The Deafening Silence of the IMB Lambs

 During the last 12 months every statutory fire safety inspection conducted in prisons by the Crown Properties Fire Investigation Group (CPFIG) failed to pass legal inspection – all were issued with Notices of Non-Compliance, and others with Enforcement Notices when corrective action was not taken.

But how could it have got to this point?

Every prison has an Independent Monitoring Board (IMB), selected and appointed by the Secretary of State for Justice they are there to monitor what is happening in our prisons; didn’t they notice how shambolic and dangerous fire safety in their prison was becoming?

Obviously not – you can see for yourself (highlighted in red throughout the text below) how often CPFIG quote as the reason for the failures they identify to be: “Inadequate Monitoring”.

And when the prison was served with a Notice of Non-Compliance surely they would report this immediately to the Secretary of State – non-compliance with fire safety regulations is a serious issue, it means people’s lives are at risk; do we need another ‘Grenfell’?

Who are the IMB – and what do they do?

  • The Prison Act 1952 and the Immigration and Asylum Act 1999 require every prison to be monitored by an independent Board appointed by the Secretary of State from members of the community in which the prison is situated.
  • The Board, a statutory body, is specifically charged to:
  • satisfy itself as to the humane and just treatment of those held in custody within its prison and the range and adequacy of the programmes preparing them for release.
  • inform promptly the Secretary of State, or any official to whom he has delegated authority as it judges appropriate, any concern it has.
  • report annually to the Secretary of State on how well the prison has met the standards and requirements placed on it and what impact these have on those in its custody.
  • To enable the Board to carry out these duties effectively its members have right of access to every prisoner and every part of the prison and also to the prison’s records.

The question is do they do it – or is it a case of The Silence of the IMB Lambs?

Overview: Below I compare what the CPFIG prison fire safety inspections found during all their June 2016-June 2017 statutory fire safety inspections, with the contents of the annual reports over the last two years of each respective prison’s IMB.

What I discovered was shocking: ONLY ONE IMB (HMP Pentonville Page 15 of their report) out of all the prisons inspected by CPFIG in the last 12 months (all of which failed their fire safety inspections) reported the Service of the Notice of Non-Compliance and Enforcement to the Secretary of State – all the rest simply airbrushed them out of existence – failing to mention them at all in their annual reports, or in previous years failing to recognise the declining and dangerous fire safety standards right under their noses and which resulted later in legal notices of non-compliance and enforcement.

I also discovered that the IMB’s at two prisons that failed fire safety inspections in the last 12 months and are the subject of Non-Compliance Notices (HMPs Garth and Lewes) have not published an Annual Report since 2014 – and one, HMP Risley, also subject to a Non-Compliance Notice, its IMB hasn’t published an annual report since 2013.

 

HMP Bristol Non-Compliant Notice 

CPFIG Fire Inspection 21/22 June 2016. Non-Compliance Notice issued 13th July 2016. IMB Report for the prison to end of July 2016 makes no mention of either the CPFIG  Inspection, the Non-Compliance Notice nor a single one of the serious failures that CPFIG found.

The CPFIG HMP Bristol  Inspection found failures in: 

  • The fire risk assessment process used was not sufficiently systematic to ensure that all factors likely to place which could place prison staff, prisoners, contractors & visitors at risk.
  • The fire risk assessment did not sufficiently consider the actual conditions and events likely to occur and which could place prison staff, prisoners, contractors & visitors at risk.
  • The fire risk assessment did not consider every group of persons at especial risk of harm, and give them sufficient consideration.
  • The risk assessment had not identified all the measures which are required to achieve an acceptable level of risk for prison staff, prisoners, contractors & visitors.
  • The actions necessary to reduce the level of risk for prison staff, prisoners, contractors & visitors were not appropriately prioritised.
  • The action plan had not set an appropriate timescale to introduce the additional necessary fire safety measures to safeguard prison staff, prisoners, contractors & visitors.
  • The fire risk assessment had not identified the necessary interim measures to safeguard prison staff, prisoners, contractors & visitors.
  • The Personal Emergency Evacuation Plan (PEEPs) did not set out suitable and sufficient individual plans for the evacuation of people with disabilities.
  • PEEPs had not been reviewed when the individual’s evacuation needs had changed significantly.
  • The fire risk assessment has not been reviewed when required.
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The procedure is not always followed for removing cigarette lighters and matches from prisoners in Healthcare, Segregation or CSU who appear to be at increased risk of self-harming through fire.
  • Immediate Cause of Failure: No appropriate corrective measure was identified for action. Likely Underlying Safety Management Failure: The fire safety policy was over-ridden by other policy or instructions.
  • Ignition sources were found too close to combustible materials.
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate. Likely Underlying Safety Management Failure: The fire safety policy was not followed.
  • The ventilation ductwork shared by cells does not provide the necessary protection against the spread of fire and fire gases from cell to cell.
  • Immediate Cause of Failure: The fire risk assessment did not identify the significance of the risk. Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The existing smoke control arrangements for enclosed landings I areas of corridor approach are inadequate to prevent smoke spread to other cells in the event of a cell fire.
  • Immediate Cause of Failure: The identified action point was not implemented. Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • The number of trained prison response staff members available was not always sufficient to implement the cell fire response plan effectively.
  • Immediate Cause of Failure: The identified action point was not implemented. Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.
  • There were insufficient contingency staff during night state to undertake the evacuation of other cells
  • Immediate Cause of Failure: No appropriate corrective measure was identified for action. Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.
  • Corridor approach areas contained an excessive level of combustible material.
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate. Likely Underlying Safety Management Failure: The fire safety policy was not followed.
  • Emergency doors were secured in a manner which prevents them from being easily and immediately opened by any person who may require to use them in an emergency.
  • Immediate Cause of Failure: The fire risk assessment did not identify the significance of the risk Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The smoke control arrangements did not ensure that the conditions outside the cell door would remain tenable for prison staff to undertake the cell fire response plan.
  • Immediate Cause of Failure: The identified action point was not implemented Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • The arrangements did not ensure that lock-back doors would be released in the event of fire.
  • Immediate Cause of Failure: The fire risk assessment did not identify the significance of the risk. Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The fire loading in the atria appeared to exceed the design size of fire for the smoke control system installed.
  • Immediate Cause of Failure: The identified action point was not implemented Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • Fire hazard rooms were not suitably enclosed with fire-resistance.
  • Immediate Cause of Failure: The identified action point was not implemented. Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions.
  • Evacuation routes were not sufficiently protected against the ingress of fire and smoke.
  • Immediate Cause of Failure: The identified action point was not implemented. Likely Underlying Safety Management Failure:There were inadequate arrangements for the maintenance of general fire precautions.
  • The emergency routes and exits were not fitted with emergency lighting of sufficient intensity.
  • Immediate Cause of Failure: The identified action point was not implemented. Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • There was insufficient water misting equipment.
  • Immediate Cause of Failure: The identified action point was not implemented. Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon
  • Insufficient information was available to evidence compliance in respect of the following matters:
  • There was insufficient evidence available to demonstrate that water misting will effectively deal with a cell fire in cells which is of a large, 4 person, dormitory design with high ceilings. The cell fire response plan did not sufficiently safeguard prison staff or prisoners because it does not take into account the increasing potential for injury from fire and toxic smoke as time elapses. [CELL FIRE DETECTION IN PLACE]
  • Immediate Cause of Failure: No appropriate corrective measure was identified for action. Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The cell fire response plan does not sufficiently take into account the limited number of trained prison staff members who will be available during night state.
  • Immediate Cause of Failure: The identified action point was not implemented. Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.
  • The fire-fighting plan is not time- based. [FITTED WATER MIST]
  • Likely Immediate Cause of Failure: No appropriate corrective measure was identified for action. Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors
  • There is no plan to use water mist equipment as soon as possible in every case, and always within six minutes of the fire starting. [NO FITTED WATER MIST]
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate. Likely Underlying Safety Management Failure:
  • The arrangements do not ensure that nominated persons receive suitable and sufficient training for them to carry out the fire action plan successfully and safely.
  • An insufficient number of prison staff members working in residential wings are currently in-date with their training in RPE wearing, using inundation equipment and carrying out the cell fire response plan.
  • An insufficient number of prison staff members working in residential wings during night state are currently in-date with their training in RPE wearing, using inundation equipment and carrying out the cell fire response plan.
  • Immediate Cause of Failure: Corrective works are under way, but not completed. Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.
  • The responsible person has not ensured that the premises and any facilities, equipment and devices are subject to a suitable system of maintenance.
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate. Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions.
  • There was insufficient testing and maintenance arrangements in place for the cell call system.
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate. Likely Underlying Safety Management Failure: Inadequate monitoring is undertaken to establish whether the fire safety arrangements are successful.
  • There was insufficient evidence available to demonstrate that the fire safety measures being tested and maintained by outside contractors were in good condition and effective working order. The responsible person has not implemented the general fire precautions set out in the action plan. Suitable contacts have not been made with emergency services in relation to arrangements for fire-fighting and rescue work. Suitable proactive monitoring is not done to confirm that key risks from fire are controlled and performance standards are achieved in practice. The fire safety policy does not avoid conflict between fire safety requirements and other organisational policies and business needs.

Question: Why did the Bristol IMB conceal these identified statutory fire safety failures from the Secretary of State in their Annual Report which covered precisely this time period – or report them immediately to the Secretary of State as matters of concern when the Non-Compliance Notice was issued?

 

HMP Coldingley Non-Compliant 28 day letter.

CPFIG Fire Inspection 29/30 March 2017. Non-Compliance Notice issued 10th April 2017 The IMB have yet to publish an annual report covering this period. But the CPFIG identified failures appear to have been long-standing, clear and gross – and none of these issues appear in their previous report.

The CPFIG Inspection found failures in: 

  • The procedure is not always followed for removing cigarette lighters and matches from prisoners in Segregation who appear to be at increased risk of self-harming through fire.
  • Immediate Cause of Failure: The fire risk assessor did not identify the significance of the risk. Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systemic process in place for identifying all relevant factors.
  • Normal and/or emergency lighting doesn’t provide sufficient illumination to implement the Cell Fire Response plan including the removal of a prisoner from the cell.
  • Immediate Cause of Failure: The fire risk assessor did not identify the hazard. Likely Underlying Safety Management Failure.The arrangements in place for carrying out fire risk assessments do not ensure that the level of risk is judged through comparison with relevant and accredited benchmarks of safety.
  • The measures to reduce the spread of fire and smoke were inadequate.
  • Immediate Cause of Failure:  The identified action point was not implemented.  Likely Underlying Safety Management Failure. There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • There was insufficient evidence available to demonstrate the effectiveness of the smoke control arrangements for E wing after it was confirmed to have extraction only.
  • Immediate Cause of Failure: The risk had not been correctly assessed. Likely Underlying Safety Management Failure. The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The generic cell fire response plan was not suitable for the circumstances in which prisoners are not locked in their cells (night san).
  • Immediate Cause of Failure: The fire risk assessor did not identify the opportunity to reduce risk. Likely Underlying Safety Management Failure: The arrangements in place for carrying out fire risk assessments do not ensure that the level of risk is judged through comparison with relevant and accredited benchmarks of safety.
  • The training package delivered to staff does not provide sufficient practical instruction on the use of Inundation equipment.
  • Immediate Cause of Failure: No suitable measure was in place. Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.
  • An insufficient number of prison staff members working in residential wings are in date with their training in RPE wearing:
  • The number of trained prison response staff members available was not always sufficient to implement the cell fire response plan effectively
  • Immediate Cause of Failure: The identified action point was not implemented. Likely Underlying Safety Management Failure: The fire safety policy was not followed.
  • The fire safety measures were not always being tested and maintained in good condition and effective working order
  • Immediate Cause of Failure: No suitable measure was in place. Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions.

Why did the Coldingley IMB not identify these obvious, clear, gross and long-standing statutory fire safety failures and immediately report them as ‘matters of Concern’ to the Secretary of State as their legal powers require them to do so once the Statutory Non-Compliance Notice was served on the prison?

 

HMP Featherstone Non-Compliant 28 day letter

CPFIG Fire Inspection 31st August 2016. Non-Compliance Notice issued 12th September 2016. IMB Report for the prison to end of October 2016 makes no mention of either the CPFIG  Inspection, the Non-Compliance Notice nor a single one of the serious failures that CPFIG found.

The CPFIG HMP Featherstone Inspection found failures in: 

  • The fire risk assessment process used was not sufficiently systematic to ensure that all factors likely to place relevant persons at risk were considered :
  • The fire risk assessment did not sufficiently consider the actual conditions and events likely to occur and which could place relevant persons at risk :
  • The fire risk assessment did not consider every group of persons at especial risk of harm, and give them sufficient consideration :
  • The actions necessary to reduce the level of risk for relevant persons were not appropriately prioritised
  • The action plan had not set an appropriate timescale to introduce the additional necessary fire safety measures to safeguard all relevant persons:
  • The fire risk assessment had not identified the necessary interim measures to safeguard all relevant persons:
  • Likely Underlying Safety Management Failure:
  • The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The induction programme does not include sufficient information about the consequences of fire-setting to deter prisoners.
  • Prisoners with a history of fire-setting and those at known risk of self-harm through fire are not located in cells where they are most appropriately safeguarded from fire:
  • Immediate Cause of Failure: The fire risk assessment did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • Periodic inspection and testing of the mains electrical installations and portable appliances have not been carried out.
  • Immediate Cause of Failure: Contractor had not carried out the remedial works
  • Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions.
  • There was insufficient evidence available to demonstrate that the ventilation ductwork shared by cells provides the necessary protection against the spread of fire and fire gases from cell to cell.
  • There was insufficient evidence available to demonstrate that the existing smoke control arrangements for areas of corridor approach are adequate to prevent smoke spread to other cells in the event of a cell fire. The number of trained prison response staff members available was not always sufficient to implement the cell fire response plan effectively.
  • Immediate Cause of Failure: The fire risk assessment did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: Inadequate monitoring is undertaken to establish whether the fire safety arrangements are successful.
  • There was insufficient evidence available to demonstrate that there was an adequate number of contingency staff during night state to undertake the evacuation of other cells Corridor approach areas contained an excessive level of combustible material.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • The smoke control arrangements did not ensure that the conditions outside the cell door would remain tenable for prison staff to undertake the cell fire response plane.
  • Immediate Cause of Failure: No appropriate corrective measure was identified for action
  • Likely Underlying Safety Management Failure: There are inadequate arrangements for the fire risk assessment findings to be taken into account when decisions are taken, which may affect fire safety matters.
  • Fire hazard rooms were not suitably enclosed with fire-resistance.
  • Evacuation routes were not sufficiently protected against the ingress of fire and smoke.
  • The arrangements did not ensure that lock-back doors would be released in the event of fire
  • Immediate Cause of Failure: The fire risk assessment did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: The fire precautions were not benchmarked against an accredited approach.
  • There was insufficient evidence available to demonstrate that emergency routes and exits were fitted with emergency lighting of sufficient intensity
  • The ancillary equipment required for firefighting (e.g. Inundation port keys) was not held at a suitable location
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate.
  • Likely Underlying Safety Management Failure: Inadequate monitoring is undertaken to establish whether the fire safety arrangements are successful.
  • The coverage of cells by automatic fire detection was insufficient to control the risk to an acceptable level.
  • Immediate Cause of Failure: Corrective works are under way, but not completed
  • The absence of fitted automatic fire detection protection for cells was not sufficiently mitigated through the use of interim measure fire detectors.
  • Immediate Cause of Failure: The identified action point was not implemented Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • Insufficient measures are in place to prevent prisoners from interfering with or attempting to defeat the detection system prior to setting a fire.
  • Immediate Cause of Failure: The fire risk assessment did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: Inadequate monitoring is undertaken to establish whether the fire safety arrangements are successful.
  • The cell fire response plan does not ensure that the actions of prison staff are sufficiently prioritised towards safeguarding those at greatest risk, in the fire cell.
  • The generic cell fire response plan was not suitable for the circumstances in which prisoners are not locked in cells and will be best safeguarded through an evacuation of the building
  • The fire-fighting plan is not time-based.
  • Immediate Cause of Failure: The fire risk assessment did not identify the opportunity to reduce risk Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • There was insufficient evidence available to demonstrate that the cell fire response plan sufficiently safeguarded prison staff or prisoners, as there are no suitable arrangements for prison staff to be alerted to the need to implement the plan.
  • The initial training for prison staff members does not provide sufficient practical instruction on the use of the inundation equipment and cell fire response procedures (including the bespoke fire detection systems installed).
  • Immediate Cause of Failure: The fire risk assessment did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure The arrangements do not ensure that nominated persons receive suitable and sufficient training for them to carry out the fire action plan successfully and safely.
  • An insufficient number of prison staff members working in residential wings are currently in-date with their training in RPE wearing, using inundation equipment and carrying out the cell fire response plan.
  • An insufficient number of prison staff members working in residential wings during night state are currently in-date with their training in RPE wearing, using inundation equipment and carrying out the cell fire response plan.
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate.
  • Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.
  • Prison staff members working in residential wings have not received sufficient training on the fire detection system to be able to carry out meaningful checks on whether it has been tampered with and whether an attempt has been made to defeat it.
  • Immediate Cause of Failure: The fire risk assessment did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: Inadequate monitoring is undertaken to establish whether the fire safety arrangements are successful.
  • The responsible person has not ensured that the premises and any facilities, equipment and devices are subject to a suitable system of maintenance.
  • Immediate Cause of Failure: The fire risk assessment did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions.
  • The responsible person has not established suitable co-operation and co-ordination with other responsible persons.
  • The responsible person has not implemented the general fire precautions set out in the action plan
  • Suitable proactive monitoring is not done to confirm that key risks from fire are controlled and performance standards are achieved in practice
  • The fire safety policy does not avoid conflict between fire safety requirements and other organisational policies and business needs.

Question: Why did the Featherstone IMB conceal these identified statutory fire safety failures from the Secretary of State in their Annual Report which covered precisely this time period – or report them immediately to the Secretary of State as matters of concern when the Non-Compliance Notice was issued – and why didn’t they report to the Secretary of State in April 2017 when CPFIG was forced to issue an Enforcement Notice because its earlier Non-Compliance Notice had been ignored?

 

HMP Garth Non-Compliant Audit Response

CPFIG Fire Inspection 7/8 March 2017. Non-Compliance Notice issued 20th March 2017 The Garth IMB have not published an annual report for 2015/2016 or 2016/2017. 

The CPFIG HMP Garth Inspection found failures in: 

  • Whilst the coverage of cells by automatic fire detection was generally sufficient, the absence of instructions to carry out checks for tampering reduces the opportunity to provide effective early warning of fire and control the risk to an acceptable level.
  • Immediate Cause of Failure: No suitable measure was in place.
  • Likely Underlying Safety Management. Failure: There are inadequate arrangements to ensure that fire precautions are implemented.
  • There was sufficient fire-fighting equipment, but the level of ancillary equipment was not sufficient to be always able to carry out the cell fire response plan safely and effectively.
  • Immediate Cause of Failure: The fire risk assessor did not identify the significance of the risk.
  • Likely Underlying Safety Management Failure: The arrangements in place for carrying out fire risk assessments do not ensure that the level of risk is judged through comparison with relevant and accredited benchmarks of safety.
  • Measures to reduce the spread of fire and smoke were sometimes inadequate.
  • Immediate Cause of Failure: The risk had not been correctly assessed.
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • There was insufficient evidence available to demonstrate that the normal and emergency lighting provides sufficient illumination to safeguard prisoners and prison staff. There was insufficient evidence available to demonstrate the effectiveness of the smoke control arrangements due to the installation of pinpoint security grilles placed on inlet vents
  • The cell fire SSoW response plan is time based, but has not been fully tested.
  • Immediate Cause of Failure: The risk had not been correctly assessed.
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • Staff do not receive training on checks for tampering with the fire detection systems.
  • Immediate Cause of Failure: No suitable measure was in place.
  • Likely Underlying Safety Management Failure: Arrangements for the day-to-day management of fire safety were inadequate.
  • An insufficient number of prison staff members working in residential wings are in date with their training in RPE wearing, using inundation equipment and carrying out the cell fire response plan.
  • Immediate Cause of Failure: The identified action point was not implemented.
  • Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.
  • The number of trained prison wing staff available may NOT always sufficient to implement the cell fire response plan effectively.
  • Immediate Cause of Failure: The risk had not been correctly assessed.
  • Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.
  • There may be insufficient contingency staff during night state to support wing staff with the cell fire response SSoW or to undertake the evacuation of other cells.
  • Immediate Cause of Failure: The fire risk assessor did not identify the significance of the risk.
  • Likely Underlying Safety Management Failure: The fire precautions were not benchmarked against an accredited approach.
  • There was insufficient evidence available to demonstrate that the fire safety measures are always being tested and maintained in good condition and effective working order.
  • Immediate Cause of Failure: Contractor had not carried out the remedial works.
  • Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions.

Question: Why have the HMP Garth IMB not published an Annual Report for 2015/2016 or 2016/2017 to the Secretary of State? 

 

HMP Gartree Non-Compliant 28 Day Letter

CPFIG Fire Inspection 16th January 2017. Non-Compliance Notice issued 23rd January 2017. IMB Report for the prison to end of December 2016 at section 7.6 states “Within the establishment staff training days are organised and where spaces are available Board members are attend session run by prison staff on matters such as IT, personal safety, and security and fire safety. All of these training opportunities are important in allowing the Board to assess and develop its work and effectiveness. An annual Board ‘away day’ also allows the Board to discuss and agree priorities for future visits / Rota visits and Areas for review.” However nowhere in its report does it identify the issues raised by CPFIG in their later Non-Compliance notice – some of which according to CPFIG date back to 2013.

The CPFIG HMP Gartree Inspection found failures in: 

  • The sanctions’ system is not used to deter prisoners from interfering with fire detectors.
  • The induction programme does not include sufficient information about the consequences of tampering with fire detectors.
  • Prisoners with a history of fire-setting and those at known risk of self-harm through fire are NOT located in cells where they are most appropriately safeguarded from fire:
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • Normal and/or emergency lighting doesn’t provide sufficient illumination to safeguard prisoners and prison staff.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The fire safety policy was not followed.
  • Measures to reduce the spread of fire and smoke were inadequate.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The existing smoke control arrangements for enclosed landings / areas of corridor approach are inadequate to prevent smoke spread to other cells in the event of a cell fire i.e. all areas of corridor approach with the exception of <Redacted>Wings.
  • Immediate Cause of Failure: The action plan did not set out a timescale for implementing corrective measures which was appropriate to the seriousness of the risk.
  • Likely Underlying Safety Management Failure: The arrangements in place for carrying out fire risk assessments do not ensure that the level of risk is judged through comparison with relevant and accredited benchmarks of safety.
  • The smoke control system, when tested, did not appear to move air sufficiently to effectively clear smoke from the corridors on <redacted>wings in the event of a cell fire.
  • The firefighting plan is not time based
  • There is no a plan to use water mist equipment as soon as possible in every case, and always within every case within 5 minutes.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The responsible person has not ensured that the premises and any facilities, equipment and devices are subject to a suitable system of maintenance. E.g. remedial works to failures identified during the 2013 fixed wiring test; lack of information on fire doors.
  • Immediate Cause of Failure: Contractor had not carried out the remedial works
  • Likely Underlying Safety Management Failure: Inadequate maintenance arrangements

Why did the Gartree IMB, who claim in their 2016 annual report (7.6) to attend meetings onn among other things ‘fire safety’ not identify that failures raised by CPFIG in 2013 had still not bee corrected? And why at these meetings did they not identify the obvious, clear, gross and long-standing statutory fire safety failures identified 12 weeks later in the CPFIG Non-Compliance Notice and report them as matters of Concern to the Secretary of State?

 

HMP Hewell Non-Compliant Report

CPFIG Fire Inspection 2/3 June 2016. Non-Compliance Notice issued 14th June 2016. IMB Report for the prison to end of September 2016 makes no mention of either the CPFIG  Inspection, the Non-Compliance Notice nor a single one of the serious failures that CPFIG found.

The CPFIG HMP Hewell Inspection found failures in: 

  • The risk assessment had not identified all the measures which are required to achieve an acceptable level of risk for prisoners and staff: E.g. Limited duration of stored pressure water misting equipment.
  • The action plan had not set an appropriate timescale to introduce the additional necessary fire safety measures to safeguard prisoners and staff: E.g. Date for fitted automatic fire detection system
  • The induction programme does not include sufficient information about the consequences of fire-setting to deter prisoners.
  • Persons at Risk: Staff and Prisoners
  • Prisoners with a history of fire-setting and those at known risk of self-harm through fire are NOT always located in cells where they are most appropriately safeguarded from fire:
  • Persons at Risk: Staff and Prisoners
  • Remedial works identified from the periodic inspection and testing of the mains electrical installations has not been carried out.
  • Persons at Risk: Staff and Prisoners
  • The existing smoke control arrangements for the area of corridor approach are inadequate to prevent smoke spread to other cells in the event of a cell fire.
  • Persons at Risk: Prisoners
  • The smoke control arrangements did not ensure that the conditions outside the cell door would remain tenable for prison staff to undertake the cell fire response plan: <redacted>.
  • Fire hazard rooms were not suitably enclosed with fire-resistance: <redacted>
  • Evacuation routes were not sufficiently protected against the ingress of fire and smoke: E.g. fire-resisting door sets in residential wings.
  • There was insufficient water misting equipment.
  • The cell fire response plan did not sufficiently safeguard prison staff or prisoners because it does not take into account the increasing potential for injury from fire and toxic smoke as time elapses.
  • The cell fire response plan does not ensure that the actions of prison staff are sufficiently prioritised towards safeguarding those at greatest risk, in the fire cell.
  • The responsible person has not ensured that the premises and any facilities, equipment and devices are subject to a suitable system of maintenance:
  • No procedure was in place for monitoring that the response times to Cell Call activations are compatible with the timescales required by the cell fire response plan.
  • The responsible person has NOT established suitable co-operation and co-ordination with other responsible persons.
  • The fire safety policy does NOT avoid conflict between fire safety requirements and other organisational policies and business needs: E.g Suitable fire-fighting equipment

 

HMP Kirkham Non-Compliant Report

CPFIG Fire Inspection 28/29 September 2016. Non-Compliance Notice issued 25th October 2016. IMB Report for the prison to end of December 2016 makes no mention of either the CPFIG  Inspection, the Non-Compliance Notice nor a single one of the serious failures that CPFIG found.

The CPFIG HMP Kirkham Inspection found failures in: 

  • The Fire Risk Assessment did not correctly evaluate the likelihood and severity of the harm that could be caused
  • The fire risk assessment process used was not sufficiently systematic to ensure that all factors likely to place at risk were considered :
  • The fire risk assessment did not sufficiently consider the actual conditions and events likely to occur and which could place at risk
  • The fire risk assessment did not consider every group of persons at especial risk of harm, and give them sufficient consideration :
  • The risk assessment had not identified all the measures which are required to achieve an acceptable level of risk for
  • The actions necessary to reduce the level of risk for were not appropriately prioritised
  • The action plan had not set an appropriate timescale to introduce the additional necessary fire safety measures to safeguard
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • There are inadequate sanctions to deter prisoners from setting fires or interfering with fire detectors.
  • The induction programme does not include sufficient information about the consequences of fire-setting to deter prisoners.
  • Immediate Cause of Failure: The fire risk assessor did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: The fire safety policy did not direct compliance in this matter
  • The existing smoke control arrangements for enclosed landings / areas of corridor approach are inadequate to prevent smoke spread to other bedrooms in the event of a bedroom fire.
  • The precautions to reduce risk from the spread of fire are inadequate.
  • Immediate Cause of Failure: The fire risk assessor did not identify the hazard
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • There was insufficient evidence available to demonstrate that ventilation ductwork shared by bedrooms provides the necessary protection against the spread of fire and fire gases from bedroom to bedroom. The number of trained prison response staff members available was not always sufficient to implement the fire response plan effectively.
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate.
  • Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.
  • The means of escape provided (e.g. corridors, stairways or other escape routes) did not adequately safeguard the safety of relevant persons.
  • Immediate Cause of Failure: The identified action point was not implemented
  • Likely Underlying Safety Management Failure: There was inadequate co-operation between responsible persons.
  • In the event of danger, it was not possible for persons to evacuate the premises as quickly and as safely as possible;
  • Immediate Cause of Failure: The identified action point was not implemented
  • Likely Underlying Safety Management Failure: There was inadequate co-operation between responsible persons.
  • Emergency doors were secured in a manner which prevents them from being easily and immediately opened by any person who may require to use them in an emergency.
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate
  • Likely Underlying Safety Management Failure: There was inadequate co-operation between responsible persons.
  • Fire hazard rooms were not suitably enclosed with fire-resistance.
  • Immediate Cause of Failure: The fire risk assessor did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The fire fighting plan did not safeguard staff members “so far as is reasonably practicable”
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate.
  • Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient persons are appointed to carry out competent fire safety roles effectively.
  • The coverage of bedrooms by automatic fire detection was insufficient to control the risk to an acceptable level.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented.
  • Likely Underlying Safety Management Failure: There are inadequate arrangements for the fire risk assessment findings to be taken into account when decisions are taken, which may affect fire safety matters.
  • Insufficient measures are in place to prevent offenders from interfering with or attempting to defeat the detection system prior to setting a fire.
  • Immediate Cause of Failure: The fire risk assessor did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The fire response plan was not appropriate for the nature of the hazard / number of nominated persons who will be available / use of the premises / size of the premises / number of people who may be present / people who are especially at risk.
  • Immediate Cause of Failure: The fire risk assessor did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The actions set out in individual PEEPs have not been included in the premises’ fire response plan.
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate.
  • Likely Underlying Safety Management Failure The arrangements do not ensure that nominated persons receive suitable and sufficient training for them to carry out the fire action plan successfully and safely.
  • The number of people nominated to roles in the fire response plan was insufficient for the requirements of the plan.
  • The fire response plans for employees, other persons, and those at special risk had not been adequately tested.
  • Immediate Cause of Failure: The risk assessor did not identify the significance of the risk.
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • There were no arrangements for people who had been exposed to serious and imminent danger to receive adequate information about the nature of the hazard and the general fire precautions in place to protect them from it;
  • Immediate Cause of Failure: No appropriate interim measure was identified for action
  • Likely Underlying Safety Management Failure: Employees are given inadequate safety information.
  • Prison staff members working in residential wings have not received sufficient training on the fire detection system to be able to carry out meaningful checks on whether it has been tampered with and whether an attempt has been made to defeat it.
  • Prison staff members working on residential wings have not received practical training in the use of portable fire-fighting equipment (such as extinguishers and fire blankets, where they are required to undertake roles that form part of the fire response plan and to aid evacuation
  • Prison staff had not received adequate training to carry out the fire response plan effectively and safely.
  • Immediate Cause of Failure: Day-to-day management of the fire safety arrangements was inadequate.
  • Likely Underlying Safety Management Failure: Employees are given inadequate safety information.
  • The responsible person has not ensured that the premises and any facilities, equipment and devices are subject to a suitable system of maintenance.
  • Immediate Cause of Failure: Contractor had not informed the occupier that the general fire precaution was not in effective working order
  • Likely Underlying Safety Management Failure: There was inadequate co-operation between responsible persons.
  • The responsible person has NOT established suitable co-operation and co-ordination with other responsible persons.
  • The responsible person has NOT implemented the general fire precautions set out in the action plan.
  • Suitable proactive monitoring is NOT done to confirm that key risks from fire are controlled and performance standards are achieved in practice

Question: Why did the Kirkham IMB conceal these identified statutory fire safety failures from the Secretary of State in their Annual Report which covered precisely this time period – or report them immediately to the Secretary of State as matters of concern when the Non-Compliance Notice was issued?

 

HMP Lewes Non-Compliant Notice

CPFIG Fire Inspection 11/12 January 2017. Non-Compliance Notice issued 25th January 2017. IMB Report for the prison to end of January 2017 makes no mention of either the CPFIG  Inspection, the Non-Compliance Notice nor a single one of the serious failures that CPFIG found.

The CPFIG HMP Lewes Inspection found failures in: 

  • Prisoners are not presented with an appropriate range of purposeful information directed at deterring fire- setting and tampering with fire detectors.
  • Immediate Cause of Failure: No suitable measure was in place
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • Prisoners with a history of fire- setting and those at known risk of self- harm through fire are not located in cells where they are most appropriately safeguarded from fire:
  • Immediate Cause of Failure: No suitable measure was in place
  • Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • There was insufficient fire-fighting and ancillary equipment to effectively carry out the cell fire response plan.
  • Corrective works are under way, but not completed
  • Measures to reduce the spread of fire and smoke were inadequate.
  • Immediate Cause of Failure: The identified action point was not implemented
  • Likely Underlying Safety Management Failure: There are inadequate arrangements for the fire risk assessment findings to be taken into account when decisions are taken, which may affect fire safety matters.
  • Insufficient information was available to evidence compliance in respect of the following matters:
  • There was insufficient evidence available to confirm that the emergency lighting provides sufficient illumination to safeguard prisoners and prison staff.
  • There was insufficient evidence available to demonstrate control systems on Wings have been designed and support the fire strate for the building.
  • The cell fire response plan is not time based
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: The fire safety policy was not followed.
  • There is no plan to use water mist equipment as soon as possible in every case, and always within 5 minutes.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: The fire safety policy was not followed
  • The training package delivered to staff does not provide sufficient theoretical/practical instruction on the cell fire response procedures and the fire detection systems.
  • Immediate Cause of Failure: The identified action point was not implemented
  • Likely Underlying Safety Management Failure: The fire safety policy was not followed.
  • There was insufficient evidence available to demonstrate that the fire safety measures being tested and maintained were in good condition and effective working order
  • Immediate Cause of Failure: Contractor had not carried out the remedial works
  • Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions.

Question: Why did the Lewes IMB conceal these identified statutory fire safety failures from the Secretary of State in their Annual Report which covered precisely this time period – or report them immediately to the Secretary of State as matters of concern when the Non-Compliance Notice was issued?

 

HMP Lincoln Non-Compliant 28 DayLetter

CPFIG Fire Inspection 22/23 November 2016. Non-Compliance Notice issued 30th November 2016. IMB Report for the prison to end of January 2017 makes no mention of either the CPFIG  Inspection, the Non-Compliance Notice nor a single one of the serious failures that CPFIG found.

The CPFIG HMP Lincoln Inspection found failures in: 

  • There are inappropriate sanctions to deter prisoners from setting fires or interfering with fire detectors.
  • The induction programme does not include sufficient information about the consequences of fire-setting and the actions to be taken on discovering a fire
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: Arrangements for the day-to-day management of fire safety were inadequate
  • Prisoners with a history of fire-setting and those at known risk of self-harm through fire are not located in cells where they are most appropriately safeguarded from fire.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The fire safety policy did not direct compliance in this matter.
  • The coverage of cells by automatic fire detection was insufficient to provide early warning of fire and control the risk to an acceptable level.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: Arrangements for the day-to-day management of fire safety were inadequate
  • There was insufficient fire-fighting and ancillary equipment to effectively carry out the cell fire response plan.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • Normal and/or emergency lighting doesn’t provide sufficient illumination to safeguard prisoners and prison staff.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The fire safety policy was not followed.
  • Measures to reduce the spread of fire and smoke were inadequate.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors
  • There was insufficient evidence available to demonstrate that the existing smoke control arrangements for CSU are adequate to prevent smoke spread to other cells in the event of a cell fire.
  • The fire fighting plan is not time based
  • There is no a plan to use water mist equipment as soon as possible in every case, and always within every case within 5 minutes.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The training package delivered to staff does not provide sufficient practical instruction on the use of Inundation equipment

Question: Why did the Lincoln IMB conceal these identified statutory fire safety failures from the Secretary of State in their Annual Report which covered precisely this time period – or report them immediately to the Secretary of State as matters of concern when the Non-Compliance Notice was issued?

 

HMP Lindholme Non-Compliant

CPFIG Fire Inspection 16/17 May 2017. Non-Compliance Notice issued 6th June 2017. IMB Report for the prison to end of January 2017 makes no mention of either the CPFIG  Inspection, the Non-Compliance Notice nor a single one of the serious failures that CPFIG found during their inspection less than a week after the annual report was completed.

The CPFIG HMP Lindholme Inspection found failures in: 

  • Measures to reduce the spread of fire and smoke were inadequate.
  • Immediate Cause of Failure: The proposed action point was not suitable or sufficient.
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors
  • There was insufficient evidence available to demonstrate that the normal and emergency lighting provides sufficient illumination to safeguard prisoners and prison staff
  • The cell fire plan is not time based
  • The generic cell fire response plan was not suitable for the circumstances in which prisoners are not locked in their cells
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • There was insufficient evidence available to demonstrate that the fire safety measures being tested and maintained were in good condition and effective working order
  • Immediate Cause of Failure: Contractor had not carried out the remedial works
  • Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions

Question: Why did the Lindholme IMB fail to identify throughout the reporting year any of the serious statutory fire safety failures that CFIG identified a week after the end of the reporting year? 

 

HMP Lowdham Grange Non-Compliant Notice

CPFIG Fire Inspection 16/17 May 2017. Non-Compliance Notice issued 6th June 2017. IMB Report for the prison to end of January 2017 failed to identify through the reporting year any of the serious  fire safety defects that CPFIG found and which resulted five months later in a Non-Compliance Notice.

The CPFIG HMP Lowdham Grange Inspection found failures in: 

  • Prisoners with a history of fire-setting and those at known risk of self-harm through fire are not located in cells where they are most appropriately safeguarded from fire:
  • Immediate Cause of Failure: The fire risk assessor did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • Inadequate provisions are not in place to ensure ignition sources are kept separate from combustible materials.
  • Immediate Cause of Failure: The fire risk assessor did not identify the significance of the risk
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The coverage of cells by automatic fire detection was insufficient to provide effective early warning of fire and control the risk to an acceptable level.
  • Immediate Cause of Failure: The identified action point was not implemented
  • Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • Measures to reduce the spread of fire and smoke were inadequate.
  • Immediate Cause of Failure: No suitable measure was in place
  • Likely Underlying Safety Management Failure: Arrangements for the day-to-day management of fire safety were inadequate.
  • The existing smoke control arrangements for areas of corridor approach are inadequate to prevent smoke spread to other cells in the event of a cell fire.
  • Immediate Cause of Failure: No suitable measure was in place
  • Likely Underlying Safety Management Failure: The arrangements in place for carrying out fire risk assessments do not ensure that the level of risk is judged through comparison with relevant and accredited benchmarks of safety
  • There was insufficient evidence available to demonstrate that emergency lighting provides sufficient illumination to safeguard prisoners and prison staff.
  • The cell fire response plan is not time based
  • Immediate Cause of Failure: No suitable measure was in place
  • Likely Underlying Safety Management Failure: Fire safety policy not followed.
  • An insufficient number of prison staff members working in residential wings are in date with their training in RPE wearing, using inundation equipment and carrying out the cell fire response plan.
  • Immediate Cause of Failure: The planned fire safety measure had been removed
  • Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry action plan successfully and safely.
  • The number of trained prison response staff members available was not always sufficient to implement the cell fire response plan effectively
  • Immediate Cause of Failure: No suitable measure was in place
  • Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely. out the fire action plan successfully and safely.
  • The number of trained prison response staff members available was not always sufficient to implement the cell fire response plan effectively
  • Immediate Cause of Failure: No suitable measure was in place
  • Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.

Question: Why did the Lowdham Grange IMB fail to identify throughout the reporting year any of the serious statutory fire safety failures that CFIG identified a few months after the end of the reporting year? 

 

HMP Moorland Non-Compliant Notice

CPFIG Fire Inspection 25/26 April 2017. Non-Compliance Notice issued 2nd May 2017. IMB Report for the prison to end of February 2017 failed to identify through the reporting year any of the serious  fire safety defects that CPFIG found and which resulted five months later in a Non-Compliance Notice.

The CPFIG HMP Moorland Inspection found failures in: 

  • Prisoners are not presented with an appropriate range of purposeful information directed at deterring fire-setting and tampering with fire detectors.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The coverage of cells by automatic fire detection was insufficient to provide effective early warning of fire and control the risk to an acceptable level.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: There are inadequate arrangements for the fire risk assessment findings to be taken into account when decisions are taken, which may affect fire safety matters.
  • There was insufficient fire-fighting equipment to effectively carry out the cell fire response plan.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • Emergency lighting doesn’t provide sufficient illumination to safeguard prisoners and prison staff.
  • Immediate Cause of Failure: The identified action point was not implemented
  • Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • The existing smoke control arrangements for areas of corridor approach are inadequate to prevent smoke spread to other cells in the event of a cell fire
  • Immediate Cause of Failure: No suitable measure was in place
  • Likely Underlying Safety Management Failure: There are inadequate arrangements for the fire risk assessment findings to be taken into account when decisions are taken, which may affect fire safety matters.

Question: Why did the Moorland IMB fail to identify throughout the reporting year any of the serious statutory fire safety failures that CFIG identified a few months after the end of the reporting year? 

 

HMP Northumberland Non-Compliant Report

CPFIG Fire Inspection 14/15 June 2017. Non-Compliance Notice issued s2nd June 2017. IMB Report for the prison to end of December 2016 – published 21st June 2017 – failed to identify through the reporting year any of the serious  fire safety defects that CPFIG found and which resulted just months later in a Non-Compliance Notice.

The CPFIG HMP Northumberland Inspection found failures in: 

  • Prisoners were not presented with a sufficient range of purposeful information directed at preventing prisoners from fire-setting.
  • Immediate Cause of Failure: No suitable measure was in place.
  • Likely Underlying Safety Management Failure: Inadequate monitoring is undertaken to establish whether the fire safety arrangements are successful.
  • WARNING OF FIRE
  • a.i) Prisoners were not presented with effective information directed at preventing tampering with fire detectors.
  • Immediate Cause of Failure: The fire risk assessor did not identify the opportunity to reduce risk
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • RISK OF FIRE SPREAD
  • There were inadequate measures to control the risk of fire and smoke spreading within common areas.
  • Immediate Cause of Failure: No suitable measure was in place
  • Likely Underlying Safety Management Failure: Arrangements for the day-to-day management of fire safety were inadequate.
  • There was insufficient evidence available to demonstrate that emergency lighting provides sufficient illumination to safeguard prisoners and prison staff.
  • Effective procedures have not been established for staff to sustain a water misting attack for 20 minutes.
  • Immediate Cause of Failure: The fire risk assessor did not identify the significance of the risk
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors
  • The cell fire response plan was not time based
  • The calculated pre-release movement times (PRMT) have not been validated through a practical test.
  • Immediate Cause of Failure: No suitable measure was in place.
  • Likely Underlying Safety Management Failure: Arrangements for the day-to-day management of fire safety were inadequate.
  • The training delivered to staff provides insufficient practical instruction on the use of:
  • Inundation equipment or Cell fire response procedures
  • The wing staff would not always able to implement the cell fire response plan safely and effectively.
  • Intervention team staff were not always available during night state to support wing staff in dealing safely and effectively with cell fires, or to undertake the evacuation of other cells in the event that it became necessary.
  • Immediate Cause of Failure: No suitable measure was in place.
  • Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.  
  • The fire safety measures were not always being tested and maintained in good condition and effective working order.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: Inadequate maintenance arrangements

Question: Why did the Northumberland IMB fail to identify throughout the reporting year any of the serious statutory fire safety failures that CFIG identified a few months after the end of the reporting year? 

 

HMP Pentonville Enforcement Notice

CPFIG Fire Inspection 30th December 2016. Non-Compliance Notice issued 10th January 2017. IMB Report for the prison to end of March 2017 Is the only IMB to have rightly reported to the Secretary of State the CPFIG Enforcement Notice issued in December 2016. The Board reported:

[Page 15]: “On 30 December the Crown Premises Inspection Group (CPIG) issued enforcement notices against the Governor and Carillion because of a cell fire on one wing where the smoke detection system did not work. Two prisoners went to hospital and four staff members were sick from smoke inhalation. CPIG said this could have been avoided if Carillion had properly maintained the equipment. At briefings in March, staff were reminded of fire safety including reporting broken equipment, knowing fire evacuation procedures and understanding how to use equipment.”

Question: Why has no other IMB done this?

HMP Portland Non-Compliant Notice

CPFIG Fire Inspection 15/16 November 2016. Non-Compliance Notice issued 25th November 2016. IMB Report for the prison to end of March 2016 – published 21st June 2017 – failed to identify through the reporting year any of the serious  fire safety defects that CPFIG found and which resulted just months later in a Non-Compliance Notice.

The CPFIG HMP Portland Inspection found failures in: 

  • The coverage of cells by automatic fire detection was insufficient to provide early warning of fire and control the risk to an acceptable level.
  • Immediate Cause of Failure: Corrective works are under way, but not completed
  • There was insufficient fire-fighting and ancillary equipment to effectively carry out the cell fire response plan.
  • Immediate Cause of Failure: Corrective works are under way, but not completed
  • Normal and/or emergency lighting doesn’t provide sufficient illumination to safeguard prisoners and prison staff.
  • Immediate Cause of Failure: Corrective works are under way, but not completed
  • Measures to reduce the spread of fire and smoke were inadequate.
  • Immediate Cause of Failure: No appropriate corrective measure was identified for action
  • Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions.
  • The existing smoke control arrangements for enclosed landings / areas of corridor approach are inadequate to prevent smoke spread to other cells in the event of a cell fire
  • Immediate Cause of Failure: Corrective works are under way, but not completed
  • Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions.
  • There was insufficient evidence available to demonstrate that the fire safety measures being tested and maintained were in good condition and effective working order
  • Immediate Cause of Failure: Contractor had not carried out the remedial works
  • Likely Underlying Safety Management Failure: There were inadequate arrangements for the maintenance of general fire precautions.

Question: Why did the Portland IMB fail to identify throughout the reporting year any of the serious statutory fire safety failures that CFIG identified a few months after the end of the reporting year? 

 

HMP Risley Non-Compliant Notice

CPFIG Fire Inspection 18/19 May 2017. Non-Compliance Notice issued 31st May 2017. HMP Risley IMB have not published an annual report since 2013

The CPFIG HMP Risley Inspection found failures in: 

  • Prisoners with a history of fire-setting and those at known risk of self-harm through fire are NOT located in cells where they are most appropriately safeguarded from fire:
  • Immediate Cause of Failure: The fire risk assessor did not identify the hazard
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • The coverage of cells by automatic fire detection was insufficient to provide effective early warning of fire and control the risk to an acceptable level.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • There was insufficient fire-fighting to effectively carry out the cell fire response plan.
  • Immediate Cause of Failure: No appropriate corrective measure was identified for action.
  • The existing smoke control arrangements for areas of corridor approach are inadequate to prevent smoke spread to other cells in the event of a cell fire
  • Immediate Cause of Failure: No appropriate interim measure was implemented
  • Likely Underlying Safety Management Failure: Inadequate monitoring is undertaken to establish whether the fire safety arrangements are successful
  • There was insufficient evidence available to demonstrate that
  • the capital bid for fire safety measures throughout the residential accommodation areas in the prison will provide the level of fire safety required.
  • the fire safety improvement programme for <redacted> wings includes all the elements necessary to bring the risk from fire down to acceptable levels
  • the level of emergency light has not been assessed to demonstrate that it would be sufficient to implement the cell fire response SSoW, including if necessary, C&R and evacuation of prisoners and staff from of all or part of the wing affected by a fire.
  • The time based cell fire response plan is not validated and cannot be achieved where a sustained water misting attack is not possible.
  • There is no plan to use water mist equipment as soon as possible in every case, and always within 5 minutes.
  • Immediate Cause of Failure: The fire risk assessor did not identify the significance of the risk
  • Likely Underlying Safety Management Failure: The arrangements in place for carrying out fire risk assessments do not ensure that the level of risk is judged through comparison with relevant and accredited benchmarks of safety.
  • There was insufficient evidence available to demonstrate that the fire safety measures being tested and maintained were in good condition and effective working order
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: Inadequate arrangements for assessing contractor performance on the ground

Question: Why have the IMB at Risley not published an Annual Report since 2013?

 

HMP Rochester Enforcement Notice1  HMP Rochester Enforcement Notice2

CPFIG Fire Inspection 12/13 October 2016. Non-Compliance Notice issued 30th October 2016. IMB Report for the prison to end of March 2016  failed to identify through the reporting year any of the serious fire safety defects that CPFIG found and which resulted just months later in an Enforcement Notice – and later a second Enforcement Notice too.

The CPFIG HMP Rochester Inspection found failures in: 

  • The smoke control arrangements do not ensure that the conditions outside the cell door would remain tenable for prison staff to undertake the cell fire response plan: Fire resisting sub-compartment doors provided to ensure the effectiveness of the zonal mechanical smoke control systems and to protect escape routes, were not fitted with the appropriate self-closing devices, placing prison staff and prisoners at risk.
  • The cell fire response plan did not sufficiently safeguard prison staff or prisoners because it does not take into account the increasing potential for injury from fire and toxic smoke as time elapses, i.e. The cell fire SSoW was not time-based.
  • An insufficient number of prison staff members working in residential wings during night state are currently in-date with their training in RPE wearing, using inundation equipment and carrying out the cell fire response plan.
  • Prison staff have not undertaken suitable practical training drills to demonstrate their ability to maintain predicted tenability within the cell in the event of a fire.
  • The responsible person has not ensured that the fire detectors provided to safeguard prison staff and prisoners from fire are subject to a suitable system of maintenance so that prison staff can receive and act upon adequate early warning of fire in every cell in order to safeguard themselves and the prisoners whose safety lies within their responsibility.
  • The responsible person has not established suitable co-operation and co-ordination with other responsible persons.

Question: Why did the Rochester IMB fail to identify throughout the reporting year any of the serious statutory fire safety failures that CFIG identified a few months after the end of the reporting year – including that staff training was out of date? 

 

HMP Wealstun Non-Compliant 28 day letter

HMP Wealstun Enforcement Notice

HMP Wealstun Enforcement Notice2

HMP Wealstun Enforcement Notice3

CPFIG Fire Inspection 7/8 March 2017. Non-Compliance Notice issued 21st March 2017. IMB Report for the prison to end of December 2016 failed to identify through the reporting year any of the serious  fire safety defects that CPFIG found and which resulted just months later in a Non-Compliance Notice – and then three Enforcement Notices.

The CPFIG HMP Wealstun Inspection found failures in: 

  • Prisoners are not presented with an appropriate range of purposeful information directed at deterring fire-setting and tampering with fire detectors.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: Inadequate monitoring is undertaken to establish whether the fire safety arrangements are successful.
  • Prisoners with a history of fire-setting and those at known risk of self-harm through fire are not located in cells where they are most appropriately safeguarded from fire:
  • Immediate Cause of Failure: The fire risk assessor did not identify the significance of the risk
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • Normal and emergency lighting doesn’t provide sufficient illumination to safeguard prisoners and prison staff.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that the action points arising from the fire risk assessment are acted upon.
  • Measures to reduce the spread of fire and smoke were inadequate
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that fire precautions are implemented.
  • The existing smoke control arrangements for enclosed landings / areas of corridor approach are inadequate to prevent smoke spread to other cells in the event of a cell fire
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented
  • Likely Underlying Safety Management Failure: There are inadequate arrangements for the fire risk assessment findings to be taken into account when decisions are taken, which may affect fire safety matters.
  • The training package delivered to staff does not provide sufficient practical instruction on the use of Inundation equipment.
  • Immediate Cause of Failure: The risk had not been correctly assessed
  • Likely Underlying Safety Management Failure: The arrangements for carrying out fire risk assessments do not ensure that there is a systematic process in place for identifying all relevant factors.
  • An insufficient number of prison staff members working in residential wings are in date with their training in RPE wearing, using inundation equipment and carrying out the cell fire response plan.
  • Immediate Cause of Failure: The action plan did not set out a timescale for implementing corrective measures which was appropriate to the seriousness of the risk.
  • Likely Underlying Safety Management Failure: There are inadequate arrangements for the fire risk assessment findings to be taken into account when decisions are taken, which may affect fire safety matters.

Question: How can an IMB allow a situation to develop where in terms of fire safety the prison they are in place to monitor is served with a Non-Compliance Notice – and then three Enforcement Notices?

 

HMP Woodhill Non-Compliant NON-28 day Notice

CPFIG Fire Inspection 7/8 February 2017. Non-Compliance Notice issued 28th February 2017. IMB Report for the prison to end of May 2016 failed to identify through the reporting year any of the serious  fire safety defects that CPFIG found and which resulted just months later in a Non-Compliance Notice – and then three Enforcement Notices.

The CPFIG HMP Woodhill Inspection found failures in: 

  • The sanctions’ system is not used effectively to deter prisoners from setting fires.
  • Adequate provisions are not in place to ensure ignition sources are kept separate from combustible materials.
  • Immediate Cause of Failure: No suitable measure was in place.
  • Likely Underlying Safety Management Failure: Inadequate monitoring is undertaken to establish whether the fire safety arrangements are successful
  • The coverage of cells by automatic fire detection was insufficient to provide effective early warning of fire and control the risk to an acceptable level.
  • Normal and/or emergency lighting does not provide sufficient illumination to safeguard prisoners and prison staff.
  • Measures to reduce the spread of fire and smoke were inadequate.
  • The existing smoke control arrangements for enclosed landings / areas of corridor approach are inadequate to prevent smoke spread to other cells in the event of a cell fire.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented.
  • Likely Underlying Safety Management Failure: There are inadequate arrangements to ensure that fire precautions are implemented.
  • An insufficient number of prison staff members working in residential wings are in date with their training in RPE wearing.
  • Immediate Cause of Failure: The planned fire safety measure had not been implemented.
  • Likely Underlying Safety Management Failure: The arrangements do not ensure that sufficient trained persons are available when necessary to carry out the fire action plan successfully and safely.
  • There was insufficient evidence available to demonstrate that the fire safety measures being tested and maintained were in good condition and effective working order.
  • Insufficient testing and maintenance arrangements are in place for the cell call system.
  • Immediate Cause of Failure: Contractor had not identified the fault.
  • Likely Underlying Safety Management Failure: Inadequate arrangements for the effective reporting of faults and the actioning of repairs.

Question: Why did the Woodhill IMB fail to identify throughout the reporting year any of the serious statutory fire safety failures that CFIG later identified as legally non-compliant? 

 

Prison Service Instruction 11/2015 Fire Safety

Prison Service Instruction 07/2015 Induction

FOIA Response From CPFIG

Parliamentary Answer March 2017 on Fires in Prisons

Prison Fire Safety Inspections – Summary (Compiled by Niamh McIntyre)

CPFIG Fire Safety Expectations – Prisons

(c) Mark Leech, Prisons Org UK 2017

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