Prison understaffing and workload issues have been flagged in at least nine inquests into deaths in custody since the start of 2021, according to an Observer analysis of coroners’ reports. Issues raised include gaps in monitoring of prisoners due to understaffing, a lack of prison-based clinical staff and shortcomings in the keyworker programme. Coroners have also repeatedly identified problems with staff training and the assessment, care in custody and teamwork (ACCT) process for prisoners identified as being at risk of suicide or self-harm. The recent escape of terror suspect Daniel Khalife from HMP Wandsworth focused attention on the impact of austerity on the prison service. Government figures analysed by the Prison Reform Trust show there are 10% fewer frontline prison staff than in 2010, with high turnover limiting their experience. “The numbers of people dying in custody is deeply worrying,” said Andy Keen-Downs, chief executive of the Prison Advice and Care Trust. “There are a range of factors that are contributing to it, but there’s little doubt that problems with recruitment and retention are playing a major part. Many thousands of prison officers do amazing work every single day, but there aren’t enough of them and too many of them have relatively little experience in the job.” At a recent inquest into the suicide of a prisoner at HMP Swaleside in June 2022, a jury found his safety had been compromised by understaffing, with shortages of support staff and prison officers that are predicted to get worse. “Prison staff did not monitor [the prisoner’s] self-seclusion in line with local expectations. They said that this was a direct result of ongoing staff shortages at Swaleside,” said a case report by the prison ombudsman. “I am extremely concerned about ongoing staff shortages at Swaleside and how these affected the level of support and monitoring that [he] received.” The report added: “The governor told us that there were ongoing staff shortages, staff fatigue and said that high levels of sickness were affecting the prison’s regime.” Another case highlighted problems with the keyworker programme, which aims to improve safety by engaging with prisoners and building relations with staff. In a prevention of future deaths (PFD) report this year, a coroner warned: “Evidence was given that there has been limited success nationally since [the keyworker programme’s] roll out which was believed to be in 2016/2017 and one of the reasons for this is resourcing. “Evidence was given that at HMP Guys Marsh they struggle to deliver the keyworker programme and that it has not been delivered at the desired level for a long time. I have concerns therefore that the current system in place is not fit for purpose.” PFD reports are written to flag problems identified during inquests that could lead to future deaths. The issues they highlight did not necessarily cause the death that the inquest examined, and suicides can be caused by multiple and complex factors. But a report published this month by the government’s independent advisory panel on deaths in custody warned that the growing prison population had caused an “imbalance” in the staff-prisoner ratio. “Prisoners cannot be given the compassionate and person-centred support, which has been highlighted as key to preventing suicide, if staff are not themselves receiving support and supervision to relieve the pressures of their job,” the report said. Lack of clinical staffing is also an issue. A recent PFD report warned that the maximum security HMP Wakefield – which holds 750 men, many with serious mental health or addiction issues – had a consultant psychiatrist available only one day a week, although NHS England was reviewing this provision. “The majority of prisons are experiencing severe staffing pressures and our members within these prisons find it very difficult to cope,” said Mick Pimblett, assistant general secretary of the Prison Officers’ Association. “There are pressures to deliver [the daily prison] regime, which includes the basic requirements for prisoners. On top of this they are dealing with violent incidents on a daily basis and they often have to juggle priorities. “While no prison officer would willingly neglect any prisoner considered to be at risk, the operational pressures of the job sometimes mean that things are missed. “[The Prison Service] and the government are complicit in these tragic reports due to their austerity measures and cuts since 2010. As this union continually says: cuts have consequences.” Lucy McKay, spokesperson for the legal charity Inquest, said: “There is widespread evidence that prisons are consistently failing to keep people safe, with the sharpest end of this being preventable deaths. “Inquests expose indefensible levels of neglect and despair in prisons, with coroners highlighting issues of staffing, basic failures in care, and inability to enact suicide and self-harm monitoring procedures.” She said prisons were incapable of reform, and accused the main political parties of ignoring the evidence and refusing to invest in alternatives outside the criminal justice system. A Prison Service spokesperson said: “There is nothing to suggest a sudden, unusual rise in the number of self-inflicted deaths in custody. The number has been broadly consistent and under 100 between 1997 and 2022, with the exception of 2016.” “We want to see far fewer self-inflicted deaths and self-harm in custody which is why we have increased staff training on self-harm prevention, are working with the NHS to improve mental healthcare and fund the Samaritans. We already have 4,000 more officers than in March 2017 – while boosting their starting salaries to over £30,000 to attract and retain the best staff.”