HMP Exeter – vulnerable men receiving shocking standards of care in early days in custody

Read the report: HMP Exeter

Inspectors returning to HMP Exeter were so concerned by the high rates of suicide and self-harm, inadequate care for vulnerable new arrivals and oversight of health care that they issued an Urgent Notification within days of completing the inspection. A report published today sets out the full findings from the inspection which triggered the first ever second consecutive Urgent Notification for a prison.

Charlie Taylor, Chief Inspector of Prisons said:

“Exeter is a reception prison – men arrive here newly sentenced or remanded and those early days are when we know prisoners are at their most vulnerable, particularly those with substance misuse problems or mental health concerns. Yet we found the highest levels of self-harm in the country for this kind of prison, and ten men had taken their own lives in the prison since 2018. The complacency with which such shocking standards seems to have been viewed by the prison service is extraordinary.”

Exeter receives more men with mental health and substance misuse problems than at similar prisons, yet despite this, early days processes did not sufficiently support these men through their first few weeks in jail when they are at their most vulnerable.

Staff shortages in health care were also impacting the provision of care, particularly in terms of support for mentally ill and neurodivergent prisoners, where there was significant unmet need. Prisoners who needed prescribed medication were not receiving it during their first few days and some were becoming unwell. Men who had begun alcohol detoxification or opiate substation were also not being routinely observed.

The prison was also falling short on a number of other fronts, with prisoners locked up for long periods of time and very few being able to attend education or training despite places being available for them to do so. Prisoners told inspectors they were bored and desperate to get off the wing and do something meaningful with their time.

In such a high-risk jail, it was particularly disappointing to find there had been three governors and eight deputy governors since our last inspection. What is needed in Exeter is a period of stability – the offender management unit, for example, which did not suffer such high turnover, was an effective and well-motivated team.

Inspectors invoked the Urgent Notification process within days of completing the inspection, concerned that more men would die without urgent action. The Secretary of State for Justice published his response 28 days later accepting the situation at Exeter was “completely unacceptable” and committing to a course of action to improve the situation.

Charlie Taylor said:

“We will be returning to Exeter in 2023 and expect to see a significant improvement as well as evidence that the prison service is investing in continuing to make change over the long-term as the Secretary of State has assured us that it will.”

Notes to editors

  1. Read the HMP Exeter report, published on 16 February 2023.
  2. HM Inspectorate of Prisons is an independent inspectorate, inspecting places of detention to report on conditions and treatment and promote positive outcomes for those detained and the public.
  3. Built in 1853, HMP Exeter is a Victorian prison of radial design, with three wings positioned around the centre. In the late 20th century, D wing was added and, more recently, education blocks were built. In recent years a refurbished reception, new visits hall and a social care unit (F wing) have been introduced.
  4. Exeter is a reception prison serving courts in south-west England.
  5. At the time of this inspection, the prison held 388 prisoners.
  6. The Urgent Notification process was introduced in 2017. Since then it has been invoked 11 times, including this occasion. We previously issued an Urgent Notification for HMP Exeter in 2018.
  7. An Urgent Notification is not an inspection. It is a process that we invoke if we are particularly concerned about outcomes for detainees. It requires us to write to the Secretary of State for Justice within seven calendar days of completing an inspection setting out our concerns. We also tell the governor of the prison that we are doing so. The Secretary of State then has 28 days to reply to us setting out an action plan of improvement. Find out more about Urgent Notifications.
  8. The Urgent Notification issued for Exeter, and the Secretary of State’s response, can be found here: HMP Exeter Urgent Notification (
  9. Inspectors identified one example of notable positive practice during this inspection.
  10. This inspection took place between 31 October – 11 November 2022.
  11. Please email if you would like more information.