providing them or all establishments.
Learning Point 8
If it has not already done so, staff at HMP Whitemoor may wish to consider reviewing local procedures for the early notification of significant incidents or events to the Independent Monitoring Board.
HMP Whitemoor communication Accepted
HMPPS Response
Informing the IMB is part of the contingency plan for all serious incidents at HMP Whitemoor. The contingency plans have all been reviewed since the incident in 2008 and continue to be reviewed on a regular basis.
Learning Point 9
Independent Monitoring Boards across NOMS may wish to consider the merits or otherwise of visiting prisoners whilst they are temporarily resident in external settings such as hospitals. This could be particularly relevant if a prisoner is absent from the prison for a protracted period of time.
Independent Monitoring Boards healthcare Rejected
HMPPS Response
The role of Independent Monitoring Boards is to monitor the day- to-day life in their local prison or removal centre and ensure that proper standards of care and decency are maintained. Visiting prisoners whilst they are temporarily resident in external settings, such as hospitals, is not within the legislative remit of IMBs.