Judge Stephen Tumim, the chief inspector of prisons, said that lengthy waiting times for a secure bed within Wessex Regional Health Authority meant that staff had to look after 'psychiatrically ill people (who should be in hospital) for many weeks despite urgent referrals to the NHS'.
One severely disturbed man was left for four days without treatment because the health centre had inadequate procedures to deal with patients who were too ill to give their consent, according to the report. Judge Tumim said that a strategy should be devised for similar situations.
Despite two suicides within the 12 months up to January 1992, suicidal patients were only checked on every 15 minutes because of staffing problems. 'Leaving patients in these rooms continuously with only intermittent supervision at 15-minute intervals was both dangerous and unacceptable by modern therapeutic standards,' Judge Tumin said. He recommended an increase in the number of nurses so that suicidal patients could be continuously observed.
The report criticised the health centre as 'claustrophobic and difficult to staff' and said it should be replaced with a new building. However, Judge Tumim praised the prison's staff for the improvement in their relationship with the inmates since the 1990 riots when 17 staff and 12 prisoners were injured. But he said staff morale on C wing was low and there was a 'general lack of faith' in the prison's management.
In C wing, where vulnerable prisoners under Rule 43 are housed with ordinary inmates, staff said there was a danger of losing control to the prisoners. Judge Tumim said graffiti on the outside of cell doors was evidence that 'inmate culture' appeared to dominate the wing and staff seemed to have relinquished control.
Frances Crook, the director of the Howard League for Penal Reform, said it was very worrying when prisoners gained control and it was a 'recipe for undercurrents of violence and bullying'.
After the riots, the 1991 Woolf Report had described the general conditions as 'unacceptable'. Apart from redevelopment work, Judge Tumim said conditions had changed very little and 'it remained a busy, overcrowded local prison offering few facilities to inmates'. The regime for those serving life sentences was inadequate and should be upgraded to include facilities for cooking, recreation, counselling and advice.
Following Judge Tumim's report Kenneth Clarke, the Home Secretary, said that the criticisms arising from the four-day inspection last June were being addressed and action included more healthcare staff as well as improvements in the prisoners' regimes.