Bradleigh Barnes

Director General Prisons 
HM Prison and Probation Service 
8th Floor Ministry of Justice 
102 Petty France 
London SW1H 9AJ 

20 December 2022 

Mrs Rachael C Griffin 
Senior Coroner for Dorset 
Bournemouth Town Hall  
Bournemouth 
BH2 6DY 

Dear Mrs Griffin, 

Thank you for your Regulation 28 report of 24 October 2022 addressed to 
Director General of Operations for HMPPS, and the Governor of HMP Portland following the 
inquest into the death of Bradleigh Barnes at HMP Portland on 28 December 2019. This 
response addresses both concerns you have raised in relation to HMPPS. I understand that 
NHS England are responding separately. 

, 

I know that you will share a copy of this response with the family of Mr Barnes and I would 
like to express my condolences for their loss. Every death in custody is a tragedy and the 
safety of those in our care is my absolute priority. 

Following evidence heard at the inquest you have raised a concern that there was no local 
operating policy on the use of force between the prison and the healthcare provider. There 
is a new healthcare provider at the prison, Oxleas NHS Foundation Trust – Offender 
Healthcare Services. When healthcare providers are commissioned, part of the contract 
refers to the fact that they must adopt HMPPS policies and be guided by them. The contract 
began on 1 December 2022 and a memorandum of understanding (MOU) has been 
produced by the Governor of HMP Portland and the Service Director of Oxleas NHS 
Foundation Trust, setting out the role of healthcare during planned and unplanned use of 
force incidents as well as post incident actions to be followed to ensure the wellbeing of 
prisoners and staff. This MOU complies with the directions of Prison Service Order (PSO) 
1600 which details the circumstances in which force can be used and the framework for 
justifying the use of force. The Use of Force policy document covers not only control and 
restraint techniques but also de-escalation skills, personal safety techniques and medical 
procedures including the role of healthcare staff in use of force incidents.  

I am aware that NHS England are providing a separate response relating to issuing national 
Use of Force guidance for healthcare staff so I will not comment on this further but I wish to 
assure you that we continue striving to improve joined up working between prison and 
healthcare staff. The national use of force policy is currently being reviewed and updated, 
and healthcare colleagues are engaged as part of this process. I fully appreciate the 
important role that healthcare play in ensuring the safety of all prisoners and staff. 

The second concern you have raised relates to the quality of mattresses provided by 
HMPPS which can lead to prisoners obtaining more than one for comfort and you have 

 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 asked that consideration be given to providing alterative better quality mattresses and 
issuing national guidance on prisoners accessing additional mattresses. 

I can confirm that a review of Prison Service Instruction (PSI 11/2015) Fire Safety in Prison 
Establishments was carried out in March 2022. The policy sets out the fire retardancy 
standards for furniture and upholstery in prisons which are assessed as being a very high 
hazard for fires. For reference, hospitals are classed as medium hazard and hotels and 
residential homes for the elderly as high hazard. For this reason there are very stringent 
regulations that HMPPS are required to comply with when considering the beds, 
mattresses, and bedding to provide to prisons to ensure the safety of prisoners and staff.  

The mattresses issued by HMPPS are 100mm thick and are produced to a very specific 
standard with each batch scientifically tested to ensure that they meet the very rigorous fire 
retardancy standards. It is unfortunate that, in order to achieve safety standards, the 
mattresses can be quite hard, however the safety of those in our care must be paramount. 

I can confirm that the metal bedframes at HMP Portland have been replaced by new 
whitewood furniture beds and am assured that the feedback received from the prison is that 
there has been a positive response to the new beds from prisoners. 

In order to reduce the risk of mattresses being used as a barricade, prisons must manage 
this locally in the same way that they monitor the potential use of other cell furniture as a 
barricade, and staff must challenge prisoners who have additional mattresses and remove 
them. This is monitored through daily accommodation fabric checks which are recorded and 
assured locally to ensure safety and security.   

Thank you again for bringing your concerns to my attention.  I trust that this response 
provides assurance that action is being taken to address the matters that you have raised.  

Yours sincerely 

Director General of Operations, HMPPS

HM Prison and Probation Service  
                                                                  HMP Portland 
Dorset 
DT5 1DL 

Mrs Rachael C Griffin 
Senior Coroner for Dorset 
Bournemouth Town Hall 
Bournemouth 
BH2 6DY 

Dear Mrs Griffin  

10 February 2023 

You  have  requested  that I provide  a  response  to  a  Regulation  28 report  which  you 
issued following the inquest into the death of Bradleigh Barnes at HMP Portland on 28 
December 2019. 

, Director General Operations, on 
As you are aware, in December 2022 
behalf of His Majesty’s Prison and Probation Service (HMPPS), wrote to you providing 
a  response  to  the  concerns  you  had  raised  in  relation  to  the  Prison  Service.    I,  as 
Governing  Governor  of  HMP  Portland,  with  responsibility  for  the  prison,  provided 
relevant information to contribute to the response. 

HMPPS is committed to learning from deaths in custody and preventing future deaths, 
and learning from regulation 28 reports helps to inform national actions and feed into 
local  actions  which  Governing  Governors  are  responsible  for  embedding  and 
managing  at  their  prisons.  Phil  Copple,  as  the  most  senior  appropriate  person  to 
provide assurances of the actions being taken at a local and national level across the 
organisation, considers and responds to all Regulation 28 reports issued to HMPPS.  
I understand that you require a separate response from me confirming this.  

I  hope  that  this  letter  provides  assurance  that  the  response  already  received  is  on 
behalf of the whole agency, HMPPS, but that I was involved in the consultation and 
drafting  of  the  response,  providing  assurance  to 
  of  the  actions  taken 
locally at HMP Portland. 

Yours sincerely  

GOVERNOR

Rachael Clare Griffin 
Senior Coroner  
Coroner Area of Dorset 
Coroner’s Office for the County of Dorset 
Town Hall  
Bournemouth  
BH2 6DY 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

22 December 2022  

Dear Ms Griffin, 

Re: Regulation 28 Report to Prevent Future Deaths – Bradleigh Trevor Barnes 
who died on 28 December 2019 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  24 
October 2022 concerning the death of Bradleigh Trevor Barnes on 28 December 2019.  
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Bradleigh’s family and loved ones. NHS England 
are  keen  to  assure  the  family  and  the  Coroner  that  the  concerns  raised  about 
Bradleigh’s care have been listened to and reflected upon. 

You  raised  several  concerns  in  your  Report  at  section  5  (Coroner’s  concerns), 
paragraphs 2 (i) to (iii). This letter has been prepared in response to the concern raised 
to  NHS  England  at  paragraph  2  (i),  regarding  the  lack  of  national  guidance  to 
healthcare staff on the use of force in prison. 

Firstly, I would like to clarify that the Prison Service Instructions (PSIs), Prison Service 
Orders  (PSOs)  and  Policy  Frameworks  set  out  the  framework  for  the  operational 
running  of  a  prison.  NHS  England  and  prison  healthcare  providers  are  required  to 
ensure  that  all  prison  healthcare  policies  and  service  delivery  are  aligned  to  the 
appropriate PSI, PSO or policy framework. NHS England cannot deliver guidance that 
is  not  cognisant  with  these  documents.  In  this  case,  as  you  have  highlighted,  PSO 
1600  Use  of  Force  is  the  operational  instruction  that  includes  the  use  of  manual 
restraint, and section 6 outlines the roles of healthcare in the planned and unplanned 
use of force. 

It  may  also  be  of  assistance  to  mention  that  healthcare  provision  in  a  prison  is 
commissioned using a principle of equivalence with what is provided in the community, 
such  as  primary  care  GP  services,  and  community  mental  healthcare  and  nursing 
services. Prison healthcare is not always a 24/7 service, and even during hours where 
healthcare staff are present in the prison, there is no guarantee they would be asked, 
or available, to attend whilst prison officers are restraining a prisoner (where this is not 
a planned intervention). PSO 1600 sections 6.1 and 6.2 set out the circumstances in 
which  healthcare  staff  are  required  to  attend  planned  and  unplanned  control  and 
restraint interventions. Specifically, for planned interventions, healthcare staff on duty 

                                                                                                                       
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 ‘MUST  attend’  and,  for  unplanned  interventions,  a  member  of  healthcare  must, 
whenever reasonably practicable, attend every incident.  

On  28  May  2015,  the  National  Institute  for  Health  and  Care  Excellence  (NICE) 
published ‘Violence and aggression: short-term management in mental health, health 
and community settings’ (NG10)1. This national guidance was published with the aim 
of  safeguarding  both  staff  and  service  users,  by  providing  evidence  based  best 
practice to support the prevention of violent situations and guidance to manage them 
safely  when  they  occur,  including  the  requirement  to  observe  the  physical  and 
psychological health of the person under restraint for as long as clinically necessary. 
The guidance was written for all healthcare staff and provides a range of factors that 
must  be  considered  to  minimise  the  risk  of  harm  to  patients  during  and  following  a 
period  of  manual  restraint.  Although  this  guidance  was  written  for  settings  where 
healthcare may well undertake control and restraint, there are sections that provide 
principles for roles and responsibilities, observations during restraint and monitoring 
physical  and  psychological  health  following  a  restraint,  which  are  applicable  for 
adoption in prison settings.  

NHS  England’s  Patient  Safety  Team  published  a  Patient  Safety  Alert  (PSA)  in 
December  2015,  ‘The  importance  of  vital  signs  during  and  after  restrictive 
intervention/manual  restraint’2.  This  PSA  was  written  for  all  organisations  providing 
NHS  funded  care,  where  restrictive  interventions  or  manual  restraint  are  used,  and 
this  included  healthcare  provided  in  prisons.  It  built  on  the  NICE  guidelines  and 
required all healthcare providers, including those in the secure estate, to undertake 
four  actions.  This  was  followed  up  with  NHS  England’s  regional  health  and  justice 
commissioners. 

Whilst the guidance and PSA referred to above were already in place around the time 
of Bradleigh’s death, NHS England recognises there is learning to be taken from the 
sad events in this case, and will be writing to all prison healthcare providers, via our 
seven regional commissioning teams, requiring them to work with their prison governor 
and have an agreed local operating procedure in place that includes: 

•  An outline of healthcare roles and responsibilities during and following a control 

and restraint incident, as described in PSO 1600: Use of Force.  

•  A  requirement  to  monitor,  record  and  act  on  vital  signs  during  and  after  all 
control and restraint incidents they attend as per NICE Guidelines 10 and NHS 
England’s PSA from December 2015. This monitoring should use the National 
Early Warning Score (NEWS) 2 tool that is commonly used across the NHS to 
support clinical assessment and decision making in deteriorating patients.  

NHS  England’s  central  team  will  request  assurance  from  our  regional  Directors  of 
Commissioning that the above actions have been implemented and evidenced by April 
2023. We are happy to provide you with a further update at this time if you consider 
this would assist?  

1 Overview | Violence and aggression: short-term management in mental health, health and 
community settings | Guidance | NICE 
2 psa-vital-signs-restrictive-interventions-031115.pdf (england.nhs.uk)  

 
 
 
 
 
 
 
 In addition to the above, NHS England will be working with colleagues in the HM Prison 
and  Probation  Service  (HMPPS) to  assist  with  their  planned  review  and  revision  of 
PSO 1600: Use of Force. We will be supporting this review through providing clinical 
leadership  on  the  revision  and  enhancement  of  section  6  and  the  roles  and 
responsibilities of healthcare.  

I hope the information above addresses the concern you have raised at paragraph 2 
(i) of your Report, and provides some assurances that NHS England recognises there 
is learning and is working to address this in an adequate and timely manner.  

I would also like to provide further assurances on the national NHSE work taking place 
around the Reports to Prevent Future Deaths. All reports received are discussed by 
the Regulation 28 Working Group, comprising Regional Medical Directors and other 
clinical and quality colleagues from across the regions. This ensures that key learnings 
and insights around events, such as the sad death of Bradleigh, are shared across the 
NHS at both a national and regional level, and helps us to pay close attention to any 
emerging trends that may require further review and action. 

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director

13 December 2022 

Oxleas NHS Foundation Trust 
Pinewood House 
Pinewood Place 
Dartford 
Kent  
DA2 7WG 

Rachel Clare Griffin, Senior Coroner                                                                                   
Dorset Coroner’s Court                                                                                            
Civic Centre, Bourne Avenue                                                                          
Bournemouth, BH2 6DY 

oxleas.nhs.uk 

Dear Ms Griffin, 

Regulation 28 report to Prevent Future Deaths Reports – Inquest touching the death of Bradleigh 
Trevor Barnes 

Thank you for your letter of 24th October 2022 containing a Regulation 28 to Prevent Future Deaths 
Reports (PFD), following the inquest into the death of Mr Bradleigh Trevor Barnes which concluded on 
the 20th October 2022. In the PDF you raised concerns in relation to the relationship between prison 
and healthcare teams namely: 

There is no local operating policy on the use of force at HMP YOI Portland between healthcare and 
prison; and you requested that the Governor of HMP YOI Portland and the Chief Executive of Oxleas 
NHS Foundation Trust consider putting a local instruction policy in place. 

We have now put in place a memorandum of understanding between healthcare and the prison 
regarding attendance of healthcare and all planned use of force interventions in accordance with the 
HM Prison Service, Prison Service Order: Order Number 1600 – Use of Force (see attached) 

Additionally, we have also agreed Healthcare staff are to be trained alongside prison officers in order 
to fully understand the techniques used and associated medical risks. 

I hope this provides you assurance that we have learned from this tragic event and will continue build 
on care of our patients. 

Your sincerely 

Chief Executive