Prison Cat HMP/YOI Key Concerns Identified Positive Findings

Downview

IMB Annual Report 2025 · Published 3 September 2025

HMP/YOI Downview, a women's closed prison and YOI, reported an average population of 319 against an operational capacity of 356. Key concerns include significant delays in mental health transfers for acutely unwell prisoners, persistently low rates of Release on Temporary Licence, and extremely high levels of property loss during inter-prison transfers. While staffing levels were generally healthy, the Board noted inconsistencies in staff effectiveness and operational oversight, alongside ongoing impacts of population pressure on safety and regime delivery.
Population
319
Operational Capacity
356
Deaths in Custody
2
Self-harm Incidents
728
prev: 1,171
Prisoner Assaults
30
prev: 26
Assaults on Staff
36
prev: 48
Use of Force
119
prev: 310
Positive Findings
Staffing levels remained healthy, and many officers demonstrated effectiveness, fostering positive relationships with prisoners. The reducing reoffending team secured post-release employment, and the prison kitchen maintained its five-star rating. CSU staff displayed exceptional professionalism and compassion, and the Board noted a positive refresh of the induction process and the value of the Gladragz prison shop. The prison also re-engaged with the Zahid Mubarek Trust for DIRF scrutiny.
Key Concerns
Mental Health Repeated
We continued to observe numerous acutely mentally unwell prisoners segregated in the care and separation unit (CSU), some of whom were awaiting to be transferred to a psychiatric facility... CSU staff exhibit extraordinary patience, professionalism and compassion, but they are not trained to support such unwell prisoners.
Other Repeated
As in previous years, we have seen a significant number of applications relating to property being lost or delayed when prisoners are transferred to Downview from other prisons.
Staffing
Often, prisoners’ basic requirements are not dealt with in a timely and proactive way by staff.
Overcrowding Repeated
Population pressure cited across the prison estate continues to impact on prisoners’ outcomes. For example, safety in the prison, timely healthcare appointments and efficient daily medication distribution, the availability of purposeful activity, release on temporary licence (ROTL) and access to family support networks.
Mental Health Repeated
Acutely mentally unwell prisoners are still waiting far too long for transfer to secure psychiatric units following assessment and referral.
Safety
A number of prisoners were transferred to Downview from other prisons who were not in a safe or stable condition for transfer.
Healthcare
Limited dementia care is provided at Downview, but there remain challenges in accessing memory assessments for those who need a dementia diagnosis.
Resettlement/Release Repeated
The number of prisoners working on release on temporary licence (ROTL) from the prison has, again, remained alarmingly low. The lack of clarity regarding ROTL opportunities at the prison, which we reported on last year, has continued.
Education/Purposeful Activity
There has been an ongoing focus on recording and increasing attendance at education and activities, but attendance remains variable.
Resettlement/Release Repeated
Despite acknowledgement by the Ministry of Justice that prisoners who have experienced ROTL have better outcomes, the prison has only a very small number of prisoners accessing ROTL... This seems to be a waste of the excellent employment links at the prison and an example of cited population pressure providing obstacles to progression.
Equality/Diversity Repeated
Last year, the Minister provided reassurance to the Board in the response to our previous annual report that allocation decisions for transgender prisoners would be made “in the quickest time possible to reduce the anxiety and uncertainty experienced whilst they await the outcome”. However, we have, again, seen a significant delay in a prisoner’s allocation by the Lord Chancellor.
Other Repeated
The HMPPS Prisoners’ Property Policy Framework states: “How HMPPS looks after prisoners’ possessions may be symbolic of how we look after the people in our care”. We continue to see extremely high levels of property loss for prisoners when transferring in from other prisons... It is unconscionable that, in 2025, HMPPS has not been able to create or manage a system that takes the transfer of prisoners’ belongings seriously. It is a disgrace.
Resettlement/Release Repeated
We have, again, seen examples of prisoners who were transferred to Downview from prisons across the country, often with just a few weeks to serve and with apparently no consideration of family networks.
Staffing
Can the Governor please comment on the issues raised earlier in this report regarding the effectiveness of certain staff in resolving prisoners’ basic issues, and on operational oversight in the prison generally?
Resettlement/Release
How is it expected that the ongoing mixed messages regarding the future viability of working ROTL at the prison will be resolved?
Regime/Time Out of Cell Repeated
Gladragz (the prison shop) is a valuable resource for prisoners. It would be a positive development if it could be adequately stocked and managed.
Staffing Repeated
Management of, and attendance at, some meetings by staff at times remains poor.
Safety
Can the Governor comment on the lack of enhanced gate security in the prison?
Regime/Time Out of Cell
There were limited wing activities and unexplained delays with accessing some off-wing activities. At various times, the atmosphere on the wing was challenging for various prisoners - with frequent conflict, bullying, exclusion and flashpoints in prisoner relationships. It was often described by prisoners and staff as “toxic” and “full of drama”.
Other
The prison’s Business Hub appeared to the Board to be inadequately staffed for much of the period. As from late 2024, it appeared incapable of functioning and was repeatedly closed for responses to staff and prisoner queries.
Other
The transfer of monies process appears particularly inefficient for transfers from HMPs Bronzefield and Peterborough (private prisons). Their financial systems are not compatible with Downview, which means that cheques need to be sent, rather than an automated bank transfer taking place.
Substance Misuse
The rising number of illicit drugs brought into the prison in the reporting period was of concern to the security department, with the first appearance of synthetic opioids amongst them in early 2025. There was a reported rise also in early 2025 in ‘street drugs’ (e.g. spice, heroin and cannabis) in the prison, with an impact on debt and violence.
Safety
There is no routine enhanced security on the gate for visitors or staff. It is notable that most of the Board’s members... have not been searched on entering the prison. People attending for social visits often commented on the relaxed searching process for visitors
Regime/Time Out of Cell Repeated
Last year, we reported our concerns regarding rule 39 breaches in the prison. There was a rule 39 breach late in 2024.
Safety Repeated
We continue to have ongoing concerns regarding a perceived failure by relevant staff to appropriately communicate with prisoners when managing certain individual outcomes arising from security intelligence.
Staffing Repeated
The delivery of the key worker scheme has, again, been below target and the quality of entries has also been a focus for staff development. The average of sessions delivered for this reporting period was 39.99%
Equality/Diversity
The Board’s perception remains that equality and diversity work has a low priority with staff outside of the function.
Equality/Diversity
Foreign national prisoners: as of the end of the reporting period, there were 49 foreign nationals in the prison, 15% of the population. We regularly monitored new arrivals who did not speak any English. They struggled with the limited translation support from HMPPS and instead relied on other prisoners and staff on an informal basis.
Complaints/Property
The prison introduced a phone-based applications process for prisoners in late 2024... Their answering service was usually full and prisoners were unable to leave a message. There is no way of a prisoner keeping a record of when a phone application has been made... the new system has been unpopular with prisoners.
Complaints/Property
Whenever overdue complaints increase, pressure is applied by governors, which often succeeds in reducing them. As a result, there has been a modest increase in the number of complaints answered within the recommended time frame: 67% compared with 64% last year. The worst offenders for overdue complaints remain other prisons, where the overdue period can exceed 100 days.
Other Repeated
It is often not possible to judge whether the transferring prison simply failed to send the property or if the transfer subcontractor failed or refused to take it. But the outcome is a considerable amount of additional work for staff and distress for the prisoners.
Board Commentary
Staffing
Staffing levels were generally at or above target, with 18% of officers having less than one year's service. However, key worker scheme delivery was below target (39.99% average sessions). Sickness absence was 10.59 average working days lost, with resignations decreasing to 1.98%. The Enable Programme aims to improve staff capability, and the Board hopes it will address poor meeting attendance and support the induction process.
Healthcare
Acutely mentally unwell prisoners face significant delays in transferring to secure psychiatric units, and some arrive at Downview in an unstable condition. Limited dementia care is available, with challenges in memory assessments. The CSU houses many mentally unwell prisoners, but staff lack specialist training for these complex cases, leading to concerns about the appropriateness of prison as a setting for them. Healthcare staff also face challenges with short-notice ACCT review attendance.
Regime & Daily Life
Population pressure continues to negatively affect various aspects of the regime, including purposeful activity and ROTL opportunities, which remain alarmingly low. Education and activity attendance is variable. Prisoners in the CSU typically spend 23 hours a day in their cells. The Board hopes a recent refresh of the induction process will improve initial experiences for new arrivals.
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
Property lost or damaged during transfer (H2) 50 47
Property within Downview (H1) 29 31
Recommendations (15)
Ministry of Justice: 4 HMPPS: 3 Governor / Director: 8 8 repeated
Recommendation 1 Repeated
Acutely mentally unwell prisoners continue to arrive at the prison. They often face long delays in transfer to secure psychiatric units, following assessment and referral (6.1). How confident is the Minister that the statutory 28-day time limit for transfer from prison to hospital, envisaged by the Mental Health Bill, will be achievable, given the low number of suitable beds for female prisoners?
Ministry of Justice Mental Health
Recommendation 2 Repeated Prev. unaddressed
Despite acknowledgement by the Ministry of Justice that prisoners who have experienced ROTL have better outcomes, the prison has only a very small number of prisoners accessing ROTL. This was described by HMPPS in the response to our previous annual report as a “significant reduction… due to capacity pressures”. This seems to be a waste of the excellent employment links at the prison and an example of cited population pressure providing obstacles to progression (7.3). The Minister’s view on this is welcomed.
Ministry of Justice Resettlement
Response
This was described by HMPPS in the response to our previous annual report as a “significant reduction… due to capacity pressures”.
Recommendation 3 Repeated Prev. unaddressed
Last year, the Minister provided reassurance to the Board in the response to our previous annual report that allocation decisions for transgender prisoners would be made “in the quickest time possible to reduce the anxiety and uncertainty experienced whilst they await the outcome”. However, we have, again, seen a significant delay in a prisoner’s allocation by the Lord Chancellor (7.3). Does the Minister agree that this delay, regarding the location of a transgender prisoner, was unfair and inhumane? It appears to the Board that the prisoner is being caught in the crossfire of a politically sensitive issue.
Ministry of Justice Equality
Response
Last year, the Minister provided reassurance to the Board in the response to our previous annual report that allocation decisions for transgender prisoners would be made “in the quickest time possible to reduce the anxiety and uncertainty experienced whilst they await the outcome”.
Recommendation 4 Repeated
We have, again, seen that population pressure impacts significantly on prisoners’ outcomes. These include increased self-harm and violence, healthcare pressures, a decrease in working ROTL opportunities and prisoners being transferred in a seemingly random fashion across the estate, away from families and other support networks. The Board is hopeful of the outcomes from the Sentencing Review and the Women’s Justice Board in better managing the population in the female estate. The Minister’s view on this is welcomed.
Ministry of Justice Overcrowding
Recommendation 5
There is no mention of ROTL in the Women’s Group Deliverables for 2025-202615. There were only three prisoners accessing working ROTL from the prison as of the end of our reporting period. This seems to be a waste of the excellent work by the prison employment lead, industries and community engagement manager, and the Employment Advisory Board in securing training partners and employment links at the prison (7.3). We understand that HMP/YOI East Sutton Park may need to be filled up, but this should not necessarily mean that working ROTL opportunities cannot also develop further at Downview, with its opportunities and local transport links.
HMPPS Resettlement
Recommendation 6 Repeated Prev. unaddressed
The HMPPS Prisoners’ Property Policy Framework16 states: “How HMPPS looks after prisoners’ possessions may be symbolic of how we look after the people in our care”. We continue to see extremely high levels of property loss for prisoners when transferring in from other prisons (5.6). The much-heralded Prisoners’ Property Policy Framework appears to have had no impact in managing the issue. The process remains labour-intensive and paper-based, and there is no system at Downview for recording how property loss and delay is followed up with other prisons. Much of the operational performance of a prison is audited and managed by various metrics and key performance indicators, yet there is no attempt to hold prisons accountable for property management. It is unconscionable that, in 2025, HMPPS has not been able to create or manage a system that takes the transfer of prisoners’ belongings seriously. How does HMPPS intend to improve this dire situation? It is a disgrace.
HMPPS Other
Recommendation 7 Repeated Prev. unaddressed
We have, again, seen examples of prisoners who were transferred to Downview from prisons across the country, often with just a few weeks to serve and with apparently no consideration of family networks (4.1, 7.4). We were informed by HMPPS in the response to our previous annual report that such transfers were a necessary response to cited population pressure (“every bed matters”). These transfers are, however, entirely at odds with HMPPS’ own research17 regarding the importance of family ties as a significant factor in rehabilitation. Given that population pressure appears likely to continue in the women’s estate for the foreseeable future, how can prisoner moves be managed in a more compassionate and rehabilitative way?
HMPPS Resettlement
Response
We were informed by HMPPS in the response to our previous annual report that such transfers were a necessary response to cited population pressure (“every bed matters”)
Recommendation 8
Can the Governor please comment on the issues raised earlier in this report regarding the effectiveness of certain staff in resolving prisoners’ basic issues, and on operational oversight in the prison generally?
Governor / Director Staffing
Recommendation 9
The Board is hopeful that the latest recent positive refresh of the prisoner induction process receives the staff support it needs for ongoing implementation (4.1).
Governor / Director Regime
Recommendation 10
How is it expected that the ongoing mixed messages regarding the future viability of working ROTL at the prison will be resolved? (7.3)
Governor / Director Resettlement
Recommendation 11
The Board hopes that the successful HMPPS audit carried out in the reporting year may be a catalyst for more ambition and creativity with family engagement at Downview. How does the prison intend to sustain the focus on families and significant others (7.4)?
Governor / Director Resettlement
Recommendation 12
Which measures recently utilised to encourage and record attendance at purposeful activity are seen as effective and will be retained going forward (7.3)?
Governor / Director Education
Recommendation 13 Repeated
Gladragz (the prison shop) is a valuable resource for prisoners. It would be a positive development if it could be adequately stocked and managed (5.1).
Governor / Director Regime
Recommendation 14 Repeated
Management of, and attendance at, some meetings by staff at times remains poor. Will the significant investment and support from the Enable Programme also provide encouragement to staff in this area?
Governor / Director Staffing
Recommendation 15
Can the Governor comment on the lack of enhanced gate security in the prison (4.5)?
Governor / Director Safety
Other IMB Reports for Downview
2024 Published 3 Sep 2024 324 1,171
2023 Published 1 Sep 2023 1,153
2022 Published 10 Oct 2022 265 752
2021 Published 29 Sep 2021 219 369
2020 Published 19 Oct 2020 287 659
PPO Fatal Incidents

Prisons and Probation Ombudsman fatal incident investigations for this establishment.

Susan Simpson
29 Jun 2024 · Natural causes · Report published
Kirsten Hocking
24 May 2023 · Other non-natural · Report published
Prevention of Future Deaths Reports

Coroner PFD reports issued to this establishment.

Cherylin Norrell-Goldsmith
27 Oct 2014 · State Custody related deaths