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

2. The PPO - investigating Fatal 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)
So the Prisons and Probation Ombudsman extends to welfare placements at SCHs … children who are not, by any stretch of the imagination, “prisoners”.
It was felt, however, that it would be a more detrimental anomaly for the PPO to have a role investigating some deaths in SCHs and not others. In addition, we also investigate when unconvicted or unremanded people die in court cells or whilst being transferred to court from police cells.
We are currently investigating the death of a child who was placed at an SCH for their welfare and the death of a man who was being driven to a Magistrates’ Court from a police station.

3. Our investigations
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;
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.

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

5. This chart is from our most recent annual report.
The rate of self-inflicted deaths has been unacceptably high for what – in theory at least – are preventable deaths
In we saw an increase in self-inflicted deaths among women and there was even one apparently self-inflicted death in a secure children’s home

6. Self-inflicted deaths
115 Self inflicted deaths in (an 11% rise)
103 Self inflicted deaths in (a 34% rise)
Last year was a 50% increase on two years ago (76 in )
These are the stats from annual reports. Each report will always include some deaths that are awaiting classification at the time of publication.
In we made 690 recommendations following deaths in custody. Every single one was accepted.
This graph shows that nearly 80 of our recommendations related to suicide and self-harm – essentially ACCT.
Nearly 40 were on mental health provision, with a similar number on substance misuse.

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
The bars here are the total number of deaths from natural causes. You can see it going up almost every year.
The line is the percentage of prisoners aged 50 or over in the prison population.
It makes sense that as the age of the prison population increases, the number of natural causes deaths increases.

9. Natural causes 19% increase in 2016-17 (to 208)
10% rise in (to 172)
There were 118 deaths from natural causes four years ago ( ). That’s a 76% increase in four years
These are the stats from annual reports. Each report will always include some deaths that are awaiting classification at the time of publication.
was a very lean year.
In we made 690 recommendations following deaths in custody. Every single one was accepted.
Nearly 150 of these related to healthcare provision, with around another 15 relating specifically to managing terminal or serious illness.
Nearly 80 related to the use of escorts and retraints. This has been a particular concern of the Ombudsman in recent years.
EMERGENCY RESPONSE is not on either this slide or the previous. It cuts across both. 100 recommendations relate to this.

10. 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

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?