Deaths in Custody: The Noose Around The Ombudsman’s Neck

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open letter from Mark Leech The Editor of The Prisons Handbook for England and Wales, to The Prisons and Probation Ombudsman

 

Dear Sue,

Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation.

Did you bother reading each of those words – or notice I had inserted a number in one of them?

Actually, I didn’t, but you went back anyway and read them again; right?

Unfortunately, that isn’t what happens to the ‘Recommendations’ you make in your Fatal Incident Reports into deaths in custody; people don’t go back and read them again.

When you set out your ‘Recommendations’ designed to learn lessons and reduce deaths in custody, no one takes a blind bit of notice of them – and, what’s worse, your Office ignores the fact they’re ignored too.

Tragically you’re not alone in looking the other way. Independent Monitoring Boards (IMBs) in whose prisons these deaths take place, and to whom monitoring the implementation of these Recommendations should be a priority, ignore them too. Year after year, they simply airbrush them out of their Annual Reports as if they have never been made; I will return to this shortly.

Every single Prisons Ombudsman that’s gone before you in the last 25 years at least had the excuse that they’ve never unlocked a prison cell door and found a prisoner swinging dead with a noose around their neck; but as a former Prison Governor you don’t have the luxury of that excuse. You know exactly what it’s like: the shock, horror, frantic attempts at resuscitation, and the wave of utter devastation that then descends on the whole prison afterwards.

Yet, despite that personal experience deaths in custody keep happening and frequently too; as I write this we are six weeks into 2019 and already 20 people have died in our prisons – 17 of whom have seemingly taken their own lives, and eight definitely have.

Your Office still keeps investigating these deaths, still keeps writing their reports, still keeps making recommendations, and still does absolutely nothing when, time after time, those recommendations are ignored – lamentably this week you’ve done it again.

John Delahaye was 46 years old when he was found dead in his cell at Birmingham Prison on 5 March 2018; let me remind you of the catalogue of errors that lead up to it.

Ten weeks before his death Mr Delahaye was taken from Birmingham prison and admitted to hospital almost certainly having taken an insulin overdose; he returned to prison 24 hours later.

In your report into his death published this week, you write:

“When Mr Delahaye returned to Birmingham on 1 January following this overdose, there was no handover between hospital and prison healthcare staff and prison healthcare staff did not know he had returned to prison until the next day. 

I am also concerned that suicide and self-harm monitoring procedures (known as ACCT) were not started until the day after he had returned to prison. In addition, I have concerns about the way the ACCT procedures were managed when they were started. Staff did not effectively investigate why Mr Delahaye had taken the overdose and healthcare staff were not involved. The ACCT was closed prematurely two weeks later, with little having been done to identify or mitigate Mr Delahaye’s risk to himself. This was compounded by the fact that Mr Delahaye was discharged from mental health services after just one appointment.

I am concerned to be repeating recommendations to Birmingham about suicide and self-harm prevention procedures. [emphasis added]

“It is very difficult to understand why Mr Delahaye was allowed to have his insulin back in his possession less than a month after his overdose. I am concerned that NHS guidelines were not followed when this decision was made. 

“I also have serious concerns about the way staff at Birmingham conducted roll checks and unlocks. When Mr Delahaye was found on the morning of 5 March, he had clearly been dead for some time and it seems possible that no member of staff had seen him for more than 13 hours.

“This needs to be rectified urgently. 

“Staff also failed to use an emergency code when they found Mr Delahaye unresponsive. Although this did not affect the outcome for Mr Delahaye, it could make a critical difference in other cases.” 

Now, take a moment to look too at the Birmingham Prison IMB Annual Report published just 10 weeks ago and covering the period in which Mr Delahaye died in the prison. Neither his name, the circumstances of his death, nor the fact that your repeated recommendations had been ignored, are ever mentioned; not even once – they’re airbrushed out of existence; small wonder then why so many consider the IMB as completely and utterly useless?

I would remind you that your Office is not investigating the loss of someone’s property here, but the loss of someone’s life; yet it consistently fails to understand this vital distinction.

I accept the fact you are new to this role, and while there are those who say that as a former Prison Governor you are not the right person to be holding this critical Independent Office, I’m not yet one of them. I think your experience as a Governor means you know where to look, what questions to ask, what answers to demand and having opened cell doors and cut dead people down you know exactly how important all this really is.

The question is: when will we see action from your Office and not just words that everyone, including IMBs, totally ignore?

Yours sincerely,

Mark Leech

Editor: The Prisons Handbook for England and Wales

@prisonsorguk

A Travesty: The lost opportunity to reform the IMB

From 1 November 2018, the governance structure for the Independent Monitoring Boards (IMBs) will change – in an announcement that critics have called ‘a travesty’.

This follows a government consultation, which was reviewed and revised by the National Chair, Dame Anne Owers after her appointment in November 2017, and discussed at four regional chairs’ forums in the first part of 2018.

The new structure will support the work of the 128 IMBs that monitor prisons in England and Wales and places of immigration detention within the UK.  It will strengthen their independence, effectiveness and impact, at a time when their role is becoming increasingly important in highlighting conditions and treatment in detention.

Dame Anne will chair a national Management Board, which will be responsible for setting the strategies, policies and procedures that underpin IMBs’ work.  The Board will produce a business plan, which will be published, along with the supporting strategies and policies.

The initial membership of the Management Board is drawn from IMB members with relevant experience in monitoring techniques, and also in HR, training, IT, information management and analysis.  Members are: Will Baker, Pauline Fellows, Keith Jamieson, Jane Leech, Mike Siswick, Alex Sutherland and Brian Thomas.

They will soon be joined by two external members, with experience in finance/audit and equality/diversity.  The Management Board has already identified priority areas of work. A business plan will be published in December and work will be reported in a new governance section of this website.

Alongside the Management Board, there will be a network of regional representatives, to provide direct support to IMBs in their region and liaise with the Chair and Management Board, ensuring that the needs and views of the regions are integral to the development of national strategies, policies and plans.  Eleven regional representatives have been appointed, and will be joined by two additional representatives.  They will formally take on their role on 1 December, after a handover period in November.

At the same time, we are working to ensure that our information is acted on more swiftly, and informs policy and practice. This includes promoting consistency in the way that we monitor and report, to strengthen the evidence base for our findings. The National Chair regularly visits boards to discuss their work, and looks at all annual reports (an overall national annual report will be published in early 2019).  So we are better able to analyse and pull out key themes, for example:

  • Our prison reports are now fed into a prison scrutiny research tool, which will make it easier for policy makers and HMPPS to use data from IMB reports.
  • Our findings are increasingly reported in the media, for example BBC Radio 4’s File on Four on prison maintenance problems, and coverage of individual annual reports – read a small snapshot of media interest in several reports that have recently been published here.
  • We provide evidence to parliamentary inquiries: the Justice Select Committee’s Prison Population Inquiry (download here) and to the Joint Parliamentary Human Rights Committee’s Immigration Detention Inquiry, which is not yet published. Anne Owers and Jane Leech (Management Board member) will be giving oral evidence to the JCHR later this month.
  • The National Chair regularly meets with Ministers and senior officials to pass on real-time information and issues arising from boards’ monitoring and to ensure that IMB findings feed into developing policy and practice: for example on prisoners’ property, resettlement, complaints handling and suicide and self-harm processes, and immigration escort arrangements.
  • We are undertaking and planning joint work with other independent detention oversight bodies, within the UK’s National Preventive Mechanism under the UN Optional Protocol against Torture.

Mark Leech, Editor of The Prisons Handbook who was invited to take part in the review that led to the new IMB structure, called the new system ‘a travesty’.

Mr Leech said: “Four years we’ve waited since the independent MOJ-commissioned Karen Page Associates Review of IMBs said the IMB was in need of ‘root and branch reform’ – and what have we got?

“Exactly the failed system we had before, just rebranded that’s all.

“This isn’t a new structure at all, it is exactly the same MOJ horses, being ridden by exactly the same discredited jockey’s, who are now just wearing different colours.

“Its a travesty of the real opportunity to reform the IMB that this review represented.”

IMB ‘New’ Governance Arrangements Announced – “A wasted opportunity”

From 1 November, the governance structure for the Independent Monitoring Boards (IMBs) will change.  This follows a government consultation, which was reviewed and revised by the National Chair, Dame Anne Owers after her appointment in November 2017, and discussed at four regional chairs’ forums in the first part of 2018 – critics have slammed the new arrangements as an old broken system of monitoring in which nothing has changed.

The new structure will support the work of the 128 IMBs that monitor prisons in England and Wales and places of immigration detention within the UK.  It will strengthen their independence, effectiveness and impact, at a time when their role is becoming increasingly important in highlighting conditions and treatment in detention.

Dame Anne will chair a national Management Board, which will be responsible for setting the strategies, policies and procedures that underpin IMBs’ work.  The Board will produce a business plan, which will be published, along with the supporting strategies and policies.

The initial membership of the Management Board is drawn from IMB members with relevant experience in monitoring techniques, and also in HR, training, IT, information management and analysis.  Members are: Will Baker, Pauline Fellows, Keith Jamieson, Jane Leech, Mike Siswick, Alex Sutherland and Brian Thomas.

They will soon be joined by two external members, with experience in finance/audit and equality/diversity.  The Management Board has already identified priority areas of work. A business plan will be published in December and work will be reported in a new governance section of this website.

Alongside the Management Board, there will be a network of regional representatives, to provide direct support to IMBs in their region and liaise with the Chair and Management Board, ensuring that the needs and views of the regions are integral to the development of national strategies, policies and plans.  Eleven regional representatives have been appointed, and will be joined by two additional representatives.  They will formally take on their role on 1 December, after a handover period in November.

At the same time, we are working to ensure that our information is acted on more swiftly, and informs policy and practice. This includes promoting consistency in the way that we monitor and report, to strengthen the evidence base for our findings. The National Chair regularly visits boards to discuss their work, and looks at all annual reports (an overall national annual report will be published in early 2019).  So we are better able to analyse and pull out key themes, for example:

  • Our prison reports are now fed into a prison scrutiny research tool, which will make it easier for policy makers and HMPPS to use data from IMB reports.
  • Our findings are increasingly reported in the media, for example BBC Radio 4’s File on Four on prison maintenance problems, and coverage of individual annual reports – read a small snapshot of media interest in several reports that have recently been published here.
  • We provide evidence to parliamentary inquiries: the Justice Select Committee’s Prison Population Inquiry (download here) and to the Joint Parliamentary Human Rights Committee’s Immigration Detention Inquiry, which is not yet published. Anne Owers and Jane Leech (Management Board member) will be giving oral evidence to the JCHR later this month.
  • The National Chair regularly meets with Ministers and senior officials to pass on real-time information and issues arising from boards’ monitoring and to ensure that IMB findings feed into developing policy and practice: for example on prisoners’ property, resettlement, complaints handling and suicide and self-harm processes, and immigration escort arrangements.
  • We are undertaking and planning joint work with other independent detention oversight bodies, within the UK’s National Preventive Mechanism under the UN Optional Protocol against Torture.

Mark Leech, editor of The Prisons Handbook for England and Wales, said the new governance arrangements ‘were pointless’.

Mr Leech said: “For four years the Ministry of Justice have been working on these much needed reforms but what they have produced is pointless.

“I was a part of the Ministry of Justice review process, what they have come up with here is nothing like the revised governance arrangements signed off by the Justice Secretary in 2016.

“This is just the same broken system repackaged as something new when it is nothing of the sort.

“Neither prisoners nor staff have any faith in the claimed independence of IMBs, prisoners refer to IMB members as ‘those old gits that visit’ – and after this nonsense that is unlikely to change.

“Opportunity for reform knocked, but the door was slammed in its face – a thoroughly wasted opportunity.”

Thameside IMB Annual Report: “There are 70+ gangs with members in the prison who need to be kept apart.”

 

 

 

 

The Independent Monitoring Board at HMP Thameside, a public sector prison in London, has published it annual report.

EXECUTIVE SUMMARY: Introduction

HMP Thameside holds a diverse and fluctuating prisoner population with different needs (young and elderly, remand and convicted [short and long sentences], UK and foreign nationals). Every day it accepts whomever the courts and HMPPS send it, and the average stay is short. Operating within, but very close to, its operating capacity of 1232 men, it has been ‘crowded’ throughout the reporting year (as defined by HMPPS). It meets these challenges well.

Main judgements

Are prisoners treated fairly?

The prison’s systems and practices are properly designed to be fair but the IMB is seriously concerned at the unfair impact of inadequate management of some processes. Areas of ‘low level’ unfairness identified in the 2016/17 Annual Report persist (5.7). Far from improving, the handling of prisoners’ complaints deteriorated markedly at the end of 2017/18 (5.9). The organisation of home detention curfew (11.6) remains unreliable. Delays making repairs when equipment is broken (7.1, 7.2, 7.8), cancellation of activity sessions (7.3), and more use of restricted regime with men spending longer in their cells (7.4), all cause the IMB growing disquiet. A simple task, like delivering necessary post to prisoners, has been taking up to two weeks (5.8). Nevertheless, the IMB can also report that the prison has implemented valuable initiatives, detailed in the evidence sections below (e.g. 4.2.1, 4.4, 5.1, 8.4, 8.7, 10.4, 11.5).

Are prisoners treated humanely?

HMP Thameside remains a humane prison with an unoppressive ethos. The nine protected characteristics are taken seriously and prisoners’ basic rights are recognised (5.1). The Early Days Centre provides appropriate oversight when men first arrive (4.6) but the care with which the ACCT system is implemented deteriorated during 2017/18 (4.3). Adjudications and Reviews are conducted humanely (6.4, 6.7). A smoking ban was introduced in March 2018 following good preparation. Men suffering from the withdrawal of tobacco are helped (8.2). The quality of healthcare is not consistent. There are unexplained delays in treatment or referral (8.4). Some men held in the In-Patient Unit have too little time out of cell (8.3.2).

Are prisoners prepared well for their release?

Prisoners committed to HMP Thameside stay for periods ranging from a few days to several years. The average is 5 weeks (11.1). Many have needs that cannot be met by the prison. Because of their diversity, it is impractical to establish all-inclusive programmes to prepare men for life in society. Disappointingly, the availability of suitable accommodation for released men remains poor (11.4). A typical prisoner leaving the establishment has not been prepared well for a law-abiding lifestyle. On the plus side, substance misusers are helped whilst in prison (8.7); maintenance of family links is supported well (7.7, 11.5); some men improve their numeracy and literacy (9.2), or gain employment-related skills in textiles or reprographics (10.4); job fairs involving employers are organised (10.5). However, such measures impacted a fraction of the ~1500 men who were released in 2017/18 (11.1).

SAFETY

Violence. Levels of violence within the prison remain too high but have declined slightly since 2016/17. During the final quarter of the reporting year the average monthly number of assaults (prisoner on prisoner and prisoner on staff) was 39 (43 in 2016/17), with 8 classed as serious (9 in 2016/17). The prison does not collect similar data about prisoner on prisoner and staff on prisoner bullying but there has been an increase in Applications to the IMB alleging bullying (Section D).

4.2 Violence reduction. There are two limbs to violence reduction – (i) organisational arrangements to minimise the opportunities for violent behaviour and (ii) behavioural interventions to help those prone to anger and violence to increase their self-control.

4.2.1 There are 70+ gangs with members in the prison who need to be kept apart. This is done well, through close understanding of gang affiliations and enmities and good intelligence. In May 2018, a revised regime for the movement of prisoners (to activities, etc.) was introduced. Early indications are that it reduces violent incidents though it appears to have consequences in other areas that need to be addressed (7.8, 8.3.2).

4.2.2 Behavioural interventions are less impressive. Given the classification of the prison, longer term violence reduction courses are not run. There is a reliance on in-cell reading packs which require the willingness, often absent, of prisoners to get involved. A new programme, due to start in August 2018, facilitates more staff interaction with violent offenders, but without good supporting courses its effectiveness will be limited.

4.3 Vulnerable prisoners. The IMB’s monitoring this year has reinforced its 2016/17 opinion that “Assessment Care in Custody Teamwork (ACCT) paper-work … does not encourage officers to monitor vulnerable prisoners thoughtfully because it promotes a box-ticking mind-set”. In May 2018, a spot check of all 42 ACCT documents then open found little evidence of mental health needs assessment or therapeutic input from NHS staff to care plans, or of regular meaningful interactions between prisoner and custodial staff as specified by an ACCT. Not all routine observation records were reliable. The prison identified this weak practice early in 2018 but has not succeeded in correcting it.

4.4 Self-harm. Prisoner self-harm incidents (as reported in the prison’s daily meeting) averaged over one a day in June 2018; few were life threatening, and repeat selfharming by the same prisoner is common. The number is static but too high. The safer custody team have introduced several initiatives, such as identifying men who seldom interact with other prisoners, spending considerable time withdrawn in their cells, and providing social opportunities to help take them out of themselves. This is good.

4.5 Deaths in Custody. There were two deaths in custody during 2017/18. Neither was apparently self- inflicted. Inquests have yet to be held.

4.6 Early days. The Early Days regime introduced in January 2017 has bedded down. All new arrivals are monitored with particular care by officers on a dedicated wing, with readily available trained prisoner ‘insiders’ to offer help and reassurance.

4.7 Health and safety. The prison’s design and construction make it generally healthy and safe. The smoking ban introduced in March is positive. Rodent infestation is now better controlled. Significant resources are committed to eliminating corruption and preventing drugs and phones entering the prison. Much is intercepted, but not everything. In June, 31% of mandatory random drug tests were positive (mostly ‘spice’).

4.8 Prisoners sometimes put themselves at risk. The monthly averages during April to June 2018 were 7 incidents at height, 2 cell fires, 16 drugs finds, 6 hooch finds and 7 improvised weapons. Sometimes men tamper with electrical equipment. Substance misuse, especially taking ‘spice’, regularly damages both health and safety.

Read the full report here

The shocking bullying of an IMB Member who simply told the truth

 

Faith Spear - the straight-talking Chair of Hollesley Bay Prison
Faith Spear – the straight-talking Chair of Hollesley Bay Prison

30/4/2016 update http://politics.co.uk/blogs/2016/04/29/targeting-the-whistleblower-prison-critic-fights-for-her-job

It was a powerfully honest article that many members of Independent Monitoring Boards (IMB) wanted to write (and which many have since applauded) but it has resulted in the shocking revelation of how bullying at one IMB is the price some can pay for their honesty.

Faith Spear is the highly regarded Chair of the IMB at HMP & YOI Hollesley Bay, an independent statutory watchdog appointed by the Secretary of State with wide-ranging powers of independence to monitor what goes on inside our prisons.

Instead of looking in to the prison however Faith took the brave step of looking at the national system of monitoring our prisons by writing “Whistle Blower Without A Whistle” a powerful expose of the IMB system itself.

It was welcomed by many, and an education to many more, but her own Board responded by shocking bullying and tried to pull off a coup d*etat which will fail as Faith is standing firm.

The article she wrote – which you can read above was a private, personal, informed, and educated view of a national monitoring system that everyone agrees needs radical reform. In it she named no one, she breached no rules, disclosed no security procedures, and there has never been any complaint about her capacity to discharge the duties of Chair – on the contrary she has been described officially in her IMB reviews as “keen, professional, team minded, results focused and enthusiastic…”

Read the shocking details of her treatment here