The risk of placing prisoners in segregation
This Learning Lessons Bulletin has been prompted by the deaths of prisoners in segregation units. The bulletin summarises learning and areas which require further attention to ensure segregation is used and managed appropriately.
A Learning Lessons Bulletin published today by the Prisons and Probation Ombudsman highlights learning from our investigations where prisoners have died while segregated.
In segregation units, prisoners will generally spend most of their time alone in a cell, leaving only to shower, make telephone calls and exercise for a short period of time.
The authorised reasons for segregating a prisoner are:
- for reasons of good order or discipline
- where it is in their own interest
- where a prisoner is awaiting a disciplinary hearing
- following a finding of guilt at a disciplinary hearing
In 2015, we published a bulletin on the self-inflicted deaths of prisoners being held in segregation units. The HMPPS Segregation Policy makes clear that segregation should only be used as a last resort whilst maintaining a balance to ensure it remains an option for disruptive prisoners. Sadly, 11 years on, we continue to see several of the same issues and more should be done by HMPPS to find a balance for vulnerable prisoners.
The impact of segregation on mental health
The Prison Safety Policy Framework states that prisoners managed under suicide and self-harm procedures (ACCT) should only be segregated in exceptional circumstances. Being placed in segregation reduces the protective factors against suicide and self-harm and is likely to heighten the vulnerability of a prisoner on ACCT.
Concerningly, we continue to investigate deaths of this type. Out of the 14 individuals located in a segregation unit who died between 1 April 2024 and 31 December 2025, 8 of these were on an open ACCT at the time of their death.
The Segregation Policy highlights that a person’s mental health is very likely to decline when they are kept in segregation. The lack of contact with other prisoners and family, as well as the lack of activity can take its toll, and the reasons for continuing segregation should be regularly monitored so prisoners do not spend longer in segregation than is necessary or justified.
Failure in following segregation procedures
In many cases we investigate, there are failures to follow the procedures set out in policy. Some of the issues we repeatedly identify are:
- Daily summaries not being completed or not being completed with sufficient detail
- Healthcare not attending daily segregation reviews
- Prisoners subject to ACCT monitoring whilst segregated not being referred to the Safety Intervention Meeting – a multidisciplinary safety risk management meeting that aims to manage and support prisoners at risk of harming themselves and others – or not being discussed properly at this meeting
- Initial segregation health screens not being completed by a nurse or a doctor within 2 hours of the decision to segregate or healthcare staff not reviewing medical records properly when completing the screen
- The OT026 form (reason for the initial segregation) not being shared with the prisoner
The impact of segregation on physical health
The Segregation Policy requires that a prisoner’s initial segregation health screen must be conducted in person and that a GP must visit them in segregation as often as their individual health needs dictate and at least every three days.
In reviewing cases for this bulletin, we found instances where this did not happen which highlighted the importance of properly considering a prisoner’s physical health when deciding whether to segregate them.
The initial segregation health screen also predominantly relates to mental health. In an investigation of the death of a prisoner who was segregated, we recommended that HMPPS amend their guidance on completing the initial segregation health screen to include assessing physical health too.
It is essential prisoners are mentally and physically fit enough for segregation and there should be clear reasoning to segregate a prisoner.
Staff should be consistently considering potential pathways to re-integrate prisoners out of those segregation units with clear support actions.
We urge prison leaders and healthcare providers to satisfy themselves that they have effective quality assurance arrangements in place within their establishments to meet and correctly follow segregation requirements.