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December 2018 — Deaths In Custody

Minutes of the meeting of the All-Party Group on Penal Affairs, held on 4 December 2018




Sue McAllister, Prison and Probation Ombudsman
Deborah Coles, Executive Director, INQUEST
Juliet Lyon CBE, Chair, Independent Advisory Panel on Deaths in Custody


Lord Ramsbotham (in the chair)
Lord Atlee
Lord Bradley
Lord Dholakia
Lord Harris
Baroness Masham of Ilton

Lord Ramsbotham welcomed everyone to the meeting, especially the three speakers. It was a great pleasure to see Sue McAllister, a distinguished governor whom he had known from his time in the inspectorate.  She had recently been appointed Prisons and Probation Ombudsman after a disgraceful gap following the departure of the previous post holder. He had always thought this post should be statutory.  Each of her predecessors had made a substantial contribution.  Now that the figures were so dreadful, it was particularly good to have someone in post with Sue’s experience of prisons.

Sue McAllister: Thank you for the opportunity to speak to you today and for giving me the chance to share with you my observations and early thinking after seven weeks in the role of PPO. I know that this group is interested in all our work, and we are very grateful for that, but I also know that you are particularly interested to hear today about our work investigating fatal incidents and about some of the learning and themes we identify in our fatal incident investigation reports.   My plan this afternoon is to talk about my emerging thinking around future priorities for the PPO and to express that in the context of our work investigating fatal incidents and of the recommendations that we make and the learning we identify.

First, though, some more general observations which will help to set our work into its current context.  I am taking over the PPO role at a time when the levels of violence and numbers of reported incidents in many prisons are high; psychoactive substances have become probably the single biggest challenge to safety, order and control and to the wellbeing of prisoners in our prisons; and at a time when resources across public services are stretched. Our own financial position in the PPO office means we are being asked to do more with less and we are having some uncomfortable conversations and making difficult decisions to guarantee our financial sustainability into the future.

But, on a more positive note, I have inherited a committed and experienced staff group, teams of people who genuinely care about the work that we do and who, typically, stay longer in the PPO office than we usually expect in other roles. Our recent move to new accommodation in Canary Wharf, completed before I took up post, has been largely positive. Despite the, inevitable, teething problems, we now have the infrastructure and technology to support more flexible working arrangements for our staff and a working environment that is fit for purpose. In terms of our staff, I am keen to look at how we can further develop and empower our people both to confirm the PPO team as a good place to work but crucially to strengthen our capability even more and improve our contribution to the justice landscape.

I should, at this point, mention the work to place the office of the PPO on a statutory footing. I know that Nigel Newcomen spoke to you about this issue shortly before he stepped down from the role and that he was hopeful that progress could be made, when an opportunity for new legislation presented itself. Unfortunately, there has been no such progress since then and we continue to wait for the legislative space and the opportunity to include this change, which would enhance our actual and visible independence and give us some practical benefits. We will, of course, keep you informed of any future developments and progress in respect of this issue.

I want now to turn to the more specific issue of our work to investigate fatal incidents and to share with you some of the most commonly recurring lessons and themes from our reports. I will also outline some of our plans to build on the work of our Learning Lessons function, which has now become an integral and important element of our work alongside our fatal incidents investigations and complaints teams. I have already expressed my commitment to strengthen and recalibrate the more thematic element of our work to focus more on outcomes, to influence policy development and to strengthen the impact our work has on practice, on what staff do, in the services in our remit, to improve safety, fairness and decency for everyone.

As you know, we investigate all deaths in prisons, immigration detention, probation approved premises and secure children’s homes.   In 2017-18, we started investigations into 316 deaths, 12% fewer than in the previous year. Of those 316, 74 were classified as self-inflicted (down 37% on the previous year), 180 were from natural causes (down 15%) and there were 7 homicides, an increase from 4 in 2016-17.

So far, this year, we have started 200 investigations- almost 20% more than at the same point last year. The proportion of deaths provisionally classified as natural causes has remained steady at about half, and there appear to have been fewer homicides. But, more worryingly, there have been 55 self-inflicted deaths so far, this year, almost 50% more than the 37 at this time last year.  Having shared these figures, it is important to remember that we cannot helpfully draw conclusions based on a single year’s figures, either because they are going up or down. It is the longer term trends, viewed in context of other variables, which are more significant.

When we investigate deaths in custody, our focus is on what happened and on whether we can identify things that could have been done better or differently. In the case of non-natural causes deaths, we often make a judgement as to whether doing things differently could have prevented the death, or changed the outcome. In the case of those deaths believed to have been from natural causes, our focus is on the way in which the end of a person’s life is managed. That includes, but is not limited to, that person’s access to healthcare and whether the treatment they received was equivalent to that which they could expect to receive in the community. There is much talk these days, and welcome it should be, on what is ‘a good death’, and those in detention have no less a right to expect that than any other citizen.  In all our fatal incident investigations, we work closely with clinical reviewers, commissioned by NHS England, or NHS Wales. Our investigators often work alongside these healthcare professionals, conducting interviews jointly, for example, and the clinical review is published as an annex to our reports.

Turning to our recommendations, last year we made 857 recommendations following deaths in custody, typically about three in each report. The top three areas in which we make recommendations are: healthcare provision (22%); emergency response (13%); and the management of suicide and self-harm prevention procedures (11%).

So, in more detail, the sort of things we comment and make recommendations on are: ensuring attendance at appointments; information sharing and record keeping; care pathways for patients with long term or terminal illnesses; and the use of restraints.  We have identified poor practice in areas such as: the quality of wellbeing checks; the lack of a multi-disciplinary approach; risk assessments; and the availability of suitably trained healthcare professionals.  We also comment on the availability of drugs, psychoactive substances in particular but also, for example, the trading of prescription medication.

So, what happens when we make these recommendations to the services in remit?  Interestingly, almost all of them will be accepted.  The service will draw up an action plan and we will review and agree the plan.  We are not, though, resourced to follow up on progress against our recommendations and, in the case of HMPPS, HMIP will monitor subsequent implementation. The chief inspector has, however, expressed concerns about the levels of implementation his inspectors have found.   We share that concern. We are making too many repeat recommendations. This is an area on which I intend to focus as PPO. A clear focus on outcomes will be one of my key priorities.  The work to identify lessons from our investigations and to disseminate that learning to the services in remit, via our recommendations and our Learning Lessons Bulletins, is now well embedded and it is on this work that I intend to build.

Whilst mindful of the crucial independence of the PPO, we need to work with practitioners to make sure that our findings and recommendations are taken seriously, that they are used to influence policy and that they have a real impact on practice. This focus on outcomes makes real sense. The office of the PPO is, quite rightly, proud of the high-quality reports that we produce, both in our Fatal Incident Investigations (FIIs) and our work responding to complaints. Our processes are thorough and our outputs are comprehensive and timely. But, what is important is what difference they make. Our reports and our thematic bulletins must form part of the work that the services do to make sure that, where mistakes are made, and poor practices are identified, the same mistakes and the same poor practice do not continue.

In recent weeks, we have met with staff from the Prisons Improvement Programme in HMPPS, where they have a team dedicated to delivering improvements to prisoner safety, including to suicide and self-harm prevention. This work, though arguably not as connected as it might be to our findings and recommendations, is welcome and it is right that we remain sighted on progress and delivery. It is encouraging to learn that the team includes those from a healthcare, as well as from a prison, background.

As well as talking to HMPPS and others, we are thinking about how we can work collaboratively with the many stakeholders who share our interest in, and commitment to, improving outcomes. We want to open up the office of the PPO to academic partners to strengthen our ability to measure the impact of what we do, and that will allow us to make sure that we are concentrating on the right things. There is, we know, research already going on which is highly relevant to our work, for example on drug use (including amongst older prisoners), on homicides in prisons, on the experiences of prisoners serving very long sentences. We need to connect with that work, we cannot operate in isolation if we are going to make the best impact we can. Partnership and collaboration are not a threat to our independence. Indeed, as resources become increasingly stretched, we have a responsibility to look at what we can do, at no cost or low cost, to improve outcomes.

I want to mention, briefly, the issue of timeliness. The PPO has made great improvements to the timeliness of reports and it is rare now that we do not meet the agreed timeliness targets for our reports (26 weeks for self-inflicted deaths and 20 weeks for natural causes deaths). But we then delay publication of our reports, apart from sharing them with families and the service in question until after an inquest is held and this can, in some cases, mean a very long delay. Where there is a police investigation, a delay can be even longer and we fully appreciate the additional distress this can cause family members and friends of the deceased. It also, inevitably, means the value of any learning is often diminished and so I would intend to consider, with other interested parties, whether there is any way to reduce the delays and publish reports more promptly.

I am very conscious of time, that we have other speakers, and that attendees may have questions and comments on what I have said today. I hope that what I have said has been of interest and, importantly, has set the scene for further conversations and collaboration in the weeks and months ahead.  Thank you’.

Lord Ramsbotham thanked the last speaker and introduced Deborah Coles of INQUEST, whom he had known since the Prison Inspectorate had produced a thematic review called ‘Suicide is Everyone’s Concern’.  Deborah had brought ten families bereaved by a prison suicide to the launch, and he had never forgotten that day.

Deborah Coles: ‘For those who are not aware of INQUEST’s work, we work with families bereaved after deaths in custody. It is important to mention the traumatic impact these deaths have on generations of family members. What is often a very protracted legal process can really impact on a family’s ability to begin the grieving process, and it can undermine the opportunity for learning.  Our work is evidence based and it informs all our policy and campaigning work for change.

It is important to stress how vital the role of the inquest is in shining a light behind the closed walls of prisons and subjecting each of the deaths to public scrutiny. Of course it is also an opportunity to test the evidence that is being gathered as part of the PPO investigation.  Properly conducted inquests where families are legally represented can play a very important preventative role.  At the conclusion of the inquest a coroner can make recommendations to prevent future deaths. It is important to say that because families’ motivation for going through what is a very distressing legal process is in the hope that future deaths can be prevented: that there can be the proper systemic learning.  I think it is also important to flag up the difficulty that families still have because there is not non-means-tested public funding for families’ representation despite the fact that there are unlimited funds for the state to be represented and of course private companies as well. Their role is too often to try and close down the inquest remit and frustrate the very important learning potential for inquests.

As Sue has outlined, we saw an unprecedented rise in deaths in 2016, and although it looked like the deaths were reducing in 2017, the latest figures show that the numbers of both self-inflicted and non-self-inflicted deaths are rising again.  The levels of self-harm and distress have never been higher, and there are record levels of those who are awaiting classification, and an unprecedented number of people being found unresponsive in their cells. Inquest has a concern that, across the political spectrum, the focus about the current crisis facing prisons is always articulated as one of understaffing, underfunding, violence and drugs, rather than looking at what comes out of investigations and inquests and how these so-called problems are better understood as symptoms with a broader social and political context – the overuse of prison to tackle issues around poverty, addictions and mental ill health, the failure that inquests reveal too often to treat prisoners with humanity, dignity and compassion.  For INQUEST – and I say this as somebody who has been around a long time – one of the burning issues is the lack of accountability and learning from these deaths.  It is difficult to convey the frustration and indeed anger that our staff see, at the fact that inquest after inquest reveals repeated systemic failings, the same issues being repeated time and time again.  I know the PPO share the same sense of despair that these are not new failings.  These are some very basic failings to implement policies around the health and safety of at-risk prisoners.

The other thing is that many of the post-death investigations and inquests have consistently demonstrated that many deaths in prison are entirely preventable. We have real concerns about the oversight, regulation and accountability of prisons and healthcare services, both private and NHS.   In particular we are concerned about the lack of a national oversight mechanism that is tasked with the statutory duty to collate, analyse and monitor the implementation of official recommendations relating to custodial deaths and prison safety, which means that opportunities to save lives are being missed.

That serious accountability gap is not something of which INQUEST alone has been critical.  Whenever there has been independent scrutiny of, and reviews of a pattern of deaths through inquiries, for example the Corston report, Lord Harris’s review of deaths of young people, the Angiolini review into deaths in police custody, and various reviews by parliamentary committees, for example the Joint Committee on Human Rights inquiry into mental health in prisons, and most recently the Health and Social Care Committee, the lack of oversight and the failure to act on recommendations has been an enduring feature.  Today’s inspection report on Birmingham Prison speaks to the problem, in respect of a pattern of deaths over the last couple of years.  This was a prison for which the Chief Inspector of Prisons invoked the urgent notification process which brought serious concerns about the prison directly to the attention of the Secretary of State. The inspection findings were particularly alarming.  Only twelve of seventy previous recommendations made at the inspection in February 2017 had been achieved.  Only three of the fifteen recommendations made in the area of safety had been achieved, with particular concerns about a lack of care about prisoners at risk of suicide and self-harm.  It does beg the question: what is the point of inspection reports and recommendations if they only disappear into the ether.

We have seen a cycle of chief inspectors and ombudsmen (and I am pleased to say, in Sue, an ombudswoman), and indeed Lord Ramsbotham, despair at the inertia of the system to meaningful reform.  Of course that is not to disregard the role of staff, who are desperately trying to do their best in what are often really awful circumstances.  I know that time is of the essence, but I wanted to tell a brief story about an inquest which finished today into the death of a woman in a Sodexo-run prison, HMP Bronzefield.  This was a death which was investigated by the PPO and indeed a clinical review.  Sadly both failed to address the serious healthcare concerns that the inquest jury and the coroner subsequently found.  What is particularly worrying about this case is that this is a death at a prison that had been the subject of a critical inspection report, which had made a number of recommendations about the management of drug services within the prison, the administration of medication, issues around medical records – recommendations that clearly had been ignored, and a young woman has died as a result.  Her death was found to be because of neglect, by systemic failure through poor governance, which led to a lack of basic care: unsafe practices, poor governance and failings of the system at the prison.  This was a woman with alcohol and drugs dependencies, a history of depression, poor physical health: a woman who was not unfamiliar in terms of the prison knowledge of women who end up in the custody of the prison service.  But for us it raised a number of questions about the way in which the state responds to inspection and ombudsman’s recommendations.  As Sue has said, the recommendations of the PPO are not followed up by them because they are not resourced to do so.  So the only time one is likely to find out whether or not those recommendations have been acted upon is really in the event of another death, or when the prison inspectors go and visit – which can be in several years’ time.  There is a real danger, as the Chair of the Prison Governors said in evidence to one of the parliamentary committees, that too often those action plans end up gathering dust because of the pressure of other work.

In conclusion, we are concerned that there is a real accountability gap in the mechanisms for learning.  We have been very consistent in our work in calling for a national oversight body tasked with the duty to collate, analyse and monitor learning and implementation, which is accountable to parliament, to ensure the advantage of parliamentary oversight.  I was very pleased that Dame Elish Angiolini in her review of deaths in police custody, and looking at the broader questions of accountability, endorsed that recommendation and recommended an office of Article 2 compliance.  She recognised that there was this accountability gap, and that we were seeing the same issues time and time again.

The other important issue is the lack of reflective learning that takes place, when prison deaths occur.  Our families never hear from prison governors, or from anybody connected with the Prison Service or NHS England, after an inquest as to what action has been taken.  We are all here because we are committed to better learning, and better accountability.  Some reflective learning, and an opportunity to meet with families after an inquest has finished, so that they could hear what has been done in response to this death, might focus minds on the importance of these issues being dealt with, both at an individual prison level, but also in respect of the value of sharing learning from prison to prison.  If we had a better system, it could help to drive learning across the prison estate.

The current systems that we have are failing not only bereaved families but the important public interest.   Thank you’.

Lord Ramsbotham thanked Deborah Coles and introduced the third speaker, Juliet Lyon, Chair of the Independent Advisory Panel; of Deaths in Custody. He reminded her of an invitation he had issued to her to come to an inspectorate training day, when she was working with adolescents.  He had also invited Michael Howard, then Home Secretary, who admitted that had had not appreciated how much was involved in prison suicide.

Juliet Lyon thanked Lord Ramsbotham for his introduction: ‘Since I started in this role, which I took over from Lord Harris, I have taken a very pragmatic view.  What could we do, as a small panel?  It took a while to get the panel reappointed, a longer while than it should have done, but we now have a very expert panel.  We have two excellent forensic psychiatrists, a human rights lawyer, a very good director of a family charity, and an expert in learning disability from the Prison Reform Trust. We are up and ready, and what we did to start with was to ask prisoners what they thought would be the best way to prevent suicide and self-harm.  It seemed a very obvious place to start.  We started with women, because in 2016 there were the self-inflicted deaths of twelve women – many more than prompted the Corston Review those years ago.  It won’t surprise you that the women came up with some extremely sensible things that could be done, some practical things that could be done quite quickly, and other things that would take longer because they involved policy shifts.

We talked to sixty women in eleven prisons, and put that together with submissions from forty health and justice professionals. We presented that in a range of formats, and in particular we presented that to the Prison Service (HMPPS).  I was really pleased that HMPPS created a grid with the recommendations, alongside the PPO thematic on women, and worked systematically through those recommendations, and delivered very many of them in practice in women’s prisons.  There were some really detailed practical things.  To give you one small example: some of the women said ‘when we move prisons, we have our pin phone number stripped away so we can’t ring our Mum or partner or a friend, at a very risky time’.  We know that any kind of transition of that kind, like first nights in custody, is a very risky time.  Other women said ‘No, that doesn’t happen to us’.  Given that women’s prisons have the same security classification, there was no reason whatever for this practice, but it had just happened – as things just happen.  And it was very easy to put right: it was put right that week. So no women lose their pin phones numbers when they are moved from one prison to another.  That felt like a very positive step.  I said I have taken a pragmatic stance. There are many things that both Deborah said, and Sue before her, that I very much agree with and would like to see change.  But I also think there are things that can be done right now, and it is worth getting on with some of those.

As well as the women’s consultation we worked with our partners on Inside Time and Prison Radio to ask men in prison to tell us what they felt would prevent suicide and self-harm.  We were very pleased to get 150 submissions from almost 60 prisons across the estate.  Between those two consultations, the main reasons that people gave for the rise in suicides were these: they talked about a reduction in staffing levels; the loss of experienced and trusted staff; vacancies in mental health teams; less activity and more time in cell; and no one to listen or talk to.  That emphasis on relationships with staff was very vivid in all the consultations and conversations we had. They also talked about unmet mental health need; learning disability; drug and alcohol treatment needs.  They talked about the increase in illicit drug use in prisons; levels of violence; and debt.  Alongside that, they mentioned a decrease in release on temporary license; an increased risk of homelessness on release; and the high level of recalls to custody.   Lastly, for women, the knock-on effects of the hasty closure of Holloway Prison and the increased distance from home.  For the men, many of them referred to the IPP sentence, and the utter hopelessness for people still serving that appalling sentence.

So those were the reasons, and as I said, we have been pursuing some of the solutions since.  May I tell you some of the things we have done.  We are an independent body, sponsored by three departments (the MoJ, the Home Office and the DoH) and we cover all forms of death in all forms of state custody.  We don’t have a statutory basis, and possibly at this stage we can do a lot as we are. But I am very open to the idea that things in this sphere need to change, and the emphasis always has to be on increasing levels of accountability.  Two examples of how we are trying to work towards that.  One is that we gathered together all the people doing regulation and scrutiny and we asked them what they believed would be the most significant changes they would like to see made.  Time and again, as we’ve heard from the Ombudsman, we’ve seen the same recommendations, seemingly endlessly.  We devised a list from those scrutiny bodies, and we are now working with that list initially to address individual prisons, and with HMPPS, and then taking that further across other aspects of custody.

They came up with a very powerful list of recommendations, top of which was effectively to show accountability.  They also talked about not using prisons as a place of safety, and drew attention to what had happened when police custody had effectively stopped being used as a place of safety, and the reduction in deaths to which that had lead. They also talked, obviously, about appropriate levels of skills and staffing; open information-sharing; proper health commissioning; emergency response; the identification of risk factors; and contact with families; as well as effective implementation of existing procedures – and often it is that gap which must lead to huge amounts of frustration.  An example of a practical way we are addressing that, taking Deborah’s reference to families, and how one does not forget meeting a family in those terrible circumstances, we are experimenting with individual prisons teams to see how they can draw the lessons they have learnt from a death and how they will present that to a family.  If that works, guidelines will be produced by the PS so that each team will be required after an investigation by the PPO and the Coroner’s report to prepare a report which will go directly to the bereaved family.  They will meet them if the family is willing and otherwise they will make sure that the family gets that report. So that feedback will be delivered, but we are hoping that that will also lead to much more reflective learning.

The last thing we are trying to do, which operates at a different level, is a safety assessment. That is something like an equality impact assessment, insofar as what we are saying is to try and prevent that horrible curve of deaths in custody, which goes up and down in a zigzag pattern, and leads to a lot of inconsistency, and the current rash of self-harm, which is at almost 50,000 incidents in the last twelve months.  What we are looking at is saying to people: before you make a huge decision about resources, or about policy, or a major change in the service, put on a pair of glasses which look through the lens of safety.  Look at prisoner safety; look at staff safety; and have an assessment of whether what you are proposing to do is going to have a major impact on that.   Ask the officials who are presenting that information to you to present ways in which that could be mitigated or ameliorated.  Or decide against a particular course of action.  I would like to suggest that, possibly at least, when the proposed almost 30% cuts were introduced, had people looked through a lens which was about safety and decency, we might have had a very different result.

I would like to draw to a close by telling you what one of the prisoners told us.  It is not all about failure, or saying to prison staff that what they are doing is just not good enough.  Sometimes, as both the previous speakers said, they are so up against it.  This is what one man told us about what had stopped him trying to kill himself.  ‘I have been in prison now for over thirty years.  During this time I have attempted suicide twice, and both times came close to death.  The second time I was in outside hospital for nine days.  These attempts came about because of the death of my sixteen year old son.  At this time I was in the segregation units of the high security prisons and I can say there has been little help for me.  It was only when I thought of attempting suicide for the third time that I met a senior officer in Wakefield segregation unit. This man had been present when the life support was switched off as his daughter passed away. This man took the time to sit and talk to me, not as a prison officer and prisoner, but as two human beings. This man turned the tide for me, and I never got the chance to thank him.’


Lord Ramsbotham thanked Juliet Lyon, and opened the floor to questions.

Lord Dholakia referred to the number of reports on this subject since he had been involved in the criminal justice world, produced by a range of organisations, which were gathering dust.  Could someone go back to look at these, to see what if anything had been done about them?  There were inevitably resource implications, now we have 83,000 prisoners, but what training was available?  And how could we bring families more effectively into the prison situation? Finally, should we be keeping so many mentally ill people in prison?

Sue McAllister responded that there was piece of work to be done about the reasons why the response to recommendations had been so poor.  She thought the some of the reasons might be cultural, some structural, and some just because people were overwhelmed.  For example, the repeated recommendation about the inappropriate use of restraints when people were near to death: she knew that prison staff were concerned about security, whilst health care staff had different priorities.  However it was difficult for a junior healthcare worker to stand up to a prison officer in uniform.  The wording of the risk assessment also lent itself to a presumption in favour of restraints. We needed to understand what was happening at the front line.  This was not about resources. There was an appetite for change at senior levels, but it was just not happening.

Deborah Coles responded to the point about involving families, more especially with prisoners identified as being at risk.  That had been a consistent recommendation, but it was still not happening, even for the most involved families. As to the point about repeated recommendations, there was a question about who was ultimately accountable for their implementation.  We had corporate manslaughter legislation relating to deaths in custody which had never been used.  There were some cases where there was evidence of appalling neglect and negligence in allowing very dangerous, life-threatening situations to continue. Sometimes it took a strong sanction to focus the mind. People were dying needlessly, because of failures to protect their lives.

Baroness Masham related a story, from many years ago, about a young offender who was asthmatic.  He had warned that he was in danger, but he did in fact die. One of the Assistant Governors had told her that there had been a problem with the prison doctor at that time, and the records had been changed. She was concerned that the national shortage of doctors and nurses currently, meant that there would be an impact on prison healthcare services.

Juliet Lyon said that numbers of people in prison had respiratory problems, and the proposed use of Pava (pepper) spray would exacerbate those problems. The vacancies in prison health teams were disturbing. As regards prisoners with mental health needs, Lord Bradley’s efforts to divert them to proper healthcare should be applauded. A clinical director who had responded to the IAP consultation had been clear that the use of prisons as places of safety should stop immediately. Prison was only likely to worsen the condition of people with mental illness. There were pockets of very good liaison and diversion work, but there should be much more of it.

Deborah Coles added that the report of the Health and Social Care Committee on prisoner health raised very serious questions.  One issue was about oversight of this provision.  The high number of what appeared to be preventable deaths, questions about the supposed parity of healthcare, and the quality of clinical reviews carried out after a death and their lack of independence, were all matters of concern.

Sue McAllister added that one of the PPO’s repeated recommendations concerned the lack of suitably qualified healthcare staff. There was no lack of appetite and commitment from the top to get this right, but it was about how this could be translated into action.  It was not all about resources.  She wanted to see the clinical reviews integral to PPO reports, rather than add-ons, and she needed to understand how that could be made to happen.

Lord Bradley returned to the question of the accountability gap.  He had been shocked that there had been nearly 900 recommendations just last year, but it was not known how many of those had been implemented, whether in an individual prison or system wide.  He was not clear who was responsible for implementing those: was it the MoJ, HMPPS, or was it a shared responsibility? This should be clarified.  As to the point about prison officers and healthcare staff, he recalled that when the street triage work had begun he had been told that police and healthcare staff would not work together.  Now they were in vehicles on the street together supporting people in crisis. Effective joint training could break down the silos in its focus on the individual, and make great cultural and organisational changes possible.

Lord Ramsbotham said that sadly the meeting had to finish. He thought that the retirement of Michael Spurr, and the reorganisation of HMPPS which would doubtless follow, provided an opportunity for him, as chair of the APPG, to write to the Secretary of State to emphasise the points made at the meeting, particularly the picking up of repeat recommendations, and to ask him to put a structure in place to ensure that this did not happen again.

He once more thanked all the speakers, and closed by announcing the date of the next meeting, on 22nd January 2019, at 5.30 in the same room, to discuss race and disproportionality in the criminal justice system.