Allan Stewart Marshall

(i) It is recommended that SPS bring the C&R manuals used for the training of prison staff up to date and that the content and delivery of training provided is kept under regular review. In that regard, it is recommended that SPS give urgent consideration to revising all versions of the C&R Manual to include the information and advice contained in GMA 048A/16 and the information contained in Annex A. (ii) It is recommended that SPS give consideration to reviewing the instruction in the C&R Manual (or elsewhere) relating to psychosis such that observation of any warning signs associated with psychosis is a trigger to require urgent healthcare advice being sought. (iii) It is recommended that SPS give consideration to ensuring that there is consistency within the instructions contained in Governors & Management Advice (GMA), and all volumes of the C&R Manuals to ensure that there can be no confusion about the circumstances to trigger a requirement for seeking NHS Prison Healthcare advice. (iv) It is recommended that SPS give consideration to the introduction of a system of working that ensures prison staff members have read and understood any instruction that is contained within a GMA directed at them. (v) It is recommended that SPS give consideration to separating out from the C&R Manual, the training module relating to the four medical conditions that may be triggered by or exacerbated by the use of force and delivering that training separately from C&R training. (vi) It is recommended that SPS give consideration to either including specific training on the use of feet as a C&R technique within the C&R Manual or, alternatively, specifically disallowing the use of feet within any restraint. (vii) It is recommended that SPS give consideration to introducing a system of working whereby there is always at least one staff member within a removal team who is a designated first responder and that there is a designated duty for that officer to respond and administer CPR when an appropriate situation arises. (viii) It is recommended that SPS devise and put in place a clear policy to provide that prisoners presenting with symptoms of EDS or psychosis must be kept secure and not be placed under physical restraint until they have been assessed by healthcare professionals and it having been deemed safe for the prisoner to be restrained. (ix) It is recommended that SPS immediately introduce a policy provision to ensure that all code blue alerts are audio recorded, preserved and, in the event of a death, not destroyed until there has been a FAI determination issued. (x) It is recommended that SPS give consideration to introducing a system of working whereby it can be ensured that information contained in GMAs is both received and understood by all intended recipients. (xi) It is recommended that SPS give consideration to introducing a system of evaluation whereby it can be effectively established that the information contained in training provided to prison officer staff has been successfully imparted to the recipient. (xii) It is recommended that SPS introduce a policy that, in any case involving police investigations, no operation debrief shall be conducted until the police have concluded their investigations and finished taking statements from SPS witnesses. (xiii) It is recommended that SPS introduce a system whereby there is a formal handover on changes of shift and a written account of any unusual prisoner activity or presentation to be kept and presented to the FLM on the following shift at shift handovers.