DM — Southampton Magistrates’ Court
Serious Self-Harm
16 March 2015
Independent investigation into an incident of life-threatening self-harm involving ‘DM’1at Southampton Magistrates’ Court on 16 March 2015 The report of the independent investigation conducted by Barbara Stow into an incident of life-threatening self-harm involving ‘DM’ at Southampton Magistrates’ Court on 16 March 2015 is published here. Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at Southampton Magistrates’ Court.
Key Findings
The investigation found that DM, with a history of self-harm and substance misuse, was left unsupervised in a court custody suite despite expressing suicidal intent and displaying concerning behaviors. This was due to significant failures in risk assessment, information sharing between agencies, non-compliance with standard operating procedures, inadequate staffing, and a lack of leadership and a "culture of curiosity and concern" among custody staff. These systemic failures contributed to the life-changing incident and highlighted broader issues in court custody safety.
Learning Points (15)
Learning Point 1
We recommend that PECS and GEOAmey review the number of custody officers required in the Southampton Magistrates’ Court custody suite and how they are deployed.
HMPPS Response
In 2017 GEOAmey completed a review of the ‘baseline’ number of custody officers allocated to each court and vehicle base location across each of its three contracted regions, as the demands of the service had reduced due to declining volumes and changes within the prison and court estate. The review clarified the number of officers required at each location to deliver a safe and secure service. GEOAmey also introduced management information (supply and demand) which produces ‘real time’ data, providing an output of the number of officers at any court location, defendants within each custody suite and the number of courtroom docks that are being resourced. The management information also identifies the specific number of officers required at any location, at any point in time, and is utilised by managers to flexibly deploy resources where required. The PECS Contractor’s operating model is flexible, which means that resources can be moved within its ‘cluster’ to support any shortfalls in resource that may occur at Southampton Magistrates Court and elsewhere. GEOAmey has internal processes in place to monitor resource levels against its operating model, including monthly business reviews with its Executive where resource variances and plans for rectification, if required, are discussed. PECS management information identifies any key concerns around GEOAmey performance that may be linked to staffing levels. Further assurance tools to gain insight into staffing levels include: a complaints process available to both those in court custody and stakeholders, CER (Court Exception Report) which enables HMCTS to report any failures to staff a dock, or delays in arriving at court, and the PECS SSDC (Safe Secure, Decent and Complaint) Audit provides a holistic approach to monitoring staffing levels and the welfare of those in court custody as part of a wider auditing tool.
Learning Point 10
We recommend that GEOAmey and HMPPS consider how friends and families of prisoners at risk can be encouraged and enabled to pass on any concerns about risk of self-harm. Protocols may be required as to how to reconcile requirements of privacy and requirements of safe custody that may be in conflict.
HMPPS Response
PECS has recently requested that Contractors ensure that families have the opportunity to telephone the Contractors with any concerns around self-harm risks. GEOAmey has reviewed and amended its relevant operating and contingency procedures and updated: SOP 063 Self-Harm and Suicide Prevention – Section 1.7 “Emergency contact from families and others,” which has also been reviewed by PECS. The SOP now states that: “Family members, legal representatives and/or other people with concerns about a prisoner’s safety may provide information direct to officers. On receipt of such information the CCM or OIC will ensure that a physical check is made on the prisoners’ safety. The information received will be used to determine: • For a prisoner who is not subject to an open ACCT plan, whether to open a SASH warning form, or what other action is necessary; • For a prisoner who is subject on an open ACCT plan, to record the relevant concern in the booklet along with any action taken.” GEOAmey communicated the changes made to the SOP to its operational colleagues via SOP Bulletin 38, which was issued on 15 July 2019. Additionally, all prisons must have systems in place to receive and act promptly on information received in an emergency, in line with the policy framework on Strengthening Prisoners’ Family Ties, which came into effect on 31 January 2019. HMPPS recognises that the intervention of a third party may be crucial in alerting staff that a prisoner is at risk, so it is important that families and friends know that prisons value their input, that any concerns raised about a loved one will be acted on appropriately and that where possible they receive feedback when they do get in touch. In March 2019, HMPPS issued two Prison Safety Learning Bulletins entitled ‘How to respond to contact from family members and friends of prisoners who are concerned about their wellbeing’ and ‘Sharing information with a prisoner’s family and/or friends: when can it be done and what can be disclosed?’ These bulletins reminded prisons that families and visitors of prisoners should be encouraged to share risk information with prisons and be provided with contact details that can be used in emergencies, and provided guidance about the importance of having consent, what information it is appropriate to share, and when it is legal and appropriate to disclose that information without consent. Additionally, HMPPS issued a Safety Briefing on emergency contact from family and friends in November 2019. In summary, every prison must have: 1. A contact process that is advertised to family members and stakeholders by a variety of means, including online and via the family services provider; 2. A means of speaking to a member of staff (duty governor /orderly officer/person in charge of residential unit) immediately about situations involving imminent risk, as well as an answering machine for less urgent matters on which calls are monitored regularly and followed up; 3. Instructions for staff receiving such calls about how to respond sensitively and what actions to take, including prompt feedback to the person who raised the concern. 4. A system for logging calls that provides assurance that action has been taken, and ensures that the information received informs the ongoing care of the individual prisoner. Furthermore, as part of the 10 Prison Project family engagement programme, Clinks1 worked with a group of prisons to produce a series of ‘Think Family’ resources explaining how prisons can develop a ‘Think Family’ approach. The resources are accompanied by four briefings, including one on effective communication with families, which sets out the benefits and encourages two-way communication channels between prisons and families.
Learning Point 11
We recommend that GEOAmey puts in place express policy for aftercare for staff involved in a serious incident through immediate informal support from managers, and further recognition over a longer period, as well as access to independent counselling for staff who wish to use it.
HMPPS Response
In 2016 GEOAmey introduced a policy “POL-OPS-0016 Post Incident Care” for hot and critical incident debrief. The policy incorporates items such as the personal impact of the incident, encouraging and enhancing mutual support, providing information and support, reducing the likelihood of Post-Traumatic Stress Disorder and encouraging coping strategies and support networks. In addition, the provision of Unum independent counselling services is available to GEOAmey employees.
Learning Point 12
We recommend that GEOAmey review the staff training modules on mental health awareness and interpersonal skills in the light of Dr Craissati’s advice in paragraphs 5.42 to 5.46, noting in particular her focus on behaviours likely to be encountered in a prisoner population, and in developing skills in listening, exploring, and responding to, complex issues and the communication of distress, in a busy and fast-moving environment.
HMPPS Response
GEOAmey worked in collaboration with the MIND charity to develop its Mental Health Awareness training. This training is delivered during GEOAmey’s Initial Training Course and also forms part of its periodic refresher training for employees. GEOAmey continues to develop its strategic relationship with the MIND charity, which includes the development of training materials and programmes. The advice from Dr Craissati now forms a focus for GEOAmey’s training material and delivery around mental health awareness. Additionally, in July and August 2020, a mental health professional from MIND delivered a two day training programme to 34 of GEOAmey’s ‘Mental Health Champions’, who provide additional support to its frontline staff. GEOAmey conducts investigations into significant serious incidents. They will ensure that any learning from future investigations will be considered to see if changes can be incorporated into their training programmes, including creating ‘case studies’ to be shared at the appropriate points during initial training courses. The PECS GEN4 Contract, which went live in August 2020, avoids specifying the content of the training courses because needs and priorities can change. However, Section 53 of Schedule 2 covers training requirements and expectations. One of the requirements is that course content should fully equip the Contractor’s staff with the skills to effectively deliver the services.
Learning Point 13
We recommend that the managers responsible for the Southampton court custody suite work with the Hampshire Liaison and Diversion Service to ensure that the service is well understood by custody staff and used effectively.
HMPPS Response
NHS Liaison and Diversion (L&D) services were introduced at Southampton Magistrates’ Court in April 2015 (currently they are provided by Berkshire Healthcare NHS Foundation Trust). There is a L&D officer on site and they visit the cells regularly and when requested to do so should concerns be raised about the wellbeing of a person in custody. Anyone who comes into contact with a person in custody is able to request L&D support. On the rare occasions that the L&D officer is not on site, they will telephone the court custody office to check on the wellbeing of detainees and any concerns raised by the PECS Contractor. The L&D service is well embedded at Southampton Magistrates’ Court. GEOAmey employees at the court engage with the L&D representative every morning to establish if any of the defendants in their care require an assessment. If required, the L&D representative attends the custody suite and undertakes the appropriate assessment. Additionally, GEOAmey employees in the custody suite are fully aware of how to contact the L&D team should they not be available on site. They have been provided with a contact telephone number to use if required, e.g. during out of hours or on a Saturday. From a national perspective, the L&D service is well embedded in the majority of court locations, as well as police custody suites.
Learning Point 14
We are aware that the project to improve the effectiveness of the Person Escort Record is a work in progress and that our observations may have been overtaken as the new form is piloted and developed. However, we invite the Project Group on the Person Escort Record to consider the defects in the use of the PER that we found in this investigation; to consider our comments on the pilot form, and in particular: the importance of entries about suicide or self-harm on the risk indicator page stating the nature and date of incidents giving rise to concern, and the source of the information considered to indicate a risk; and ensuring that there is clear guidance to staff about when an entry for suicide and self-harm on the risk indicator page should prompt completion of a warning form and/or the Red Flag page.
HMPPS Response
A significant amount of work has been undertaken by HMPPS, working alongside partner agencies and key stakeholders, to improve the effectiveness of the Person Escort Record (PER). The PER project is nearing its completion and at this time we are content that improved guidance for those completing the PER has been developed, and that this guidance will assist staff in appropriately recording and flagging suicide or self-harm risk where identified. The revised PER has been trialled in the Women’s Estate and there were no concerns raised or changes to the PER suggested during this trial period. HMPPS recognises that completing the PER document with as much information as possible is key to the management of individual risk. As such, whilst the PER document provides better guidance, HMPPS has also developed a separate guidance article that outlines the key principles of the PER and provides guidelines for the accurate completion of the document. This guidance was issued to all prisons via a Senior Leaders Bulletin in December 2019. Furthermore, HMPPS issued a learning bulletin in December 2019 to ensure that staff understand the importance of fully completing the PER. HMPPS is also producing a pocket guide on completing the new PER which will be available to order alongside the PER forms.
Learning Point 15
We recommend that HMPPS and HMCTS review and report on their progress in implementing the recommendations on Court Custody made by the Inspectorate in 2015. We recommend specifically that: Automated external defibrillators should be provided in all courthouses, accessible to the custody and court staff, who should be instructed in their location and use (see also recommendation 6 above). HMCTS local managers should have access and a responsibility to visit court custody suites regularly to monitor conditions and resolve problems. HMPPS ensures that performance requirements for contractors, and contract monitoring, include measures focusing on treatment and conditions for those in custody, a requirement for regular liaison with HMCTS staff, and an understanding that HMCTS have a responsibility to monitor standards. that where magistrates wish to visit custody suites to see the conditions in which people appearing before the courts are held, HMCTS, HMPPS and the contractors facilitate this.
HMPPS Response
Shailesh Vara MP, then Parliamentary under Secretary for Justice, wrote to HM Chief Inspector of Prisons on 28 June 2016 to provide an update on the progress that had been delivered around the areas of improvement identified in HMIP’s 2015 thematic review of court custody in England and Wales. In response to the specific points raised in this recommendation, HMCTS has advised that nearly all HMCTS buildings have an automated external defibrillator (AED). Those buildings without an AED are located within proximity to a local hospital/emergency services, or accessibility of an AED in neighbouring premises/immediate vicinity. The provision for AEDs is set out in HMCTS Security and Safety Operating Procedure 13e. In response to the second bullet point, the responsibility of HMCTS local managers is set out in the Key Control Checks (KCCs) for Prisoner Escort and Custody Services (PECS). The KCCs are in place to ensure that managers undertake their duties to monitor the conditions in the court custody suite and provide assurance that cells and the custody suite are safe, decent and secure. In respect of the third bullet point, the PECS contract check and test document provides HMCTS court managers with a checklist and a record to document any weaknesses or areas of non-compliance. Additionally, each HMCTS site has regular meetings at local level that provide the opportunity for the supplier to come together with HMCTS Building Champions and local managers to discuss identified defects and issues that arise within the custody suite. The role of the Building Champion is, depending on the issue, to raise the matter directly with the cleaning contractors or if a maintenance matter or other identified defect through the Facilities Management (FM) helpdesk requesting review and action by the FM Team or our sub-contractors. Escalated concerns are discussed by HMCTS, PECS, the FM team or the supplier at the quarterly multi-agency meetings that operate either at HMCTS regional or cluster level. In addition, there is also a forum that exists at a national level between PECS and HMCTS Operations/Property Directorates where ongoing issues that concern the welfare and dignity of the defendant whilst in the custody suite can be discussed until resolution. Furthermore, PECS conducts Safe Secure Decent and Compliance audits in all court custody suites at a minimum of once every two years. Where areas of concern are identified these audits can be increased or a targeted approach applied to ensure that remedial action is taken. PECS is part of a wider stakeholder regional forum hosted by HMCTS, which discusses and resolves stakeholder issues on a quarterly basis. Finally, in response to the fourth bullet point, magistrates wishing to visit custody suites may do so whenever they wish and this will be facilitated by court custody suite staff.
Learning Point 2
We recommend that PECS and GEOAmey review the access for staff in the custody suite at Southampton Magistrates’ Court to update computerised or manual records to ensure it is sufficient to enable compliance with requirements.
HMPPS Response
Since the time of the incident in 2015, GEOAmey has transitioned to a new ICT provider (SCC) who provide all the computer systems within its court locations. As part of the GEOAmey ICT solution it has been agreed that each court location must be assigned a minimum of three ‘full user’ accounts. GEOAmey is satisfied that Southampton Magistrates Court has a sufficient number of officers in place to update computerised records. In addition, GEOAmey’s baseline resource levels include the requirement for officers to be allocated to roles that involve updating computerised and manual records. Additionally, PECS Contract Delivery Managers conduct site visits, and part of this includes a requirement to check PER (Person Escort Record) completion which is expected to correlate with what has been entered on GEOTrak (GEOAmey’s IT system).
Learning Point 3
We recommend that there should be a requirement in place that some means of distraction should always be offered to prisoners in court custody suites.
HMPPS Response
Although most court suites had some distraction items in the form of free newspapers and staff donated books, following a recent pilot and subsequent findings, PECS has subscribed to a monthly supply of puzzles (crosswords, word searches and quizzes) from the charity Recoop (which provide such materials to prisons) and shared with both PECS Contractors and distributed around their respective contract areas. This provides an alternative form of distraction to people in custody whilst they are waiting in court cells. The above is now available in all courts in England and Wales. Following feedback from Contractors and people in court custody, PECS negotiated with Recoop, who will produce a PECS-specific monthly distraction pack to cater for the specific needs of people in the custody and care of the PECS Contractor.
Learning Point 4
We recommend that GEOAmey investigates the practicality of providing telephone access to the Samaritans for prisoners in the custody suite at Southampton Magistrates’ Court.
HMPPS Response
PECS had planned to conduct a feasibility study in the Midlands region to explore the possibility of allowing people in court custody to have telephone access to the Samaritans. Unfortunately, the situation with the Covid-19 pandemic has resulted in these plans being paused. PECS intends to revisit this recommendation and the feasibility study once the Covid-19 situation has improved but the timetable will remain flexible. In the interim, the SHUSH card (which is a Samaritans initiative for tips to improve and become a better listener) has been introduced in all court custody suites.
Learning Point 5
We recommend that GEOAmey reviews the advice and training to staff to ensure that it is clear that a prisoner who is ill is not left unattended.
HMPPS Response
GEOAmey has reviewed its relevant operating and contingency procedures through its Standard Operating Procedure (SOP) Policy Group meetings. As a result, GEOAmey has updated the following procedures to incorporate this recommendation: • The “Threat to Life” contingency plan was updated to include this recommendation on 24 June 2019. • SOP 051 Medical Requirements Section 1.2 and 1.4 were updated to include this on 1 July 2019. GEOAmey communicated these changes to operational colleagues via SOP Bulletin 37, which was issued on 24 June 2019.
Learning Point 6
We recommend that consideration should be given to locating defibrillators accessible to court custody staff and ensuring that all staff are competent to recognise the circumstances when they should be used and to use them. (It may be practicable to provide defibrillators in conjunction with the courts – see Recommendation 15 below).
HMPPS Response
There are Automated External Defibrillators (AEDs) on site in both the custody suite and public areas of Southampton Magistrates’ Court. Nationally, nearly all HMCTS buildings have an AED. Those buildings without an AED are located within close proximity of a local hospital/emergency services, and/or accessibility of an AED in neighbouring premises/immediate vicinity. The AEDs available in court buildings display instructions for use and no training is required. The provision for AEDs is set out in HMCTS Security and Safety Operating Procedure 13e. From November 2017, GEOAmey introduced training on automatic defibrillators within its first aid syllabus for all new employees and as part of the ongoing three year first aid refresher training. Included within GEOAmey’s accredited first aid training is the theory around the circumstances in which its employees should consider the use of a defibrillator.
Learning Point 7
We recommend that a local contingency plan is put in place for the steps to be taken in the event of an emergency. This should include notification of court security staff when an ambulance has been called and that a member of staff able to report changes in the patient’s condition and to act on advice needs to stay on the telephone to the emergency services.
HMPPS Response
HMCTS has confirmed that, if the PECS Contractor summons emergency services to attend the court custody suite, they should notify HMCTS security suppliers to facilitate their expeditious entry into the building. This is set out within the HMCTS Security and Safety Operating Procedure 9 for dock officers and PECS. In support of this a protocol has been developed that requires sign off between each operating site and the supplier(s) at local level. This was reviewed by PECS with the suppliers and distributed to HMCTS managers to implement on a site by site basis in April 2020. Security and Safety Operating Procedure (SSOP) 9 has been updated to direct that each site must have a local agreement in place between the cells and court security that clearly sets out the notification process to be followed if the emergency services are called to a court custody suite. This will ensure that emergency vehicles can enter through barriers/vehicle dock gates without delay. The SSOP was amended and reissued to HMCTS staff in April 2020 with a request for them to oversee sign up to the protocol referred to above in line with security contract assignment instructions. At Southampton Magistrates’ Court there is already a local agreement in place that GEOAmey staff will alert HMCTS security suppliers when the emergency services are called so the access gates can be opened without delay. GEOAmey has reviewed the relevant operating and contingency procedures and, as a result, GEOAmey has made the following updates: • The “Threat to Life” contingency plan updated to include “notification to court security staff when an ambulance has been called” on 24 June 2019. • SOP 051 Medical Requirements - Sections 1.2 and 1.4 were updated to include “notification to court security staff when an ambulance has been called” on 1 July 2019. GEOAmey communicated these changes to operational colleagues via SOP Bulletin 37, which was issued on 24 June 2019. Additionally, cordless telephones have been installed in all Court Custody Suites operated by GEOAmey. This enables officers to communicate with emergency services during critical incidents and to relay information to other officers that may be providing emergency first aid.
Learning Point 8
We recommend that in conjunction with PECS, GEOAmey puts in place a procedure for a senior manager to be notified whenever a serious incident of illness or other harm occurs. The designated senior manager should take immediate responsibility for ensuring that families are notified at the earliest opportunity, facilitating access for family members, and anticipating the need for decisions about restraints, with due regard to access for medical procedures, the paramount requirement to preserve life, and an appropriate balance, based on risk assessment, between the claims of compassion and security.
HMPPS Response
In April 2019, GEOAmey introduced a process whereby serious incidents of illness or harm are escalated to a senior manager through its Operational Support Centre. The designated manager is subsequently responsible for ensuring that families are notified of a serious incident of illness or harm at the earliest opportunity, for facilitating access for family members and for anticipating the need for decisions about restraints. The designated manager may be supported by a HMPPS family liaison officer, where necessary. The new Generation 4 PECS Contracts, which commenced in August 2020, stipulate that it is the Contractor’s responsibility to provide a Family Liaison Officer (FLO) who will ensure that families are notified and maintain contact. GEOAmey has also reviewed SOP 59 1.8 to ensure that the section around detained persons who are seriously ill are only restrained after careful consideration. PECS incident management processes ensure that an investigation is commissioned into any critical incident . Information is collated, and reports and action plans are monitored by the Head of PECS via the PECS Critical Incident Log, which tracks the progress of actions and improvements that have been identified in response to recommendations from serious incidents.
Learning Point 9
We recommend that in conjunction with PECS, GEOAmey develops a policy for family liaison, with a senior member of staff designated as family liaison lead and with training for that role.
HMPPS Response
The new Generation 4 PECS Contracts, which commenced in August 2020, stipulate the Contractor’s responsibility to provide a FLO who will ensure that families are notified and maintain contact. GEOAmey has secured two staff places on HMPPS FLO courses in Spring 2021, although courses are currently on hold due to Covid-19-related training restrictions. In the meantime, support from FLOs within the prison estate will continue to be available should it be required.