Investigations of deaths in custody – trends and themes

1. Investigations of deaths in custody – trends and themes 25 October 2017 Richard Pickering – Deputy Prisons and Probation Ombudsman

2. The PPO - investigatingFatal Incidents • The fatal incidents function was established in 2004 • The Ombudsman is required to investigate all deaths in prisons, young offender institutions (YOIs) probation approved premises, immigration detention facilities and secure training centres (STCs) • We can also investigate where someone dies under probation supervision outside approved premises • In 2016, the PPO agreed to investigate youth justice and welfare placements at local authority secure children’s homes (SCHs)

3. Our investigations • Provide explanations and insight for the bereaved relatives; and • Help fulfil the investigative obligation under Article 2 of the ECHR (‘the right to life’) by working with coroners to ensure the full facts are brought to light and any failing is exposed, any commendable action or practice is identified, and lessons from the death are made clear. • Establish the circumstances and events surrounding the death; • Examine whether any change in operational methods, policy, practice or management arrangements would help prevent a recurrence; • Examine relevant health issues and assess clinical care;

4. Last year … We started investigations into 361 deaths in 16-17: • 208 (58%) deaths from natural causes • 115 (32%) self-inflicted deaths • 16 were ‘other non-natural’, 9 of these related to drug toxicity • 4 homicides

6. Self-inflicted deaths • 115 Self inflicted deaths in 2016-17 (an 11% rise) • 103 Self inflicted deaths in 2015-16 (a 34% rise) • Last year was a 50% increase on two years ago (76 in 2014-15)

7. We say … “Major themes must be acted upon, for example the pervasiveness of mental ill-health and an epidemic of new psychoactive drugs.” “I remain concerned that suicide prevention measures were designed when prisons had fewer prisoners and many more staff. I continue to question their fitness for purpose.”

8. Older prisoners

9. Natural causes • 19% increase in 2016-17 (to 208) • 10% rise in 2015-16 (to 172) • There were 118 deaths from natural causes four years ago (2012-13). That’s a 76% increase in four years

10. All reports, lots of lessonswww.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

11. We say … “One of the systemic failures has been the apparent inability of prisons under pressure to learn lessons or to sustain improvement based on that learning.” “Our recommendations will be accepted and an action plan put in place.” “But too frequently HM Inspectorate of Prisons will subsequently visit and find a lack of action.” “Worse, we will be called to a new death only to find that previous lessons have not been learned.”

12. The future • So far, the picture for 2017-18 is, cautiously, better • Year to date: fewer deaths and fewer self-inflicted deaths • The exam question – what, if anything, has changed?