Prison self-harm programme evaluation

The Governor and the Head of Healthcare

prompt and thorough investigations are made when a prisoner is thought to have taken an illicit substance, committed an act of self-harm or commenced a dirty protest.

Send (2021)

HMP Send operated under severe COVID-19 restrictions during the reporting year, significantly impacting the regime, education, and prisoner wellbeing, with women often confined for up to 23 hours daily. Despite these challenges, staff were commended for their professionalism and efforts to maintain safety and humane treatment, including the introduction of in-cell phones and improved canteen services. Key concerns highlighted by the Board include rising self-harm incidents, continued drug entry, the inhumane detention of IPP prisoners, and the detrimental long-term effects of restricted education and resettlement opportunities.

PRISON Key concerns

Swaleside (2021)

HMP Swaleside experienced a challenging year due to COVID-19, but management and staff were commended for their exceptional response and innovative strategies. The prison maintained a positive trajectory with declining violence and improved humane treatment, though concerns persist regarding resettlement provision and the mental health impact of prolonged lockdown. Key issues include kitchen capacity, access to confidential complaints, and disparities in opportunities for vulnerable groups.

PRISON Key concerns

Erlestoke (2021)

HMP Erlestoke generally maintained a safe and humane environment during the reporting year ending March 2021, despite the challenges of Covid-19. Key improvements included a significant reduction in violence, commendable healthcare management of a Covid-19 outbreak, and improved resettlement planning. However, concerns remain regarding a troubling increase in self-harm, inadequate provision for prisoners with complex needs and IPP sentences, estates issues, and the impact of regime restrictions on purposeful activity.

PRISON Key concerns

Doncaster 2019 – (2019)

The reporting year for HMP Doncaster (October 2019 – September 2020) was dominated by Covid-19, which heavily impacted the prison regime and the IMB's monitoring capabilities. The Board praised staff dedication during the pandemic and noted positive changes in senior management and improvements in the DIRF and healthcare complaints processes. However, key concerns persisted regarding self-harm risks, drug use, and the timely provision of healthcare, especially mental health services.

PRISON Key concerns

Eastwood Park (2021)

This has been another challenging year due to Covid-19, impacting regime and IMB monitoring. While staff professionalism is commended, the Board remains concerned about high self-harm and violence levels, inadequate mental health provision, and the impact of lockdowns on prisoners' wellbeing. Despite some improvements in healthcare applications and infrastructure investment, significant issues persist with staffing, accommodation options post-release, and the segregation of a severely brain-injured prisoner.

PRISON Key concerns

Foston Hall (2021)

HMP/YOI Foston Hall faced significant challenges in the reporting year ending November 2021, primarily from persistent Covid-19 restrictions and severe staffing pressures. The IMB acknowledged the dedication of staff and noted improvements in areas like induction and welfare checks. However, serious concerns remain regarding the prison's high self-harm rates, inadequate mental health provision, unsuitable accommodation, and the impact of staff shortages on regime delivery and prisoner resettlement.

PRISON Key concerns

Full Sutton (2021)

HMP Full Sutton, a high-security prison, navigated 2021 with constantly changing COVID-19 restrictions, maintaining safety and generally meeting prisoner health needs despite challenges. While the regime ensured basic provisions, purposeful activity and education were severely limited, and staffing was tight, impacting some functions like drug testing and key worker sessions. The Board noted progress in complaint handling and praised the Covid team, but highlighted ongoing concerns regarding work provision, the STEP unit's funding, equality forums, and delays in Category A reviews.

PRISON Key concerns

Exeter (2021)

HMP Exeter, a Category B local and resettlement prison, averaged 406 prisoners with an operational capacity of 431, and continued to operate under restricted regimes due to the Covid-19 pandemic. The prison experienced high levels of violence (256 prisoner assaults, 128 staff assaults) and a return to very high self-harm rates (monthly average around 70 incidents towards year-end). Key concerns include persistent staff shortages and high turnover, particularly within the SMT, the ineffectiveness of CSIPs, and the inadequacy of resettlement opportunities. Despite these challenges, the Board noted improvements in use of force management, cleanliness, and ACCT procedures.

PRISON Key concerns

Bronzefield (2022)

HMP/YOI Bronzefield, a female local/YOI prison, held an average of 480 prisoners during the reporting year. While offering a generally safe environment and some positive regime initiatives like new gym sessions and an ESME room, the prison faced significant challenges. Key issues included rising self-harm incidents, severe staff shortages curtailing the regime and services, and persistent problems with resettlement accommodation for released prisoners.

PRISON Key concerns

Ashfield (2022)

HMP Ashfield, a Category C training prison for convicted male sex offenders, maintained a safe environment despite increased self-harm (157 incidents) and violence (15 prisoner-on-prisoner assaults). The prison returned to a normal regime in March 2022 following Covid-19 restrictions. Key concerns include staff shortages in healthcare, ongoing issues with last-minute accommodation for released prisoners, and continued perceptions of discrimination among BAME prisoners.

PRISON Key concerns

Foston Hall (2022)

HMP/YOI Foston Hall faced significant challenges in the reporting year, primarily due to acute staff shortages which severely impacted the regime, leading to frequent curtailments and long periods of cell confinement. Key concerns included high levels of self-harm and violence, inadequate accommodation, and slow progress in healthcare provision and resettlement outcomes. Despite these difficulties, the Board commended staff dedication and noted some improvements, such as the opening of better quality accommodation and enhanced chaplaincy services.

PRISON Key concerns

Winchester (2023)

HMP Winchester made steady progress in a challenging environment, marked by improved staff numbers and a positive shift in culture, yet persistent issues with its Victorian infrastructure and overcrowding remain. While self-harm incidents decreased overall, the number of individuals involved increased, and prisoner-on-prisoner assaults rose. Healthcare experienced staffing shortfalls affecting GP and dental waiting times, and activity placements remained inadequate for the population. Key concerns include the dilapidated estate, resettlement support, and delays in critical infrastructure projects.

PRISON Key concerns

Wymott (2023)

HMP Wymott faces significant challenges including a rise in violence and self-harm, severe staff shortages impacting safety and regime, and inhumane conditions on A and B wings where refurbishment is repeatedly delayed. Overcrowding forces prisoners to double up in unsuitable cells, while healthcare struggles with inadequate facilities and high agency staff reliance. The Board commends efforts in education and resettlement, and the positive feedback on the new J wing.

PRISON Key concerns

Long Lartin (2023)

HMP Long Lartin experienced another challenging year ending December 2023, marked by an increased prisoner population and significant staffing shortages, leading to an unpredictable regime and increased prisoner frustration, self-harm, and violence. The prison's infrastructure, particularly in-cell sanitation on four wings and outdated security systems, is severely degraded, compounded by unsatisfactory maintenance services from Amey. Despite improvements in education and library provision and commendable efforts by chaplaincy and gym staff, mental health services are stretched, and purposeful activity and key worker sessions remain limited.

PRISON Key concerns

Moorland (2025)

HMP/YOI Moorland faced significant pressures this year from a high turnover of prisoners and early release schemes, yet reception staff performed well. While positive developments include improved ACCT records, successful translation programs, and some regime liberalisations, the report highlights concerns over increased violence, self-harm, and use of force. Key areas for development include addressing overcrowding (single cells as doubles), improving healthcare quality and access, and enhancing rehabilitation and purposeful activity for prisoners, particularly for IPPs.

PRISON Key concerns

Dovegate (2025)

HMP Dovegate, a Category B training prison, experienced an increase in self-harm incidents and use of force during the reporting period, alongside five deaths in custody. Key concerns include a lack of specialist resources and exit plans for prisoners with personality disorders, significant pressure on offender management due to policy changes, and disruptions to the Therapeutic Community. Positively, education attendance and achievements are strong, and the Board notes improvements in property management, healthcare access, and various purposeful activity initiatives.

PRISON Key concerns

Wakefield (2021)

HMP Wakefield, a high-security prison, faced significant challenges during the COVID-19 pandemic, operating under severe lockdown regimes with prisoners spending only 1.5 hours out of cell daily. While violence reduced, self-harm incidents and deaths in custody increased. The Board raised serious concerns about persistent issues with mental health transfers, a lack of consultant forensic psychiatrist provision, and the absence of in-cell telephony, which impacted prisoner wellbeing and family contact. Staffing shortages and recruitment delays were also significant concerns.

PRISON Key concerns

Isle of Wight (2021)

HMP Isle of Wight operated under a continued restricted regime in 2021 due to Covid-19, impacting daily life and increasing tensions. While the Board praised staff efforts and noted positive developments in healthcare, equality, and complaint handling, significant concerns persisted regarding the dilapidated laundry, unhygienic meal services, and underfunded estate repairs. Staffing shortfalls in mental health and probation services critically hampered prisoner support and progression, alongside challenges posed by the delayed transfer of Category C prisoners.

PRISON Key concerns

Bullingdon (2022)

HMP Bullingdon faced chronic overcrowding and significant staff shortages, which impacted safety, regime delivery, and staff-prisoner relationships throughout the reporting year. While healthcare provision was generally good and improvements were seen in some areas like equality data analysis and IT systems, challenges such as high violence, drug availability, and prisoner churn hindering progression persisted. The Board highlighted a continuing high number of self-harm incidents, though a recent decline was noted.

PRISON Key concerns

Bedford (2022)

HMP/YOI Bedford faced significant challenges during the reporting year, operating under "restrict" regimes due to COVID-19 and staff shortages, leading to widespread cell confinement. While positive steps were made in safety initiatives, particularly with a new young adults' wing and improved ACCT processes, the prison continues to struggle with high levels of self-harm and violence. Mental health services are critically under-resourced and inadequate, further exacerbated by persistent overcrowding and delays in relocating the inhumane segregation unit.

PRISON Key concerns

Eastwood Park (2022)

HMP/YOI Eastwood Park faced a challenging reporting year (Nov 2021 – Oct 2022), marked by critical staffing shortages (17.5% below target), two deaths in custody, and exceptionally high self-harm levels, leading the IMB to no longer consider it safe for all women. The prison struggled with an increasing number of women with complex mental health needs, exacerbated by inadequate facilities and a lack of external secure placements, resulting in extended periods of segregation for some. Despite these issues, the Board commended staff professionalism, welcomed the new ONE women’s centre, and noted the prison’s high functional skills achievements.

PRISON Key concerns

Gartree (2022)

HMP Gartree experienced an increase in assaults and self-harm incidents during the reporting year, alongside nine deaths in custody. The Board raised significant concerns about the lack of progress on essential infrastructure improvements, the quality and availability of purposeful activity, and delays in mental health transfers. Positive developments included improvements in the complaints system and effective detection of illicit items, but staffing retention and the lack of data to assure healthcare equivalence remain challenges.

PRISON Key concerns

Aylesbury (2022)

HMP/YOI Aylesbury faced a challenging year due to Covid-19 restrictions and severe staff shortages, which impacted the regime, purposeful activity, and staff-prisoner relationships. Despite these difficulties, the prison completed significant refurbishment projects and effectively contained Covid infections. Key concerns included persistent gang culture, high use of force, inadequate education and resettlement support, and issues with staffing levels and property management.

PRISON Key concerns

Lowdham Grange (2023)

HMP Lowdham Grange experienced a challenging reporting year (Feb 2022 – Jan 2023) marked by significant contract transition and refurbishment works. This led to a deterioration in safety, increased self-harm and assaults, and a decline in staff morale and prisoner engagement. Despite some positive healthcare developments like a new wellbeing centre, services remained below community standards, compounded by staffing shortages.

PRISON Key concerns

Exeter (2022)

HMP Exeter, a Category B local and resettlement prison, experienced persistent high levels of violence and self-harm, alongside challenges with staffing instability and extensive refurbishment work in 2022. While healthcare provision was generally satisfactory, access to psychological therapies remained limited, and living conditions were often impacted by overcrowding and restricted regimes. Progress towards successful resettlement was hindered by short sentences, lack of work opportunities, and staff shortages.

PRISON Key concerns

Norwich (2023)

The IMB report for HMP/YOI Norwich highlights persistent staff shortages as the overarching issue, leading to a restricted regime with prisoners locked up for extended periods daily. Key concerns include high levels of self-harm and violence, an overstretched mental health team, and a lack of purposeful activity and rehabilitation programs for long-term and IPP prisoners. The Board also notes the inhumane detention of foreign national prisoners beyond their sentences and prisoners with severe mental health issues in unsuitable facilities.

PRISON Key concerns

Send (2023)

HMP Send is a closed women's prison that made significant efforts to ensure prisoner safety and humane treatment during a challenging year. While the Board noted positive staff-prisoner relationships, persistent staff shortages, particularly in OMU and probation, negatively impacted services and progression. Key concerns include high self-harm rates, the lack of digital in-cell technology, the unjust detention of IPP prisoners, and property issues during transfers.

PRISON Key concerns

Swaleside (2023)

HMP Swaleside experienced an unprecedented year of staff shortages, severely impacting the regime and humane treatment of prisoners with restricted time out of cell. Despite these challenges, the Board commends the SLT and staff for implementing an improving regime, which saw a decline in violence and self-harm incidents. Key concerns remain around staff retention, the poor state of facilities, long segregation times, inadequate resettlement support, and the high number of deaths in custody.

PRISON Key concerns

Styal (2023)

HMP/YOI Styal faced significant challenges during the reporting year, primarily due to staffing shortages that compromised safety, regime consistency, and access to essential services. The prison recorded high rates of assaults and self-harm, often linked to an unpredictable daily routine. Despite these issues, the Board noted positive staff-prisoner relationships, improvements in induction and MBU facilities, and Styal's leading performance in employment outcomes for women on release.

PRISON Key concerns

Wealstun (2023)

HMP Wealstun, a Category C prison, has an operational capacity of 856 and a CNA of 809. The IMB reports improvements in reception processes and generally good collaboration between prison and healthcare teams. However, significant concerns persist regarding unacceptable time out of cell, pervasive part-time work, and critically low key worker session delivery. Overcrowding, the poor condition of older wings, and challenges in managing illicit items also remain key issues.

PRISON Key concerns

Isle of Wight (2022)

HMP Isle of Wight experienced a challenging 2022, marked by a population increase and the gradual easing of Covid restrictions, which allowed for a return to some normal regime activities. However, chronic staff shortages significantly hampered access to work, education, and healthcare, leading to prisoners spending considerable time locked up. The Board raised serious concerns regarding the inadequacy of mental health provision, the impact of staff shortages on all aspects of prison life, and the need for clarity and funding for the estate and the management of the Category C prisoner population.

PRISON Key concerns

Stoke Heath (2023)

HMP/YOI Stoke Heath, a Category C training and resettlement prison, experienced an increase in self-harm incidents and near misses, alongside a noticeable rise in illicit items. While overall violence remained low, prisoners spent more time in their cells due to staffing shortages and inadequate purposeful activity, impacting sentence progression. Healthcare provision was generally met, though dental waiting times were long and planned mental health interventions limited. The Board highlighted concerns regarding prisoner property, resettlement support, and the need for more varied education and work opportunities.

PRISON Key concerns

Whatton (2023)

HMP Whatton, a Category C training prison, had an average population of 802 against an operational capacity of 817. While staff maintained a safe environment and implemented a normal daily regime, the Board highlighted concerns including increased assaults, high self-harm incidents, and significant delays in transferring mentally unwell prisoners to secure care. Substandard B wing accommodation and inadequate resettlement support for released prisoners were also noted.

PRISON Key concerns

Portland (2023)

HMP/YOI Portland demonstrated a well-controlled environment with positive staff-prisoner relations and good physical facilities during the reporting year ending March 2023. However, the Board highlighted significant challenges in mental health provision due to staffing shortages, a fragmented resettlement program, and persistent issues with property delays. Recommendations focused on better funding for resettlement, improved communication regarding property, and prioritising key work to support prisoner wellbeing and progression.

PRISON Key concerns

Bedford (2024)

HMP Bedford, a Category B YOI, continues to face significant challenges including persistent overcrowding and an inconsistent induction process, despite some improvements in wing cleanliness and key worker implementation. The report highlights serious concerns regarding healthcare, characterized by poor communication and a decline in drug rehabilitation services. Security remains an issue with illicit items readily entering the prison, and high levels of assaults on staff, although recent improvements are noted. The Board also raises concerns about the unaddressed needs of its large remand population, the lack of digital infrastructure, and disproportionate adjudications.

PRISON Key concerns

Bronzefield (2024)

Bronzefield faced significant challenges in the reporting year, primarily due to severe staff shortages impacting all aspects of the regime, leading to prisoners being locked up for extended periods and missing activities. Healthcare delivery was suboptimal due to lack of staff and poor coordination, resulting in medication delays and cancelled appointments. The prison also grappled with a high incidence of self-harm and challenges in managing complex, mentally unwell prisoners, compounded by external bed shortages.

PRISON Key concerns

Cardiff (2024)

HMP Cardiff, a Category B local training prison, maintained a 'Good' HMIP rating despite significant population pressures, with the IMB noting positive staff-prisoner relationships and cell refurbishment efforts. However, the Board expressed serious concerns over rising self-harm, violence, and use of force incidents, alongside persistent overcrowding leading to inhumane eating conditions. Key challenges included inadequate mental health staffing at weekends, a doubling of medication complaints, and poor key worker scheme delivery.

PRISON Key concerns

Low Newton (2025)

HMP/YOI Low Newton is a women's closed prison that has seen improvements in culture and regime under new leadership. While safety is prioritised, challenges remain with a high number of self-harm incidents and significant mental health needs among the population, often leading to the prison acting as a place of safety. Efforts are being made in purposeful activity, resettlement, and healthcare, with strong staff dedication noted.

PRISON Key concerns

Send (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.

PRISON Key concerns

Lindholme (2021)

HMP Lindholme operated under significant Covid-19 restrictions, leading to prolonged lockdowns, reduced regime, and limited purposeful activity, though self-harm and violence incidents decreased. While healthcare adapted well and staffing levels improved, concerns persist regarding high numbers of OCG prisoners, substance misuse, overcrowding, and delays in sentence progression. The IMB highlighted the negative impact of limited time out of cell and poor staff-prisoner relationships.

PRISON Key concerns

Lewes (2021)

The IMB report for HMP Lewes (Feb 2020-Jan 2021) highlighted the severe impact of Covid-19 restrictions, which led to prisoners being locked in cells for up to 23.5 hours daily, deemed inhumane. While a new healthcare provider brought improvements, significant concerns remain regarding mental health bed availability, disproportionate use of force against BAME prisoners, and the plight of IPP prisoners. The Board commended staff resilience but expressed ongoing concerns about regime restrictions and the lack of purposeful activity.

PRISON Key concerns

Onley (2021)

HMP Onley successfully managed the COVID-19 pandemic, implementing a restricted regime that initially reduced violence and self-harm, though incidents began to rise late in the year. Prisoners generally experienced fair and humane treatment, and healthcare staffing issues were resolved. However, the pandemic severely impacted resettlement services, education, and purposeful activity, posing challenges for prisoners' progression and preparation for release.

PRISON Key concerns

Pentonville (2021)

During a reporting year dominated by the Covid-19 pandemic, Pentonville successfully avoided a widespread deadly outbreak through stringent measures, though two prisoners sadly died. However, the Board found that the highly restricted regime led to inhumane conditions, with prisoners confined to cells for extended periods, impacting mental health and resettlement progression. Key concerns remain around overcrowding, inadequate facilities, the safety of vulnerable prisoners, and persistent violence and drug issues, with limited progress on ACCT quality and disproportionality in disciplinary actions.

PRISON Key concerns

Risley (2021)

HMP Risley demonstrates high safety standards with reductions in self-harm and violence, good healthcare provision, and strong equality and diversity initiatives. However, the Board raises significant concerns about long repatriation times for foreign nationals and property management issues. The pandemic severely impacted regime, education, and Key Worker scheme delivery, leading to limited time out of cell and restricted activities.

PRISON Key concerns

Chelmsford (2021)

HMP/YOI Chelmsford, a Category B local prison, faced significant challenges during a reporting year heavily impacted by COVID-19 restrictions, leading to a restricted regime with limited purposeful activity and prolonged cell confinement. Key concerns included persistent overcrowding, a severe rat infestation, and substantial delays in handling prisoner complaints and property issues. The prison also struggled with staffing shortages, particularly affecting the key worker scheme and healthcare provision, alongside high self-harm rates and increased assaults on staff.

PRISON Key concerns

Hindley (2021)

HMP/YOI Hindley is deemed overall safe, though violence and self-harm increased, particularly among young adults. Prisoners are generally treated humanely despite challenges from Covid-19 restrictions, which often led to 23-hour lock-ins. While health needs are met satisfactorily, concerns persist regarding lost property, outdated accommodation, and resettlement support. The Board commends staff efforts and welcomes planned prison expansion.

PRISON Key concerns

Channings Wood (2022)

HMP Channings Wood reported a largely settled year (Sept 2021-Aug 2022) despite a gradual return to a near-normal regime after Covid-19 restrictions. While self-harm incidents reduced by 17% and total assaults remained similar to the previous year, the use of force increased by 27%. Key concerns highlighted include the persistent challenges in mental healthcare, specifically accessing specialist placements, the ongoing issue of lost prisoner property during transfers, and the ineffectiveness of the key worker scheme in supporting sentence progression. The Board commended efforts in E&D, chaplaincy, and health and wellbeing initiatives while noting that many cells and showers need refurbishment.

PRISON Key concerns

Lewes (2025)

HMP Lewes saw improvements in its regime, leading to increased time out of cell and a fall in prisoner-on-prisoner violence. Healthcare provision also improved, with reduced waiting times for routine appointments. However, significant challenges persist with the prison's heating system, gaps in mental health services, and a worrying increase in self-harm and assaults on staff. The Board highlighted ongoing concerns regarding disproportionality in the use of force and adjudications against certain prisoner groups.

PRISON Key concerns

Onley (2025)

HMP Onley, a Category C prison, experienced a challenging year with significant increases in violence and self-harm incidents. Key concerns include high levels of illicit substances, poor living conditions, and unacceptable waiting times for healthcare. Despite some positive developments in key worker delivery and resettlement initiatives, staffing shortages and backlogs in offender management continue to hinder progression.

PRISON Key concerns

Styal (2025)

HMP/YOI Styal, a local women's prison, grapples with a complex population, leading to concerns about high self-harm rates and an increased number of deaths in custody. The Board highlights persistent issues with estate maintenance, fire safety, and a lack of consistent staff supervision on houses, which impacts prisoner safety and regime delivery. Despite improvements in healthcare and education attendance, significant delays in mental health transfers and pressure on resettlement accommodation remain critical challenges.

PRISON Key concerns

Swinfen Hall (2020)

The number of self-harm incidents increased this year, from 803 to 881. While the Board acknowledges that some of this increase derives from a small number of prisoners repeatedly self-harming, it commends the efforts of staff supporting these prisoners. The Board welcomes regular updates on new initiatives to reduce the extent of self-harm and their impact and would like to …

Governor / Director

Lincoln (2020)

Although it is noted that there was no further increase in the number of self-harm incidents reported in 2019, the Board remains concerned about the high level of self-harm (see paragraph 4.5).

Governor / Director

Isis (2020)

ensure that plans are in place to prevent a return to the levels of self-harm over the first three months of the year, when a normal regime is resumed (see section 4.2)

Governor / Director

Channings Wood (2020)

While the Board very much welcomes the continued downward trend in many key safety indicators, progress in reducing levels of self-harm and the use of psychoactive substances is slower. What steps are planned to further reduce the number of prisoners self-harming at Channings Wood? Despite successes in the interception of drugs, can even more effective measures be taken to reduce …

Governor / Director

Usk and Prescoed (2021)

With respect to the promotion of prison safety, the Board supports the concerns of Dame Anne Owers (letter to the Director General of Prisons, November 2020) regarding the decision that making a ligature (also known as noose making) by prisoners should no longer be a nationally reportable self-harm incident.

HMPPS

Lancaster Farms (2021)

To reconsider and improve the strategies available to the prison to manage and reduce the number of incidents of self-harm, particularly among the small number of prisoners who frequently self-harm and could be assessed as demonstrating severe mental health difficulties (paragraphs 4.2.2, 6.3.5).

Ministry of Justice

Thameside (2022)

Address Listener call-out issues across the houseblocks (see section 4.2).

Governor / Director

Elmley (2024)

Remove prisoners’ access to razor blades as an instrument of self-harm and replace these with safer electric shavers.

HMPPS

Eastwood Park (2024)

Ensure individuals who prolifically self-harm are more evenly distributed throughout the women’s estate to help reduce the adverse pressure on the regime and staff in a single prison.

Ministry of Justice

Onley (2020)

The Board is concerned at the number of self-harm incidents in the reporting year (4.8), and we would like assurances about the actions being taken.

Governor / Director

Lancaster Farms (2020)

Urgent consideration of the increasing number of incidents of self-harm by prisoners, and the very large numbers of self-harm incidents associated with a small number of individuals facing mental health difficulties, is required (see paragraph 4.9).

Ministry of Justice

Wandsworth (2021)

Listeners, trained to support other prisoners, provided a highly valuable role but were not always unlocked. The Board also noted that the Listener suites, which provided a private space, were often not available due to maintenance and other issues. What changes will be made to ensure a full and continuous Listener service is provided across all wings?

Governor / Director

Swaleside (2021)

The continued downward trends in safety measures are noted, however, at the very end of the reporting period there has been evidence that assaults against staff and incidents of self-harm have risen. These figures need analysis in order to establish the cause and prevent any upward trend setting in. (see sections 4.2 and 4.3)

Governor / Director

Norwich (2021)

The Board reiterates the concerns of Dame Anne Owers in her letter of 11 November 2020 to the Director General of Prisons regarding the decision that the making of a ligature by prisoners is no longer a nationally reportable self-harm incident.

HMPPS

Elmley (2021)

There should be greater, more formal analysis of self-harm. The assessment, care in custody and teamwork (ACCT) documents are valuable for recording such events and their possible triggers, but the underlying causes seem never to be identified in their relation to the prison environment, which could be modified.

Governor / Director

Bronzefield (2021)

The number of self-harm incidents has escalated to an average of 220 incidents each month in the reporting year. How is the prison service supporting the prison to manage this high level of risk on an urgent and long-term basis?

HMPPS

Foston Hall (2022)

Limited access to Listeners, resulting in a significant increase in phone calls to the Samaritans (see paragraph 4.2.4)

Governor / Director

Bullingdon (2022)

What plans does the Governor have to address the continuing high number of cases of self-harm in the prison?

Governor / Director

Bronzefield (2022)

The number of self-harm incidents has continued to rise to an average of 238 incidents a month. Given that a few prolific self-harmers account for a high proportion of these incidents, how does the Prison Service plan to provide support to the prison to manage these extremely challenging prisoners? (See section 4.2.)

HMPPS

Bedford (2022)

As far as we are aware there have been no attempts to evaluate the effectiveness of the assessment, care in custody and teamwork (ACCT) process to understand whether it has achieved (or failed) its objective of supporting those at risk of self-harm.

HMPPS

Styal (2023)

How is the prison addressing the reduced number of programmes which support prisoners to understand and modify their behaviour?

Governor / Director

Long Lartin (2023)

Self-harm. What further measures can be to be taken to reduce self-harm?

Governor / Director

Liverpool (2023)

Whilst HMP Liverpool is a cluster death site, with an increase in suicide attempts and self-harm incidents, there does not appear to have been any substantial additional resources for a meaningful period to reduce risks of additional deaths. What resources will the Prison Service provide to HMP Liverpool to ensure that safety for prisoners is improved over the long term?

HMPPS

Lancaster Farms (2023)

To monitor the number of Listeners. Given the turnover of existing Listeners, to ensure that there is a rolling programme of training for future Listeners.

Governor / Director

Lancaster Farms (2023)

To further improve the strategies available to the prison to manage and reduce the number of incidents of self-harm, particularly among the small number of prisoners who frequently self-harm and could be assessed as demonstrating severe mental health difficulties.

HMPPS

Foston Hall (2023)

Challenge, support and intervention plans (CSIPs) continue to be underused and there is a high rate of ‘no further action’ following a referral. Furthermore, investigations are often not completed within 72 hours, all of which affects the level of support to prisoners. How can this be addressed?

Governor / Director

Foston Hall (2023)

Listeners are being trained, but often step down, so there is limited access to Listeners. How can retention rates be improved?

Governor / Director

Bullingdon (2023)

What plans does the Governor have to address the continuing high number of cases of self-harm in the prison?

Governor / Director

Nottingham (2024)

To consider what further steps can be taken to address the increase in self-harm.

Governor / Director

Elmley (2024)

Work with external partners to reinstate the prisoner Listener scheme, as a matter of urgency, to support a culture of safer custody.

Governor / Director

Brinsford (2024)

Enhance key worker sessions to reduce reliance on peer support for self-harm prevention.

Governor / Director

Bure (2025)

Due to the number of self-harm incidents using razor blades, will the Governor consider removing wet shave razors and replace them with electric shavers, as is happening across other prison establishments?

Governor / Director

Lancaster Farms (2022)

To further improve the strategies available to the prison to manage and reduce the number of incidents of self-harm, particularly among the small number of prisoners who frequently self-harm and could be assessed as demonstrating severe mental health difficulties.

Other

Wakefield (2020)

we encourage the Governor to consider a review of how psychologically informed regimes at Wakefield may, or may not, be efficacious.

Governor / Director

Rye Hill (2020)

The Prison Service is asked to review their action plans for IPP prisoners and ensure that all categories of prisoner with these sentences can access funded help for progression.

HMPPS

Lancaster Farms (2020)

Similarly, access to telephone calls to the Samaritans at night has been absent for much of the year, and a solution should be implemented with urgency (see paragraph 4.4).

Governor / Director

Lancaster Farms (2020)

Immediate action is required to reverse the decline in the number of trained Listeners to just two, as prisoners have not had sufficient access to this important form of support (see paragraph 4.4).

Governor / Director

Swansea (2021)

We applaud the establishment in its efforts to maintain key worker sessions during the restricted regime but would ask that consideration be given to whether the cross-deployment of key workers affected the incidence of self-harm (see paragraph 5.3.2).

Governor / Director

Swaleside (2021)

Efforts must be made to increase the levels of Keywork. This proved itself to be extremely beneficial and will be fundamental to addressing the issues that could result in self-harm and violence post-COVID. (see sections 3.2 and 5.3)

Governor / Director

Lincoln (2021)

How soon will Samaritan training of Listeners (see paragraph 2.4) resume?

Governor / Director

Hewell (2021)

The Board again restates its previously recorded concern at the prevalence and treatment of prisoners held in custody indefinitely under indeterminate sentences for public protection. We have seen no evidence of attempts to manage the sentences of these individuals with any focus on forward progression. Nor have we seen recognition that the despair of endless detention results in self-destructive behaviour, …

Ministry of Justice

Foston Hall (2021)

The IMB is concerned about: the continued high level of self-harm

Governor / Director

Exeter (2021)

Undertake to improve the effectiveness, management and oversight of CSIPs.

Governor / Director

Dartmoor (2021)

Ensure that Listeners and the Samaritans services are available at all times of the day and night, including ensuring all staff understand that access to these services should be allowed, following occasions where prisoners have not been able to access them at night.

Governor / Director

Bullingdon (2021)

There are some prisoners in Bullingdon whose state of mental health is such that the prison is not equipped to cope with them; it is very likely that they need to be sent to secure psychiatric institutions. Some of these prisoners have spent far longer in the SSCU than 42 days, after which continued segregation has to be reported to …

HMPPS

Bullingdon (2021)

There are some prisoners in Bullingdon whose state of mental health is such that the prison is not equipped to cope with them; it is very likely that they need to be sent to secure psychiatric institutions instead. Some of these prisoners have spent far longer in the SSCU than 42 days, after which continued segregation has to be reported …

Ministry of Justice

Bedford (2021)

While there is a steady decrease in self-harm incidents, we feel that a better system of investigation of incidents, to understand the causal links, would lead to further improvements.

Governor / Director

Swaleside (2022)

Challenge, support and intervention plan (CSIP) should receive more attention from custody managers (CMs) as evidenced by minutes from the weekly safety intervention meetings (SIMs).

Governor / Director

Hull (2022)

Continue to develop the attitude-changing interventions with young adults.

Governor / Director

Grendon (2022)

Delivery of staff training e.g. suicide and self-harm (SASH) (4.2.6).

Governor / Director

Katie Allan; William Brown

Remove double bunk beds from young prisoner cells; replace door-stops with anti-ligature designs; pilot signs of life technology; restrict access to belts and cords; system for court documentation to reach SPS on admission; 24-hour family reporting number; 72-hour TTM presumption for all young admissions; enhanced risk assessment forms; improved electronic documentation; increased staff training frequency

Jan 2025 Custody 25 recs Scotland

Sarah Jane Riley

1. The Scottish Ministers and SPS should consider (a) establishing a system in respect of prisoners who have been sentenced to an OLR to allow for a psychological formulation focussed on the prisoner's risk to themselves, based on the information already available from the Risk Management Plan, to be prepared and shared with the prisoner's personal officer and other SPS …

Nov 2025 Custody 8 recs Scotland

Robert Wagstaff

Transition report information to be shared with all relevant SPS and NHS staff; SPS Prevention of Suicide in Prison Strategy guidance to be amended for healthcare assessments; regular training including refresher training on suicide prevention

Jan 2019 Custody 3 recs Scotland

— LP 4

We recommend that Swansea Prison considers the selection, appointment and training of a Family Liaison Officer as a member of the Safer Custody Team, to promote engagement with families as part of the ACCT scheme, to monitor the operation of this in practice, and to report periodically to the safer …

HMPPS Accepted

— LP T

Performance on Suicide and Self-Harm Prevention should continue to be a high priority element in the audit of prisons.

HMPPS

— LP 7

I recommend that NOMS reviews the guidance to establishments about action following life-threatening incidents of self-harm to ensure that it makes clear that evidence must be preserved.

NOMS

— LP 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 Accepted

— LP 5

I recommend that the Governor of HMP Ranby is asked: to note the absence of case notes or other evidence of constructive engagement with WA; to consider what practical arrangements are now in place at Ranby to cultivate positive interaction between staff and prisoners and whether more can be done; …

The Governor (HMP Ranby)

— LP 3

I recommend that the Governor of HMP Ranby establishes: that the prison’s current practice complies with the requirement to check the OASys risk assessment of newly admitted prisoners and to inform their location of any identified risk of harm to self or others; and that residential staff at Ranby are …

The Governor (HMP Ranby)

— LP 16

Good practice guidelines should be published on the supervision of recess areas to cover standard risk and high-risk prisoners.

HMPPS Accepted

— LP 15

Recess areas should be added to the list of examples of locations where a prisoner with a high-risk cell-sharing risk assessment should be prevented from using with other prisoners.

HMPPS Accepted

— LP 10

We recommend that GEOAmey and HMPPS consider how friends and families of prisoners at risk can be encouraged and enabled to pass on any concerns about risk of self-harm. Protocols may be required as to how to reconcile requirements of privacy and requirements of safe custody that may be in …

GEOAmey and HMPPS Accepted

— LP 11

We recommend that training in suicide prevention is undertaken by all staff who come into contact with prisoners and that the training is refreshed on a regular basis with managers having responsibility for ensuring continued understanding and compliance with the areas covered.

HMPPS Accepted

— LP 4

I recommend that NOMS look into whether the requirement for early checking of OASys assessments for new prisoners is consistently observed in other prisons and consider whether further measures are necessary to ensure that the system is used and understood.

NOMS

201004020 — Scottish Prison Service

Mr C complained that there was a delay in him being assessed for the Substance Related Offending Behaviour Programme, to which he had been referred in late 2008. He said that he was unable to progress through his prison sentence until he completed the programme. He also said that even …

SPSO (Scottish Public Se… Prisons Not Upheld Jul 2011

201003734 — Scottish Prison Service

Mr C, who is a prisoner, complained that there had been an unreasonable delay by the SPS in assessing him for the Substance Related Offending Behaviour Programme. He felt that this meant he was being overlooked for progression as he worked through his sentence. As in other similar cases, the …

SPSO (Scottish Public Se… Prisons Not Upheld Jul 2011

201005201 — Scottish Prison Service

Mr C, who is a prisoner, complained about delay in being assessed for offending behaviour related programmes for which he had been identified as suitable. Mr C felt his progression to less secure conditions would be affected by the delay. He said he was identified for programmes at his Integrated …

SPSO (Scottish Public Se… Prisons Not Upheld Aug 2011

201005382 — Scottish Prison Service

Mr C, who is a prisoner, complained that he was delayed in being identified for inclusion in an intervention programme. He said this was unreasonable. Mr C was worried the delay would affect his progression to less secure conditions and his chance of early parole. Our investigation found that as …

SPSO (Scottish Public Se… Prisons Not Upheld Dec 2011

201103477 — Scottish Prison Service

Mr C, who is a prisoner, complained because he was unhappy that he would be unable to access the Substance Related Offending Behaviour Programme (SROBP) before becoming eligible for consideration to progress to less secure conditions. SROBP is a programme focusing on the relationship between prisoners' substance use and their …

SPSO (Scottish Public Se… Prisons Not Upheld Apr 2012

201202302 — Scottish Prison Service

Mr C, who is a prisoner, complained about a delay in getting on to a particular behaviour course in prison. He thought the delay might hold up his release from prison. From previous complaints, we were aware that the Scottish Prison Service were dealing with a temporary backlog of people …

SPSO (Scottish Public Se… Prisons Not Upheld Dec 2012

201201815 — Scottish Prison Service

Mr C, who is a prisoner, complained that a prison officer inappropriately passed information about him to another prisoner. Mr C said that, as a result of this, he was assaulted and had to move to an alternative house block (prison accommodation). In addition, Mr C complained that he was …

SPSO (Scottish Public Se… Prisons Partly Upheld Feb 2013

201300527 — Scottish Prison Service

Mr C, who is a prisoner, progressed to the national top end (NTE) in January 2012. This is a less secure prison facility, to which prisoners can progress before moving to open prison conditions. The risk management team (RMT) there were concerned that Mr C had not been assessed for …

SPSO (Scottish Public Se… Prisons Upheld Feb 2014

201101057 — Scottish Prison Service

Mr C, who is a prisoner, complained about the unreasonable delay in him being assessed for the Constructs programme (which aims to help participants reduce the likelihood of being involved in further offending by helping them change the way they think and behave). Mr C was concerned that the delay …

SPSO (Scottish Public Se… Prisons Not Upheld Oct 2011

201101053 — Scottish Prison Service

Mr C, who is a prisoner, complained because the prison were asking him to engage in offending behaviour programmes and he said this was inappropriate because he maintained his innocence and, therefore, was unsuitable for the identified programmes. The prison explained that because Mr C was a convicted prisoner, the …

SPSO (Scottish Public Se… Prisons Not Upheld Oct 2011

201203355 — Scottish Prison Service

Mr C, who is a prisoner, complained that there was an unreasonable delay in the prison referring him for a generic assessment (which identifies whether or not a prisoner should participate in offending behaviour programmes). In Mr C's case, in January 2012 the risk management team (RMT) considered whether he …

SPSO (Scottish Public Se… Prisons Upheld Apr 2013

201603321 — Scottish Prison Service

Mr C complained that the Scottish Prison Service (SPS)'s handling of his position on the waiting list for an offending behaviour programme had been unreasonable. He was temporarily transferred to prison in England and because of this, Mr C said that he was removed from the waiting list in error. …

SPSO (Scottish Public Se… Prisons Not Upheld Dec 2016

201507929 — Scottish Prison Service

Mr C complained about the content of a psychological risk assessment, which he said contained out-of-date information which had been obtained during discussions when he was unwell. We found the psychologist was entitled to take historic discussions into account, even if Mr C was now saying different things. We were …

SPSO (Scottish Public Se… Prisons Not Upheld Feb 2017

201808763 — Scottish Prison Service

C complained on behalf of their spouse (A) regarding the lack of support the Scottish Prison Service (SPS) provided in relation to assisting A to participate in an offending management course, specifically that they needed a translator to assist them. During our investigation, SPS apologised to A for the delay …

SPSO (Scottish Public Se… Prisons Jun 2020

201100335 — Scottish Prison Service

Mr C was deselected from an offending behaviour programme. His solicitor contacted the prison about the deselection. When the prison responded, Mr C felt that the information that they provided to his solicitor about the reasons for his deselection was incorrect. As part of our investigation, we saw notes of …

SPSO (Scottish Public Se… Prisons Not Upheld Aug 2011

201004917 — Scottish Prison Service

Mr C, who is a prisoner, complained about a delay in being assessed for the Controlling Anger and Regulating Emotions (CARE) programme. The prison told Mr C that he was assessed as suitable for the programme in 2010 but that he had to wait for space on the programme to …

SPSO (Scottish Public Se… Prisons Not Upheld Aug 2011

201202112 — Scottish Prison Service

Mr C, who is a prisoner, complained that, having been considered unsuitable several years previously for two behaviour-related courses in prison, it had now been decided that he should attend them. He considered that this might hold up his progression to more open conditions (ie to less secure prison conditions). …

SPSO (Scottish Public Se… Prisons Not Upheld Mar 2013

201204088 — Scottish Prison Service

Mr C, who is a prisoner, complained that he was unreasonably denied access to offending behaviour programmes that he had been identified for. Mr C is serving a life sentence and the punishment part of his sentence expires in late 2017. Mr C said that the earliest that he could …

SPSO (Scottish Public Se… Prisons Not Upheld May 2013

201204575 — Scottish Prison Service

Mr C, who is a prisoner, was attending a course in prison. He considered that the course facilitator was not supportive when he had particular difficulties at one session. He also complained that the Scottish Prison Service (SPS)'s reply to his complaint had inappropriately criticised him. Our investigation concluded that …

SPSO (Scottish Public Se… Prisons Not Upheld Aug 2013

201204353 — Scottish Prison Service

The programmes case management board (PCMB) is a group of prison staff who decide in which offending behaviour programmes a prisoner should participate. Mr C, who is a prisoner, complained that communication of the PCMB's decision that he should take part in the Controlling Anger and Regulating Emotions (CARE) programme …

SPSO (Scottish Public Se… Prisons Not Upheld Aug 2013

201301240 — Scottish Prison Service

Mr C, who is a prisoner in a closed prison, complained that the Scottish Prison Service were unreasonably holding him back from progressing to less secure conditions. A prisoner must meet standard criteria before the risk management team (RMT) will consider his application for progression. The RMT at the closed …

SPSO (Scottish Public Se… Prisons Not Upheld Nov 2013

201305996 — Scottish Prison Service

Mr C, who is a prisoner, complained because he said the prison inappropriately identified him as being suitable for the substance related offending behaviour programme. Mr C was unhappy with this because he said substance misuse was not part of his offence. The prison told Mr C that because of …

SPSO (Scottish Public Se… Prisons Not Upheld Jul 2014

201303338 — Scottish Prison Service

Mr C, who is a prisoner, was identified as needing to participate in programmes before he could be considered for access to less secure prison conditions. He complained to us because he felt the prison had failed to adequately prepare him for progression because the date on which he became …

SPSO (Scottish Public Se… Prisons Not Upheld Jul 2014

201303972 — Scottish Prison Service

Mr C, who is a prisoner, complained that the Scottish Prison Service (SPS) had decided that he no longer needed to be managed under their process for prisoners at risk of suicide or self-harm. Mr C had been managed under this process for a number of days, as he had …

SPSO (Scottish Public Se… Prisons Upheld Aug 2014

201505033 — Scottish Prison Service

Mr C complained about a delay in accessing the Self Change Programme (a programme aimed at addressing offending behaviour). The prison said that prisoners had to have a General Programme Assessment before being eligible to access this programme. They said that Mr C had initially refused to engage with the …

SPSO (Scottish Public Se… Prisons Not Upheld May 2016

201200044 — Scottish Prison Service

Ms C, who is a prisoner, complained about a delay in accessing an offending behaviour programme. She was due to start a programme in December 2011 but was still waiting when she contacted us around three months later. The Scottish Prison Service told us that Ms C started an offending …

SPSO (Scottish Public Se… Prisons Not Upheld Aug 2012

201202618 — Scottish Prison Service

Mr C, who is a prisoner, complained that there was unreasonable delay in the prison generically assessing him. A generic assessment is carried out on individual prisoners to identify whether or not they are required to complete offence-focused programmes. In investigating Mr C's complaint, we were satisfied that he had …

SPSO (Scottish Public Se… Prisons Not Upheld Jan 2013

201202272 — Scottish Prison Service

Mr C, who is a prisoner, complained about a delay in getting onto a behaviour-related course which he had been identified as needing. He was concerned that the delay could hold up his progression to more open prison conditions. From previous complaints, we were aware that since a new type …

SPSO (Scottish Public Se… Prisons Not Upheld Jan 2013

201202262 — Scottish Prison Service

Mr C, who is a prisoner, complained that the prison delayed in assessing him for offending behaviour coursework. The prison explained that they prioritise prisoners in line with their key progression (movement through the prison system to less supervised conditions) dates. They assured him that he was on the waiting …

SPSO (Scottish Public Se… Prisons Not Upheld Jan 2013

201104875 — Scottish Prison Service

Mr C, who is a prisoner, complained because he said the programmes case management board (PCMB) considered false information before deciding what programmes he should be required to participate in. Mr C identified information in the record of the PCMB meeting which he felt was incorrect. Before we investigated Mr …

SPSO (Scottish Public Se… Prisons Not Upheld Feb 2013

201400854 — Scottish Prison Service

Mr C, who is a prisoner, complained that the prison unreasonably failed to explain to him why they had imposed security measures on him that meant he was unable to attend work or education. The Scottish Prison Service (SPS) confirmed that Mr C had been placed on risk management precautions. …

SPSO (Scottish Public Se… Prisons Partly Upheld Oct 2014