Investigating deaths 16 October 2018 Richard Pickering, Deputy Prisons and Probation Ombudsman - Amazon AWS

Investigating deaths

16 October 2018

Richard Pickering, Deputy Prisons and Probation Ombudsman

The PPO investigates:
• Complaints from prisoners, children and young people in
  YOIs and STCs, immigration detainees and those under
  probation supervision

• Deaths from any cause of prisoners, children and young
  people in YOIs, STCs and secure children’s homes,
  immigration detainees and those in probation approved
  premises.

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A new Ombudsman:
• Sue McAllister became the Prisons and Probation Ombudsman
  on 15 October

• 25 years in the Prison Service, former Governor of HMP Onley
  and HMP Gartree

• DG of the Northern Ireland Prison Service from 2012 to 2016

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2017/18 Annual Report:
• Laid before Parliament on 11
  October

• Copies sent to every prison

• Theme: “Still much work to do”

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Death in 2017/18:
• PS ‐ the “new normal”
• ACCT ‐ repeating the same
  findings
• Mental health ‐ insufficient
  skilled staff
• Older prisoners ‐ inhumane,
  unnecessary use of
  restraints

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Numbers
• In 2017‐18, we started investigations into 316 deaths, a 12%
  decrease
• The majority of these deaths were of prisoners (93%)
• 180 deaths from natural causes, 15% fewer than last year
• 74 self‐inflicted deaths, 37% fewer than last year (the first
  decrease for 2 years)
• 23 ‘other non‐natural’ deaths (including accidents and drug
  overdoses)

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19/09/2018   Criminal Justice Management 2018   7

The last two years, by month

27/09/2018     Mental Health in the Criminal Justice System   8

Psychoactive Substances (PS)

• The previous Ombudsman identified 79 deaths
  between June 2013 and September 2016 where PS use
  was a key issue. Of these, 56 were self‐inflicted.
• Almost certainly an under‐estimate because it is very
  difficult to define a drug‐related death.

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What is a drug-related death?

• Apparently intentional overdoses
• Apparently accidental overdoses
• Suicides apparently caused by mood‐altering effects
• Suicides apparently related to drug debts and bullying
• Unexplained deaths of relatively young men from heart
  attacks and seizures
• Electrocutions and deaths from burns
• Homicides related to control of the drugs trade or
  triggered by PS‐induced psychosis
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Drugs - four themes

• Drugs are very readily available in most prisons

• PS is the main problem but there is also a problem
  with illicitly traded prescription and street drugs

• Staff tell us that they were unaware that prisoners
  were using drugs or being bullied over debts

• Staff tell us that they cannot stem the supply and
  demand for drugs

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ACCT
• We continue to see many cases where staff do not follow
  national instructions and do not complete ACCT procedures
  properly
• This means that prisoners do not receive appropriate
  support to reduce their risk of suicide and self‐harm
• Issues include:
   • Poor caremaps
   • Triggers not being identified
   • Weak multidisciplinary approaches
• We hope that the Safety Programme will make a difference

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Mental Health
• Our 2016 study found that 70% of those who took their
  own lives had an identifiable mental health problem
• Identifying prisoners’ needs and accessing appropriate
  services to manage those needs can be incredibly
  challenging
• Staff will sometimes place too much emphasis on how a
  prisoner seems at their brief contact and fail to take
  account all of the available information
• Multidisciplinary team working is essential and must
  include expertise from a range of professionals

                                                       13

Mental Health
• The most challenging prisoners may well be the most
  vulnerable
• Punitive rather than therapeutic action may not be the
  best response to challenging behaviour
• The restrictive and isolating regimes in segregation units
  can accelerate deteriorations in a prisoner’s mental and
  physical health
• Critical that staff follow national instructions on
  segregation

                                                           14

Older prisoners

• We continue to see cases in which very elderly, frail
  and/or very unwell prisoners with limited mobility were
  routinely escorted to hospital in handcuffs

• Some remained restrained until shortly before they died

• Case law is clear – the use of handcuffs on a prisoner
  who is receiving treatment or care must be necessary
  and proportionate

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How to learn lessons?

• Often, our recommendations amount to “follow the
  agreed HMPPS policy”
• Our recommendations will be accepted and an action
  plan put in place
• But too frequently HM Inspectorate of Prisons find a lack
  of action
• And we are called to investigate another death
• How can we work together to make recommendations
  meaningful and effective?

                                                          16

All reports, lots of lessons
www.ppo.gov.uk
             •Older Prisoners
             •Prisoner Mental Health
             •ACCT
             •New Psychoactive Substances (NPS)
             •Segregation
             •Early Days and Weeks in Custody
             •Dementia
             •Homicides
             •Female Self‐Inflicted Deaths
             •Emergency Response