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Hmp Woodhill

Volume 407: debated on Thursday 19 June 2003

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The report of the investigation into the circumstances surrounding the act of self-harm by Ian Huntley was received by the Prison Service on Friday 13 June. I received that report together with the Prison Service's response to it in my office on Tuesday 17 June. Whilst the investigation report itself is, for a variety of reasons, confidential, I am providing this statement because I want Parliament and the public to have confidence that this matter has been properly dealt with. I have been mindful of the Attorney General's guidance concerning the publication of matters relating to Mr Huntley prior to his trial, to matters of security and medical confidentiality.The report highlights a number of serious systems failures. I can confirm that these have already been addressed and corrected. In essence the systems for managing Ian Huntley concentrated more on protecting him from other prisoners than on the risk of self-harm. The Prison Service should have given equal importance to both risks. The report also highlighted the risks in managing a single prisoner in special conditions for a protracted period. The arrangements for briefing staff supervising Mr Huntley and the arrangements for overall management oversight were not robust enough to combat complacency and conditioning. Finally, the procedures for dispensing medication to Mr Huntley fell well short of accept able standards and failed to take into account the risk of self-harm.The report acknowledges the complex multifunctional role of Woodhill Prison and the challenge this poses to managers and staff but I have made it clear that the safe custody of Mr Huntley is an absolute priority for the Prison Service and that revised arrangements for his supervision must reflect this. The report concludes that lines of accountability for the management of Mr Huntley were unclear. I have made it clear to the Director General that there must be clear lines of accountability in the future so that all staff are fully aware of their responsibilities and that management oversight is to a consistently high standard. The report did not recommend that any disciplinary action be taken against individual officers.The Investigating Officer concluded that:

Any failures were corporate failures and not the failure of any one individual.
The management arrangements for Mr Huntley lacked clarity, were not communicated well and failed to respond effectively to the developing needs of the circumstances.
The day-to-day management of this situation had effectively become the responsibility of one manager who had a wide range of other responsibilities. This was not appropriate.
There were failings in communication and input from senior managers.
There were deficiencies in searching practices, which were predictable and did not include the items stored outside of his cell.
The management of staff deployed to carry out the task of supervision of Mr Huntley did not fully recognise the full risks inherent in working long shifts without relief.
Information was not systematically reviewed. There was a time lapse in some cases between information being submitted and consideration being given to that information.
Staff must have the appropriate resources, instructions and support to enable them to remain vigilant at all times they are carrying out this duty.

The recommendations of the Investigating Officer include:

One operational Manager should have responsibility for the care of Mr Huntley.
A clear and effective structure for the management of Mr Huntley must be established and published to staff.
A multi disciplinary team should review the current operational instruction. An amended instruction must be authorised by the Governor.
The amended operational instruction must be communicated to all staff who have contact with Mr Huntley. The implications of the new instruction should be communicated to Mr Huntley.
A multi disciplinary team should meet weekly to review the management of Mr Huntley.
Staff still in their probationary period should not supervise Mr Huntley.
All recommendations made by Prison Service Safer Custody Group should be actioned.
The searching strategy should be reviewed. There should be management oversight of the reviewed strategy.
A review of security intelligence systems, including use of CCTV, at Woodhill should be carried out by an independent person.
All recommendations made in relation to medical issues should be implemented.
There should be an audit of prescribing practice after three months.
Staff should be reminded of their personal responsibilities in relation to the supervision of prisoners.
The findings of the significant event audit should be circulated to Health Care staff who should be engaged in resolving issues raised and implementing change.
There should be an audit of compliance with the administration of medication policy after three months.
There must be a specific Integrated Care Plan for Mr Huntley, which should record all issues relating to him. This document should be reviewed daily and submitted to the Governor weekly.

The Prison Service has advised me that all the recommendations in the report have been accepted and have been implemented with effect from Monday 16 June. Revised and comprehensive operational instructions have been put in place that will be overseen by a clearly identified manager at all times who will report direct to the Governor. The instructions are underpinned by an integrated care plan in which comprehensive written details of all events concerning Mr Huntley will be recorded. This plan will be reviewed daily. Medical procedures have also been reviewed in consultation with the appropriate Primary Care Trust and a multi-disciplinary team will supervise Mr Huntley's health care. The effectiveness of these revised procedures will be formally reviewed each week by the accountable manager together with those other managers who have designated responsibilities laid down in the operational instructions. The Governor will supervise their work. The Prison Service will also make arrangements for regular audits of the operational instructions to be carried out independently of the establishment to provide assurance that full compliance with the instructions is being maintained. Audit reports will be sent to the Deputy Director General for his personal attention.

I have made it clear to the Director General that the conclusions of the report describe a completely unacceptable situation, that the lessons to be learned must be applied immediately and that the highest standards of supervision must be sustained from now on.