Investigations of deaths in custody trends and themes

Investigations of deaths in custody trends and themes 25 October 2017 Richard Pickering Deputy Prisons and Probation Ombudsman 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 childrens homes (SCHs) 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. 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 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)

We say Major themes must be acted upon, for example the pervasiveness of mental illhealth 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. Older prisoners 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). Thats a 76% increase in four years 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

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. 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?