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October 2014 — Deaths In Custody

Minutes of the All-Party Penal Affairs Parliamentary Group held on 21 October 2014
at the House of Commons

Deaths in custody: can the state learn lessons?


Nigel Newcomen, Prisons and Probation Ombudsman
Lord Harris, Chair, Independent Advisory Panel on Deaths in Custody
Lord Ramsbotham, in the chair
Lord Bradley
Lord Woolf
Lord Judd
Lord McNally
Baroness Howe of Idlicote
Lord Ponsonby of Shulbrede
Earl of Listowel
Lord Fellowes
Lord Lowe
Fiona Mactaggart MP
Lord Harris
Nigel Newcomen


Lord Ramsbotham opened the meeting by acknowledging the work of Geoff Dobson, who recently retired from the position of Clerk to the All Party Group on Penal Affairs; a post which he held for the past 12 years. He presented Geoff with a copy of the Crimes and Courts Act 2013, which he and Lord Woolf had signed. He wished Geoff well and thanked him on behalf of the group.

Lord Ramsbotham noted that the subject of self-inflicted death forms a very important part of the annual report of the Chief Inspector of Prisons. Today’s presentations come after a very powerful article in the Guardian, drawing attention to the situation in our prisons where the numbers of suicides are rising. The reasons for this are not well understood and are not being recognised by those in charge in the Ministry of Justice.

Lord Ramsbotham recalled how, as Chief Inspector of Prisons, he was asked to write a report entitled ‘Suicide is Everyone’s Concern’. The recent rise in self-inflicted deaths in prison suggests that not all the recommendations have been followed. He noted the problems that prisons face with cuts in resources, not least of all staff.

He went on to advise that there would be two separate presentations. He noted the attendance of Lord McNally, Chairman of Youth Justice Board, who had brought copies of the latest Youth Justice Board report on suicides of young persons. He asked Lord McNally if he would speak about his report at the end of the presentations and advised that copies of the report were available for those who were interested.

He then introduced the first presentation by Nigel Newcomen, the Prisons and Probation Ombudsman.

Nigel Newcomen thanked the group for the invitation to speak: ‘For those not familiar with my role, I independently investigate complaints from those in prison and immigration custody or on probation, and more relevant to this meeting, I investigate all deaths in custody. Sadly, I and my staff have been very busy over the last year or so.

I was appointed in 2011, I have made a considerable effort to try and ensure that my organisation identifies learning from both individual investigations and, increasingly, from across investigations, to try and mitigate and minimise the number of deaths in custody.

My individual investigations contain recommendations for improvement arising from the particular case. These recommendations are invariably accepted and action plans put in place – so some specific learning, going back to the title of tonight’s discussion, ‘Does the state learn from deaths in custody?’, some individual cases can be demonstrated, although even in individual cases I find myself making repeated recommendations. However, I have also begun producing a growing body of learning lessons publications looking across investigations. The aim is to make a broader contribution to safer and fairer custody by identifying wider lessons that can support improvement in prisons.

The fact that I put such store by identifying lessons illustrates clearly that I believe that the parts of the state that I investigate can and, indeed, should be expected to learn lessons.

However, with an appalling 64% increase in suicides in prisons last year – with some cases exhibiting familiar failings – it is a legitimate question whether lessons are being learned. Some have even suggested that the current pressures on prisons are such that learning is no longer possible and lower levels of safety are becoming the new norm.

I cannot accept this counsel of defeat. Yes prisons are under enormous strain, but in my experience the vast majority of prison staff want to improve things, not least safety – and I have seen for myself the traumatic impact of prisoner suicide, not just on bereaved families, but also on staff.

So, I do not doubt the will to improve exists, but the current wholly unacceptable levels of suicide in prison mean that the issue must be put more bluntly: whatever the challenges, given the state’s duty of care, lessons – not least from my investigations – must be learned and safety in prison improved. My office will continue to do all it can to support this improvement.

I was asked by the organisers to speak specifically about one particular learning lessons bulletin which I published in August on self-inflicted deaths among young adults aged 18 to 24. This illustrates the sort of lessons that I expect prisons to learn.

The bulletin looked at a sample of 80 young adults who took their own lives between 2007 and 2013.

I have to say that deaths among this age group are not disproportionate to their representation in the prison population, but they are a complex group of prisoners who have only recently left childhood behind. They display varying levels of maturity and a wide array of risks and needs which need to be addressed if their safety is to be assured and their offending behaviour confronted.

The bulletin – which can be found on our website – explores a number of these risks and needs. I can only provide a brief and selective synopsis tonight.

Let me start with bullying. Although not age restricted, bullying is particularly prevalent in young offender institutions. It takes many forms, including violence, harassment, intimidation, ostracism and abuse. The effects can be devastating, even if a direct causal relationship with self-inflicted deaths can often be hard to establish.

In our sample, 20% of young adults were recorded as having experienced bullying from other prisoners in the month before their death, compared to 13% among other prisoners. So it is not entirely age specific but particularly amongst this population that the problem exists.

Mr B’s case is typical. Aged 19, with no previous convictions or experience of custody, he arrived scared, but said he had no thoughts of self-harm. After a week, and to be closer to home, he was transferred to a new prison, but a newspaper article was passed round his new unit which gave details of his offence. This led to him being verbally and physically abused by other prisoners.

The next day, he was moved to another unit and a transfer arranged to a different prison. However, he was found hanged in his cell before the transfer could take place. He left a note saying he could no longer bear the abuse. Although disciplinary action was taken against his immediate assailant, my investigation was concerned that inadequate action had been taken against the bullying and inadequate recognition within the context of safer custody and suicide prevention had been taken given the bullying he had been suffering.

So the lesson we drew was that the impact of bullying should be fully considered in suicide prevention and the bullying properly addressed, with protection for victims and action against bullies.

Bullying is but one manifestation of the difficult and challenging behaviour that can characterise young adult prisoners. Among our sample, challenging behaviour was common, with prison records detailing warnings for poor behaviour, formal adjudications and punishments for breaches of prison rules. Many had spent time in segregation or on the basic level of the incentives and earned privileges scheme (IEP).

Yet misbehaviour can also mask underlying distress. A previous learning lessons bulletin identified that self-inflicted deaths occur disproportionately among prisoners on the lowest (“basic”) level of privileges, which reduces protective factors against suicide and self-harm such as association, activities and access to television. This was even more marked among young adults, with 16% of those committing suicide doing so when on basic, compared 6% among other prisoners.

In a review of self-inflicted deaths among children in 2013, I highlighted similar concerns. The children’s behaviour was sometimes challenging, but this was too often considered only as a discipline issue, with little consideration of any underlying issues. I recommended that the discipline and care aspects of custody needed to be more closely aligned. The same learning applies to some young adults.

One particular lesson which can help achieve this balance, particularly in the most complex cases, is the greater use of what are called enhanced case reviews. These are designed to help manage individuals with multiple and challenging issues through a co-ordinated, multidisciplinary and holistic approach overseen by senior staff.  This would seem to be an appropriate response to the mixture of poor behaviour, aggression and vulnerability evident in a number of suicides of young adults.

The bulletin goes on to make clear that suicide and mental ill health often go hand in hand. Overall, 67% of the young adults in our sample had mental health needs and 27% had previously been admitted for psychiatric care. While these are similar proportions to other prisoners, this is a high level of need and my investigations reveal just how acutely unwell some young adults were before they died.

Referrals for mental health assessment or transfer to a secure mental health bed need to be made and actioned promptly. In several cases, mental health teams could not provide prompt care for individuals in crisis.

For example, one newly transferred young man was referred to the prison’s mental health team, but not seen. The mental health team at his previous prison were sufficiently concerned to get in touch with their counterparts and an appointment was made, but later cancelled. In addition, the records of his medication were not reviewed, so his treatment stopped abruptly after the move. Ceasing medication can have a significant impact on mood, thereby increasing risk, so should be only undertaken carefully and with support. It wasn’t and he hung himself shortly after.

The lesson we drew was that mental health referrals need to be made and actioned promptly, and continuity of care ensured between prisons and between hospitals and prisons.

The bulletin goes on to echo concerns from other publications from my office about weaknesses in how prisons assess and then manage risk of suicide and self-harm. To begin with, there is often a need to improve information sharing between and within criminal justice agencies – and a particular frailty can be a failure to pick up on concerns expressed by families.

Unfortunately, when information about risk is available, some risk assessments place too much weight on how the prisoner ‘presents’, rather than on known risks, such as recent acts of self-harm. If you appear to a prison officer to have decent body language and decent eye contact and not immediately display issues of concern that can override the static known risk factors that may be in existence. Yet we know that these static risk factors are the best predictor of future action.’

Lord Ramsbotham, interrupted the presentation to allow members to attend a division. After a short break, he reconvened the meeting.

Nigel Newcomen: ‘I will just quickly finish off what I was going through in this paper, which basically was trying to paint a picture of the sorts of learning that my learning lessons bulletins identify in particular, within the context of the tragic self-inflicted deaths of 18 to 24 year olds. I am really trying to make the point that there are areas of learning that have been distilled and I think that we should expect that action is taken on them, and not just my learning but also other sources of learning like the Inspectorate.

The bulletin goes on to echo concerns from other publications from my office about weaknesses in how prisons assess and then manage the risk of suicide and self- harm. To begin with there is often the need to improve information sharing between and within criminal justice agencies and a particular frailty can be a failure to pick up on concerns expressed by families.

Unfortunately, when information about risk is available, some risk assessments place too much weight on how the prisoner presents rather than known risks such as recent acts of self-harm. Yet as we know these static risk factors are the best predictors of future issues, and even when risk was properly identified and suicide and self-harm procedures put in place, investigations found these procedures deficient in a troubling 50% of cases. For example, because poor or inappropriate objectives were set; or staff did not carry out agreed actions; or reviews being inconsistent; or key staff not being involved.

Inevitably, the lessons we drew were that risk needs to be better identified, including involving families where possible, and then it needs to be effectively managed. Staff training is clearly key to achieving this.

This has been a rapid review of only some of the material in my learning lessons bulletin on suicides among young adult prisoners. Clearly, my expectation is that the Prison Service can and should learn the lessons it contains, whatever other challenges it may be facing. And I will continue to focus my investigations on helping to support improvement in safety and continue to expect the state to learn lessons.

In this regard, I am also pleased to have been able to share the bulletin with Lord Harris as he reviews self-inflicted deaths among this age group in the coming year. I am sure his work will add a further important stimulus for the state to learn and improve.’

Lord Ramsbotham thanked Nigel Newcomen and introduced Lord Harris, who chairs the Independent Advisory Panel on Deaths in Custody and is leading the Independent Review into the deaths of 18-24 year olds in NOMS custody.

Lord Harris: ‘It is worth just putting in context that there has been an Independent Advisory Panel on Deaths in Custody for about five years. Its responsibility is to report to the Ministerial Board on Deaths in Custody. It has a broad remit so it looks at not only prison deaths, but deaths in police custody, deaths in secure mental hospitals, deaths in immigration detention centres and so on. Earlier this year however, we were asked by the Minister for Prisons to conduct an additional independent review into the self-inflicted deaths of 18-24 year olds, since the roll-out of the assessment, care in custody and teamwork process. We started work in April, we are due to report by the end of March next year, so I calculate that by the end of next week we should be seven twelfths of the way through the process, which I have to say is filling me with some trepidation in terms of the amount of work which is still to be done.

The Ministry of Justice, or the Minister, decided that the remit should be limited to 18 to 24 year olds and that we should look at the period from 1 April 2007. Having said that, the panel is also intending to look at the four deaths of children that took place during this period. This is to extract any lessons that are of relevance from the youth estate for young adults in the main prison estate. Where we think there are recommendations which are of general relevance to the prison system, we will also make them. We are going to focus on a range of issues, many of which Nigel has touched on in his presentation today, and in his helpful submission. But we will be looking at vulnerability, effective communication and information sharing, safety, staff prison relationships, family contact, staff education and training. So we are looking at all of those as well as the cases of the young people who have died during that seven year period.

We have heard evidence from quite a number of senior stakeholders, from government, from the public service, but also from a number of the organisations represented in this room. We’ve made a public call for submissions. We’ve received more than 50 written submissions. And there are one or two submissions that are still straggling in even long after the closing date. We have visited a number of institutions with our members where not only have we heard from the governor and from prison staff, but also particularly from young adults in custody themselves, and that has been extremely important.

We have also had a meeting with a group of young adult ex-offenders, who have spent time in custody recently, again, a very useful session. We have held an open stakeholders consultation meeting and community group engagement day, which took place earlier this month. Last week we held the first of two engagement meetings with families who have lost a child or young adult through self-inflicted deaths in custody. We also have some independent research that has been commissioned; one a literature review and one a qualitative piece of work looking at the perspectives of staff working in prisons and YOIs.

So the timetable as such means that we are due to complete our work, the written report, and present it to ministers by 31 March. Those of you with a political turn of mind will note that this is just before the next general election. It means that in practice, the report will not be published this side of the general election because it will be presented during the purdah period. So essentially, we are providing a report which the ministers in office after the general election will consider and decide what they want to do with.

I would like to highlight two points from the terms of reference. The first is while it is recognised in the terms of reference that the review will focus on the 18 to 24 age group, you should take into account the learning that has been undertaken with respect to the youth estate That is why we are intending to take into account under 18 year olds as well as over 18 year olds. We were also asked to identify wider learning that would be of benefit to any age group. So that is the basis on which we will make recommendations, which might have wider ramifications for the prison system. We were specifically asked to look at vulnerability, information sharing, safety – including violence reduction and bullying which Nigel referred to -, the built environment – which includes safer cells -, and emergency response. We were asked to look at staff prisoner relationships, family contact and staff training.

Now it would not be appropriate for me to pre-judge the findings of the review, not the least because we have not discussed them at this stage as a panel. One of my panel members is sitting in the room and so will no doubt be keeping careful watch that I don’t stray beyond the likely areas of agreement. But I think that it is inevitable that we will look at a number of factors in our recommendations. The first must be about the leadership of individual institutions. There is no question that this makes a difference and I note from visiting some of the prisons, that it is very interesting what the governor thinks are the most important things to tell you at the start of your visit. Then I think there are going to be issues about owning or taking responsibility for the individual prisoner. Now, I am sure that in theory, it is the governor who takes responsibility for every individual prisoner. But I am talking about who takes responsibility for the individual needs of a prisoner, the individual safety that prisoner, their security, their education, their rehabilitation. And it is not clear to me, again we haven’t finished our work, whom that person is at the moment, if such a person really exists. There has been a system of personal officers, but that in most cases is not working as originally intended, if it works at all.

But then there is a fundamental question as to why there are so many 18 to 24 year olds in prison in the first place. What is it that could have been done earlier in their lives to provide them with appropriate mental health services, for example. What could have been done earlier in their lives to divert them from the criminal justice system, by investing in their education and training or rehabilitation from drugs and other dependencies. Those are questions. And also, what alternatives should have been available to prison, when they enter the criminal justice system, at the point of which they now go into prison. There are clearly a whole group of issues about mental health services and their availability in prison and in the community. There are issues about the way in which the prison regime operates, in particular what can and is being done to reduce the impact of bullying. What is the relationship with staff? There are clearly issues about staff training. There are issues about the physical safety of the environment and the availability of safer cells. There is a whole set of issues around how you identify and manage vulnerability. It has even been put to us by one witness that it is almost worth not attempting to identify and manage vulnerability, in that if you identify and manage it in respect of some individuals, there will be other individuals who will then be at risk. And then there is the whole question of information sharing.

So perhaps Lord Chairman I should stop there, before I get tempted to be more specific about the areas in which we might make recommendations on. But I hope this gives you some idea about the process that we are following and the issues that we will need to consider and reach conclusions on by the end of March.’

Lord Ramsbotham thanked Lord Harris and commented that it is hugely encouraging to hear that the review is covering such a spectrum. He then invited Lord McNally to make some comments on his report.