Prison
Cat closed women's
Key Concerns Identified
Positive Findings
Send
IMB Annual Report 2025 · Published 10 September 2025
HMP Send, a closed prison for adult women, managed a population of 245 prisoners against an operational capacity of 255. The Board commended staff efforts in ensuring safety and positive relationships, noting improvements in complaint handling. However, the report highlighted significant increases in self-harm, assaults, and use of force incidents, along with persistent concerns regarding the adequacy of mental health provision for complex needs prisoners, the lack of digital technology access, and issues with inter-prison transfers.
Positive Findings
The Board commended HMP Send management and staff for their significant efforts to ensure prisoner safety and for the compassionate care provided, particularly to those with complex needs. There were positive staff-prisoner relationships, improved timeliness in complaint responses, and notable improvements in managing Discrimination Incident Report Forms (DIRFs). Prisoners also reported positive experiences with education courses, the extension of salon training to include African Caribbean hair, and the IMB commended OMU's work with IPP prisoners. The prison also achieved a high rate of accommodation for prisoners upon release.
Key Concerns
Safety
There are more prisoners who need to be kept apart for safety reasons; self-harm has risen by approximately 20%; there was a significant increase in the number of assaults, particularly prisoner-on-prisoner.
Safety
The number of newly opened assessment, care in custody and teamwork (ACCT) documents increased this year to 234 from 158 in 2023/24.
Safety
There were 101 use of force incidents in the reporting year, compared with 45 incidents in reporting year 2023-2024.
Substance Misuse
Prisoners told members of the Board that drugs are available in one particular wing.
Regime/Time Out of Cell
Enhanced prisoners do not have a dedicated area in the prison and do not consider that their accommodation is significantly different from that of other prisoners.
Food/Catering
There seems to be a tendency for prisoners to elect to eat in their cells despite efforts made by the prison to encourage prisoners to eat in the dining room.
Staffing
The arrival of more prisoners during the year with complex needs led to an increase in the challenges faced by staff.
Regime/Time Out of Cell
Some prisoners have told the Board that the policy concerning healthy relationships between prisoners is unfair or inconsistent.
Equality/Diversity
Repeated
Prisoners continued to report that they did not always have confidence in the discrimination incident report form (DIRF) process.
Equality/Diversity
Statistics concerning those prisoners with disabilities were not regularly reported at the monthly diversity and inclusion meetings.
Regime/Time Out of Cell
Repeated
Prisoners complained to the IMB about the incentives policy (IP) process as unfair, and one that was viewed as a punishment and not used to encourage reward.
Complaints/Property
Repeated
Problems persist with missing property when prisoners arrive at Send from other prisons.
Healthcare
Repeated
There has been erratic, and sometimes poor, communication between prisons regarding the transfer of prisoner health information.
Healthcare
Repeated
The Board continues to be concerned at the number of prisoners who decline breast screening.
Healthcare
Repeated
The Board believes that the use of an escort chain for a prisoner to a member of staff during a healthcare appointment outside the prison, where the appointment involves an intimate examination and/or confidential consultation, should be the exception rather than the norm.
Mental Health
Repeated
The Board strongly believes that the needs of complex individuals with multiple mental health issues cannot be adequately met in prison.
Regime/Time Out of Cell
Repeated
Prisoners complain that they have less access to the gym than at other prisons.
Education/Purposeful Activity
45% of prisoners surveyed were assessed at entry level and below for maths.
Education/Purposeful Activity
Only 44% of respondents reported feeling confident in using IT.
Education/Purposeful Activity
Railtrack training was discontinued after only two courses due to lack of funding.
Regime/Time Out of Cell
Repeated
Prisoners still think pay is unfair and less than they received at other prisons.
Resettlement/Release
Repeated
The continued detention, and repeated recalls of IPP prisoners for relatively small breaches of licence conditions, is unfair and inhumane.
Education/Purposeful Activity
Repeated
Prisoners need access to digital technology to prepare themselves for re-entry to life in the community.
Education/Purposeful Activity
The Board would like to see longer-term funding for training initiatives - such as the Railtrack training programme (now discontinued) - where needs analysis shows that they provide relevant skills for employment in the community.
Regime/Time Out of Cell
Repeated
The inconsistency in pay rates in different prisons, particularly between those in the private and public sector, is unfair and needs to be addressed.
Estate/Conditions
The Board would like to see a differentiation in accommodation for those enhanced prisoners who do not qualify for the ISFL wings.
Healthcare
The Board would like to see a process in place for healthcare professionals to record why prisoners decline breast screenings.
Board Commentary
Staffing
HMP Send faces challenges in recruiting and retaining staff due to a lack of London weighting allowance and poor public transport links, exacerbated by the increased complexity of the prisoner population. Staff shortages led to redeployments affecting keywork delivery, with average waiting times for a key worker session increasing. While POM vacancies have improved, a shortage of gym staff persists.
Healthcare
Feedback on healthcare was variable, with many finding GPs and specialist staff helpful, but applications concerning medication and delays were significant. The Board is concerned about poor communication of health information between prisons, the number of prisoners declining breast screening, and the routine use of escort chains for intimate external appointments. Fundamentally, the Board believes complex mental health needs cannot be adequately met in a prison setting.
Regime & Daily Life
A high turnover of prisoners, coupled with staff pressure, impacted regime delivery. Staff shortages sometimes forced prisoners to eat in cells, although prisoners also elected to avoid the dining room despite prison efforts to improve the environment. Gym access was limited due to staff shortages affecting the regime, but classroom capacity for education increased.
Applications to the IMB
Prisoners can apply to their IMB about any aspect of their treatment. This table shows application counts by category.
| Category | Current | Previous | Change |
|---|---|---|---|
| Accommodation (including transfers) | 25 | 19 | |
| Canteen, facility list, catalogues | 5 | 5 | — |
| Discipline, including adjudications, incentives scheme, sanctions | 18 | 15 | |
| Equality | 5 | 13 | |
| Finance, including pay, private monies, spends | 11 | 22 | |
| Food and kitchens | 6 | 11 | |
| Health, including physical, mental, social care | 34 | 30 | |
| Letters, visits, telephones, public protection, restrictions | 21 | 24 | |
| Miscellaneous | 21 | 21 | — |
| Property during transfer or in another facility | 29 | 30 | |
| Property within the establishment | 13 | 24 | |
| Purposeful activity, including education, work, training, time out of cell | 9 | 16 | |
| Sentence management, including HDC (home detention curfew), ROTL (release on temporary licence), parole, release dates, re-categorisation | 20 | 19 | |
| Staff/prisoner concerns, including bullying | 18 | 17 | |
| Transfers | 4 | 4 | — |
Recommendations (16)
Governor / Director: 7
Other: 2
HMPPS: 7
6 repeated
Recommendation 1
The shortage of gym staff needs to be addressed.
Governor / Director
Regime
Recommendation 2
Repeated
Prev. unaddressed
The Board reiterates that the needs of complex individuals with multiple mental health issues are not served well in prison. Such prisoners also take up a disproportionate amount of staff time (4.2) (6.2).
Other
(minister)
Mental Health
Response
I am committed to improving mental health outcomes for individuals in contact with the criminal justice system, to ensure that those with acute mental health needs receive timely support, in the most appropriate setting. We at the Ministry of Justice are working with the Department of Health and Social Care to introduce the Mental Health Bill as soon as possible. This will include a range of reforms to support people suffering with severe mental illness in the criminal justice system and aims to speed up access to specialist inpatient treatment so that those affected are able to access the timely care they need. NHS England are also working strategically across the system to improve the pathways into treatment.
Recommendation 3
Repeated
Prev. unaddressed
The Board continues to believe that the continued detention, and repeated recalls of IPP prisoners for relatively small breaches of licence conditions, is unfair and inhumane (7.3).
Other
(minister)
Resettlement
Response
The IPP sentence was recently reformed in the Victims and Prisoners Act which gained Royal Assent on 24 May 2024. The changes will provide a clear pathway to a definitive end to the licence and sentence by reforming the termination of the licence for IPP offenders. On 5 September 2024 the Secretary of State announced the timings for these changes. I can confirm that the government commenced the IPP measures in the Act in a phased approach from 1 November. This means the IPP sentence automatically ended for around 1,800 people on 1 November and c.600 referrals will be made to the Parole Board for consideration of licence termination following commencement of phase two on 1 February 2025. There is also support for those in custody, with the HM Prisons and Probation Service (HMPPS) director general of operations commissioning executive directors for England and Wales, including the women’s estate to develop operational IPP delivery plans. These directly target front-line delivery to support those serving IPP sentences to work to achieve the objectives within their sentence plans and move towards a future sustainable release. At HMP Send there is small cohort of IPP prisoners. This cohort has been identified as a priority in relation to key work and are provided with specialist support from IPP keyworkers, which ensures that the individuals are fully informed regarding how their sentences are managed as well as reducing risk.
Recommendation 4
Consistent volumetric control would help to address problems with property on inter-prison transfers. Many prisoners report missing property on arrival at Send (5.3)
HMPPS
Complaints
Recommendation 5
Poor communication has led to delays in the provision of medication to newly arrived prisoners (6.1).
HMPPS
Healthcare
Recommendation 6
Repeated
Prev. unaddressed
The Board would like to see a policy which states that the use of escort chains for prisoners during intimate medical examinations or confidential consultations outside the prison be the exception rather than the norm (6.1).
HMPPS
Healthcare
Response
Prior to any external escort taking place, HMPPS will undertake a robust risk assessment, which is a multi-disciplinary approach. This will ensure that all relevant information is gathered and used to inform the decision-making process. Healthcare staff are always included in the escort risk assessment process and security departments work collaboratively with healthcare to inform their decisions. The need for the prisoner’s privacy must be considered as part of the escort risk assessment, with the decision clearly documented, particularly where the prisoner is to undergo an intimate examination or procedure. Privacy should be accommodated in so far as it does not compromise the security of the escort. HMP Send is exploring the possibility of escorting prisoners to mobile breast screening buses that are visiting HMP Downview and HMP Bronzefield, where no restraints would be needed.
Recommendation 7
Action is required to ensure the availability of sufficient gym staff, taking into account the needs of the women’s estate (6.3).
HMPPS
Regime
Recommendation 8
Repeated
Prev. unaddressed
Prisoners need access to digital technology to prepare themselves for re-entry to life in the community (7.1).
HMPPS
Education
Response
HMPPS is keen to deliver in-cell technology across the estate, which is subject to funding being available. However, in the interim prisoners are able to access IT via the education provider, allowing prisoners to complete distance learning along with other courses. Additionally, HMP Send have also sourced 10 laptops, which are available to prisoners to use as part of their education.
Recommendation 9
The Board would like to see longer-term funding for training initiatives - such as the Railtrack training programme (now discontinued) - where needs analysis shows that they provide relevant skills for employment in the community (7.2).
HMPPS
Education
Recommendation 10
Repeated
Prev. unaddressed
The inconsistency in pay rates in different prisons, particularly between those in the private and public sector, is unfair and needs to be addressed (7.2).
HMPPS
Regime
Response
The national minimum and flat pay rates for prisoners have been in place for a number of years and are set through the Prisoners’ Pay PSO 4460. However, budgetary pressures for prisons does mean that there is little scope to significantly improve the prisoner pay budget. Nevertheless, Governors do have the discretion to pay above the nationally set minimum rates of pay and are required to review their local pay policy annually. At HMP Send prisoner pay was reviewed earlier this year, resulting in an increase of 12.5% across all activities. In September 2022, a national approach to the rising cost of living was implemented and a 10% uplift in private cash allowances was introduced to help mitigate against price increases. In November 2022, several new value brand product lines were made available through the Prison Retail service which give prisoners the choice to purchase less expensive, non-premium branded items just as people in the community are doing. Purchases of the value brands are becoming increasingly popular.
Recommendation 11
The Board is concerned that prisoners have reported that drugs are available on one particular wing (4.5).
Governor / Director
Substance Misuse
Recommendation 12
The Board would like to see a differentiation in accommodation for those enhanced prisoners who do not qualify for the ISFL wings (5.1).
Governor / Director
Regime
Recommendation 13
Data reviewed in the diversity and inclusion meetings should include information concerning prisoners with disabilities (5.4).
Governor / Director
Equality
Recommendation 14
Repeated
The perception of prisoners is that the IP policy is still unfair (5.6).
Governor / Director
Regime
Recommendation 15
The Board would like to see a process in place for healthcare professionals to record why prisoners decline breast screenings (6.1).
Governor / Director
Healthcare
Recommendation 16
The shortage of gym staff needs to be addressed (6.3).
Governor / Director
Regime
Other IMB Reports for Send
HMIP Inspections
Recent inspections by HM Inspectorate of Prisons for this establishment.
17 Mar 2025
Unannounced
PPO Fatal Incidents
Prisons and Probation Ombudsman fatal incident investigations for this establishment.