Prisons Ombudsman – 4th edition of The Investigator: “she’s doing her best, bless her”

Introductory comment by Mark Leech, Editor: The Prison Oracle

She is doing her best – that is the best that can be said.

But try and find the word ‘prisoner’ or ‘inmate’ anywhere in her self-penned introduction below – because I can’t.

I can find ‘Ministers’, ‘Academics’, ‘HMPPS’ – but not a word about prisoners.

That is what I find so revealing and yet so disappointing in equal measure.

But not surprising.

Mrs McAllister spent 30 years as a prison governor and in March this year, five months after she became PPO she said that her most important audience weren’t prisoners at all, they never got a look in nor a mention; “Our most important audience” she tweeted, are the “Officers on the landings.”

It is a statement she has never retracted, never apologised for and which still makes my blood both boil and run stone cold at the same time.

But she’s doing her best, you can’t expect someone to change their focus from one side of the cell door to the other after 30 years on one side of it, just because you’ve changed the name plate on their office door from ‘Governor’ to ‘Ombudsman’.

If only life were so simple.

She does however make good points about property, the absolute failure to have her recommendations implemented, the complaints and deaths of IPP prisoners (but ‘scorecard’ – really?) – these are valid and timely points – but she could do so much more.

She is told of every single death in custody – but despite occupying an Independent office she refuses point blank to announce deaths she is investigating to the public – all she has to do is issue a press statement every time there is a Death in State Custody, setting out just basic anonymous details: the establishment in which it happened, along with the age and gender of the deceased so the public know – but she will not say a word; that is what they do when people die in prisons in North Korea or China, they say nothing – it should not be what we do when people die in our prisons in the UK.

It is that failure to discharge the Independence of her office, an independence people fought and died for at Strangeway Prison 30 years ago, that she so disrespects and which I for one will never shut up about – we have a right to know when people die in our prisons and as the Independent Ombudsman who is told about every one of them, she has a duty to speak out not stay silent.

Still she’s doing her best, bless her.

Mark Leech 6th November 2019.

Prison & Probation Ombudsman

‘The Investigator’ November 2019 – 5th November 2019

I took up the post of Prisons and Probation Ombudsman in October 2018, so my first anniversary in the role coincided with the publication of the PPO’s Annual Report for 2018/19 earlier this month. It has been a learning year, and one spent on the road visiting as many establishments within our remit as possible.

While the past year has been invaluable in enabling me fully to understand the challenges facing the Ombudsman’s office, the demand for our services remains critically high: in the last quarter, alone, we have begun investigations into eighty-five deaths (twenty-four of them self-inflicted), and received 1,277 complaints.

In the Annual Report, I wrote about a worrying 23% increase in self-inflicted deaths on the previous year, and an overall increase in the number of fatal incidents of 6%. In all, the PPO began 334 fatal incident investigations. In many cases, we had to make the same recommendations as in previous years, where remedial action had been promised.  This led me to ask two seemingly obvious questions:

  • Why are we making so many repeat recommendations?
  • What is preventing our work from having the impact it should?

Obvious, perhaps, but which go to the heart of some long-standing and systemic issues which will require determination and new thinking to resolve. I believe that our collective response to these questions will shape the rest of my tenure.

We have stepped up our engagement with those stakeholders we see as crucial to the success of this mission:

  • at ministerial level as we continue to press to gain statutory footing for the office;
  • with academia as we look to use our unique evidence base to influence new policy thinking on safety and fairness in custody;
  • with the HMPPS leadership in prisons and at both regional and national level as we establish clear lines of communication to help us track the implementation of our recommendations; and,
  • on the wings and landings as we take steps to improve complainants’ access to and confidence in our service.

It’s a tough challenge – I expect demand to remain high even as we are being asked to continue to do more with less. However, I can assure you that everyone at the PPO remains wholly committed to delivering high-quality, effective independent investigations, while we explore every means at our disposal to help make custody safer and fairer.

Thank you for reading,

Sue McAllister, Prisons and Probation Ombudsman

Investigating cases involving IPP prisoners

Imprisonment for public protection (IPP) sentences were introduced in 2005 and were designed to protect the public from serious or repeat offenders whose crimes did not merit a life sentence.

Those sentenced to an IPP are set a minimum term (tariff) which they must spend in prison. After they have completed their tariff they can apply to the Parole Board for release. The Parole Board will release a person subject to an IPP only if it is satisfied that it is no longer necessary for the protection of the public for the person to be confined. If IPP prisoners are given parole they will be on supervised licence for at least 10 years. If they are refused parole they can only apply again after one year.

The sentence was abolished in 2012, although existing IPP prisoners continue to serve their sentences.

The Prison and Probation Ombudsman (PPO) has investigated several cases, related to both deaths in prison and complaints, of prisoners who were serving IPP sentences over the years. Between 2007 and 2018 the PPO investigated 54 self-inflicted deaths of prisoners serving IPP sentences.

The following case studies highlight examples of these cases.

Case Study A

Mr A, who was 35, received an IPP sentence for robbery with a tariff of two years and nine months. After five years in custody he was released, but three years later he returned to prison when he breached the terms of his licence.

During the three years after his return to prison, he repeatedly told staff he could not cope with his sentence and sought help from healthcare for anxiety. He was often challenging to manage.

Three weeks before he died, Mr A was moved to the segregation unit after he and two other prisoners barricaded themselves in a cell. That evening, Mr A made cuts to his wrist and staff began ACCT procedures. He was assessed by the mental health team, GPs and a psychiatrist. He was offered medication for anxiety and depression but often refused to take it because he said it made him feel worse.

Mr A said his IPP sentence was “killing him” and that he was concerned at plans to recategorise him from category C to B, which he feared would mean a move to a prison further from his family. He repeatedly told staff that he would kill himself after his next visit from his family.

Mr A’s mother visited him a week later. On the same day, he was told he was being recategorised to B. At an ACCT review that afternoon, staff considered that Mr A’s risk of suicide and self-harm had increased but they did not increase the frequency with which he was checked (which remained at once an hour). In the early hours of the next morning, an officer found Mr A hanged in his cell.

Case Study B

Mr B entered custody as a teenager on a short minimum tariff. When he complained to the PPO, he had been in prison for over 10 years. He had recently been recategorised from C to B and transferred to a new prison. He believed these decisions were unfairly impeding his progress.

Mr B believed that returning to his previous prison was important for his release because he had been working well with his therapist and had access to an onsite therapeutic community, a facility his new prison lacked.

Mr B wrote to us about the decision to recategorise and transfer him. Our investigation found that while Mr B had worked hard to reduce his risk of serious harm, we also found evidence of poor behaviour and control issues, and did not uphold this part of his complaint. Further, we agreed that Mr B’s behaviour presented a challenge to the prison and likely had an impact on other prisoners.

We were concerned about the case more broadly, however. While we found that efforts had been made to secure a progressive transfer for Mr B, he was essentially still in prison due to his poor behaviour. We felt that a failure of provision (specifically – the inability to locate Mr B with a therapeutic community and the inability to address his decline in behaviour) were preventing Mr B from making progress. We called for a review of the case and that this review should assess Mr B’s sentence plan and provide further support for progression.

Case Study C

Mr C received an IPP sentence with a tariff of three years. After seven years in custody, the Parole Board recommended a transfer to open conditions to prepare for release. He was recategorized to D and transferred, and was looking forward to proving himself and working towards his release. Later that year, he was approved to begin community work, made eight unescorted visits in the community and completed offending behaviour programmes.

Two days before Mr C’s death, he was accused of assaulting a prisoner and was moved to the segregation unit during the investigation. While there, Mr C was safety screened and assessed, at which point he said he was fine and made no complaints. The following morning, a duty manager visited Mr C and recorded that he seemed in good spirits. That afternoon an officer delivered a letter confirming Mr C was being transferred. It read: ‘It is alleged you assaulted another offender. You are to be moved to closed conditions pending police investigation’. That officer delivering the letter recorded that he took the news well.

Mr C was assessed by staff on arrival in his new prison. They were told he had not self-harmed, did not have a history of depression or thoughts of suicide, and concluded that he was not at risk of suicide. At reception, however, he called his father and said: ‘All right man, it’s coming back here and all that going through the same procedure again, feel like proper locked up again not even getting up’.

That night Mr C was not placed on special monitoring measures as he was found to not be at risk. At morning roll check, he was found hanging with jogging bottoms tied around his neck. Arriving paramedics assessed that he had been dead for some time.

Our investigation found several issues with the management of Mr C’s risk of suicide. During the two days he spent in segregation, he was assessed as not being at risk of suicide. We did not find staff had considered that Mr C’s new circumstances had increased his risk as an IPP prisoner. We also found that on arrival at closed conditions, again staff concluded that Mr C was not at risk of suicide. There was no evidence that staff had considered that Mr C’s transfer might have added considerable time to his sentence.

We recommended that prisons should ensure that all the known risk factors for newly arriving prisoners are fully considered and documented when determining an individual’s risk of suicide and self-harm.

As at September 2019, 2,059 prisoners continue to serve an IPP sentence in custody. We are aware of initiatives in HMPPS to identify, and prioritise, those cases where people are over tariff and not progressing towards release. These include progression units in some prisons and a review of all cases. We will continue to record, and share, the learning from our investigations as it relates to the IPP sentence and its impact on those serving it.

Property pitfalls and how to avoid them

Complaints about missing or lost property consistently make up around a third of complaints the PPO investigates and we uphold almost half of them.  In 2018/19, we upheld 46% of property complaints, compared to 32% for all other complaints.

What are the some of the most common property complaints?
Many of those upheld complaints concern property going missing when a prisoner is transferred to another prison or relocates to the prison’s Segregation Unit/Care and Separation Unit (CSU), and then possibly to another prison after that.

We often recommend prisons pay compensation for lost property, because our investigations find common and recurring failings based on prisons’ failure to comply with the mandatory requirements of national policy governing the handling of prisoners’ property.

What are the most common failings relating to upheld property complaints?
The most common avoidable failings that lead to upheld complaints are:

  • lack of records such as missing property cards; and
  • lack of a cell clearance certificate (where there should be one).

What can prisons do to make sure they are following best practice?
Our property complaints investigators have put together a checklist to help prison staff avoid these and other common failings. It’s not exhaustive, but we hope it will help to reduce the number of complaints against them and ensure their actions are clear, transparent and defensible at all times.

Every issue of The Investigator provides you with the headline statistics from PPO’s work in the previous complete quarter. These headlines will cover the Ombudsman’s independent investigations of both complaints and fatal incidents.

Case studies: complaints from those under 21

As in previous years, the number of complaints from those under 21 in 2018/19 remained disproportionately small: accounting for just 26 of the 2,569 that we investigated. We know there are a number of reasons why young people do not complain to us. Anecdotal evidence suggests that they find the complaints process overly bureaucratic or complicated.

We continue to welcome the fact that we receive complaints from advocates, solicitors and charities made on behalf of young people. In the following case study the Howard League, acting on behalf of a number of young men at a Young Offenders Institution (YOI), submitted complaints about the use of segregation.

The Howard League complained that a number of young men had spent prolonged periods in the Segregation Unit, spending at least 22 hours a day in their cells without any meaningful human contact. They said that this breached YOI rules as well as the young men’s rights under Article 8 of the Human Rights Act. In considering all of the complaints, we were satisfied that the decisions to locate each of the young men in the Segregation Unit were justified in the circumstances. However, in some of the cases, we were concerned that the segregation paperwork had not been fully completed and, in all cases, we were concerned about the quality and timeliness of the segregation review process and/or the regime that was available to each of the young men.Although we appreciated the considerable challenges the YOI faced in managing some of the young men in the Segregation Unit, we concluded that more had to be done to improve the regime for those held in the unit. We upheld or partially upheld all the complaints and made a number of recommendations across the different investigations, all of which were accepted.

The most common cause of complaint from young people was missing property, but we also investigated two complaints about use of force. Prison service policy on the use of force against young people is clear that staff must always: view the physical restraint of a young person as the last resort; use techniques to de-escalate the situation before resorting to force; apply the least force necessary for the shortest period of time. These investigations require us to very carefully consider all the circumstances, as in the case of Mr K.

Mr K, then aged 17, complained that staff at the YOI had assaulted him by slamming his head against the floor and used excessive force while restraining him. We viewed the CCTV footage covering the incident, which showed that Mr K had been using the wing telephone when he was assaulted by another prisoner. A large number of staff responded and began to restrain Mr K. The staff eventually moved Mr K to his cell and it was here that Mr K claimed they assaulted him by slamming his head against the floor. Unfortunately, none of the staff involved were wearing body worn cameras so there was no footage of the incident. We found that while the restraint and initial use of force was justified, the ongoing management of the incident was poor. We saw no obvious attempts by staff to talk to Mr K or de-escalate the incident before they restrained him; too many staff were involved in the restraint (we counted 11 at one point); and the incident paperwork suggested that pain-inducing techniques had been used, although we could not identify who had used these techniques or why. Some of the concerns we identified echoed those previously raised by HM Chief Inspector of Prisons during his last inspection of the YOI.As a result of our concerns, we upheld Mr K’s complaint and made a number of recommendations. The YOI did not accept our finding that the force used against Mr K was excessive.


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