Deaths in Custody: Key themes from two recent reports
20/09/23
In the below insight, we outline the key themes and learnings from the following reports:
The PPO published its annual report on 14 September 2023 for the period of 2022 to 2023, which focuses on the outcomes of complaint investigations and fatal incidents. Alongside this, on 12 September 2023 the IAPDC published a report on the “Priorities for detention for the Department of Health and Social Care’s suicide prevention strategy”. The report focuses on the key themes to ensure detainees’ rights to live are protected through policy and practice.
There are a number of key issues that appear in both reports regarding recommendations and potential improvements.
Staff culture, leadership and training
The first recommendation of the IAPDC report identifies the need for person centred and trauma informed training for staff around responding to mental health crises. This involves building positive relationships and incorporating the voices of prisoners and their families to provide practical and scenario based training. The aims of this training would be to ensure individuals receive compassionate and personalised support.
When a death occurs in custody, the IAPDC suggests that there should also be learning from community postvention initiatives to ensure that people in detention and staff are supported. The IAPDC highlights these measures as key to address staff burnout and to prevent problematic cultures where staff may display antipathy towards people who harm themselves.
Multiagency support and information sharing
Both the IAPDC and PPO also focus heavily on the need for information to be shared in a timely manner within institutions, and also across the criminal justice system. Staff should understand their responsibilities in a medical emergency, and have regular input from all core services at multidisciplinary case reviews.
For health services, the PPO makes additional recommendations including ensuring robust record keeping, and following up on health tests with timely referrals.
Self-harm and suicide prevention
A key recommendation from both reports is a need to include non-clinical factors in ACCT (Assessment, Care in Custody and Teamwork) care planning processes (for example, court appearances), and to carry out meaningful welfare checks following these factors.
The PPO report also emphasises the need to look at more than the presentation of the prisoners when carrying out a risk assessment. Similarly, the IAPDC suggests the involvement of families, where appropriate, in ACCT reviews and care planning.
The IAPDC further highlights the need for all risks to be recorded in one place for easy access to up to date information.
Emergency response
Where the IAPDC report focuses on planning and prevention, the PPO report also makes recommendations for emergency responses. The report emphasises the need to avoid delay when
- entering cells
- radioing the correct codes
- calling an ambulance immediately when responding to a medical emergency.
The report also advises that staff should satisfy themselves with the wellbeing of all prisoners during roll checks, and have easy access to the correct equipment to respond to a medical emergency.
Family involvement
In terms of preventing emergency situations, the IAPDC report emphasises the importance of means to contact families for support, or sufficient access to charities who can provide this support.
The recommendations for achieving this include prisoners being detained in a location close to their families, or with schemes which facilitate visits or video calls, in cell telephony and the removal of out of area placements for individuals detained under the Mental Health Act 1983.
Custodial landscapes
Both reports also make recommendations on the use of segregation, with the PPO highlighting the need for mental health input when making decisions to segregate prisoners and the IAPDC suggesting alternative provisions to segregation for prisoners at risk of self-harm or suicide.
The PPO also suggest prisoners in segregation are allocated a designated officer to ensure meaningful conversation, and are provided with sufficient distraction material.
Capsticks comment
Both reports offer valuable insight into the challenges facing our secure environments. However, given current staffing levels coupled with the projected growth in the prison population, it is now more than ever absolutely imperative that those working within this sector are afforded the proper support and resources to enable them to operate safe environments for both prisoners and staff.
How Capsticks can help
Capsticks aims to be the firm of choice for organisations working within the Health and Justice Sector, offering a full range of services including representation at Inquests and Public Inquiries, assistance with PPO responses and Action Plans, Judicial Reviews, Civil Claims arising from Inquests, Human Rights Act Claims, Serious Incident investigations, Investigations undertaken by the police or regulatory bodies and Information law.
For further information on the services we can provide, please see here.
If you have any queries around what's discussed in this article, or the impact on your organisation, please speak to Naomi McMaster to find out more about how Capsticks can help.
