Harris Review: Deaths in Custody
Report of the Independent Review into Self-inflicted Deaths in Custody of 18-24 Year Olds
Justice & Legal
Independent review into self-inflicted deaths in custody of 18-24 year olds, commissioned by the Ministry of Justice. Published July 2015 with 108 recommendations covering mental health support, safer custody, and staff training.
108recommendations
108Not Yet Responded
Recommendations
Recommendation 1
MoJ must publish a new statement setting out that the purpose of prison is to hold safely and securely those people sent there by the courts, either because they have been sentenced to imprisonment or because they have been remanded in custody while awaiting trial or sentencing. A prison should provide to those in custody a regime whose primary goal is rehabilitation. The penalty of imprisonment is the removal of liberty; all persons deprived of their liberty shall be treated with respect for their human rights (including the European Convention on Human Rights) and their individual protected characteristics (as defined by the Equality Act 2010). Restrictions placed on persons deprived of their liberty shall be the minimum necessary and proportionate to the legitimate objective for which those restrictions are imposed. Life in prison should approximate as closely as possible the positive aspects of life in the community.
Recommendation 10
Window design in safer cells should allow an air flow and be free of possible attachment points for a ligature.
Recommendation 100
We recommend that HM Inspectorate of Prisons should have a statutory duty to check that their recommendations are being acted upon
Recommendation 101
The responsibility for the oversight and funding of the IMBs should transfer to HM Inspectorate of Prisons. 101.1 The IMB membership must be representative of the community it serves, and where possible should reflect the local prison population. HMIP should develop an action plan to address this, which might include provision of a living wage for participation.
Recommendation 102
PPO and Coroners should be given the remit, where they think it appropriate, to look beyond the circumstances of any individual death to see whether there were other factors that occurred earlier in the prisoner’s history that might have contributed to the death.
Recommendation 103
The Chief Coroner should be provided with sufficient resources to enable him to report on themes emerging from prevention of death reports involving deaths in custody.
Recommendation 104
All inquest findings, PFD reports and responses that relate to deaths in custody should be centrally collated and available for public search (subject to any necessary redaction).
Recommendation 105
CQC should undertake regular inspections of health provision in prisons and YOIs and these should include an assessment of whether initial health screening and the 48 hour multi-disciplinary holistic needs assessment is occurring, and how well healthcare is engaging and leading in the SAVRAS work.
Recommendation 106
Responsibility for the co-sponsorship role for the work of the IAP should be transferred from NOMS to the MoJ.
Recommendation 107
Each body to which a recommendation in this Review is directed should produce an action plan on implementing those recommendations within three months of the Government’s response to this review being published. These action plans should contain SMART targets. The IAP should have responsibility for discussing these action plans with the bodies concerned and also monitoring the progress of the implementation.
Recommendation 108
The MoJ (on behalf of the Government) should produce and present to Parliament an annual report on progress on delivering the action plans, accompanied by a commentary from the IAP. This should be informed by a Cross-Departmental working Group.
Recommendation 11
Each establishment, guided by instructions from NOMS if necessary, should review their estate and their population demographics and make a formal ongoing assessment of the minimum number of “Safer Cells” that are considered necessary to accommodate those requiring this additional protection.
Recommendation 12
NOMS should provide sufficient capital funds to allow for the building or the modernisation of sufficient cells to “Safer Cell” standards to meet that assessment and also for the subsequent maintenance of the sufficient cells to that standard.
Recommendation 13
All cells that have achieved certified to “Safer Cell” standards should then be maintained to that standard unless there is a documented decision by the Governor to allow the “Safer Cell” designation for that cell to cease.
Recommendation 14
Every prison should record and publish details of the time spent out of the cells for every prisoner; including time spent engaging in purposeful activity out of their cells. This information should be collated nationally for management information purposes and also to enable further analysis of outcomes. Primary Recommendations
Recommendation 15
A new specialist role must be created to work specifically with all young adults in custody. The Custody and Rehabilitation Officer (CARO) will be required to take responsibility for the overall well-being of the young adult and must have a caseload of no more than fifteen or twenty prisoners, so that as a central part of the role it is possible to build and sustain a close and effective relationship with each individual prisoner. This role will be specialist and skilled, understanding developmental and maturity issues that impact on young adults, and will require competencies at least equivalent to a professional youth worker or qualified Social Worker.
Recommendation 16
A senior individual, supported by a dedicated unit within NOMS, must be given clear responsibility for ensuring the particular needs of all young adults are provided for appropriately across the estate.
Recommendation 17
CARO training must begin within 12 months of publication of this report.
Recommendation 18
The role of all operational staff including governors must be further professionalised, with the improvement of skills and knowledge across the workforce, including governors. A process of Continuous Professional Development must be introduced so that these skills are kept up to date.
Recommendation 19
MoJ and NOMS must take urgent steps to fill the recruitment gap that is putting undue pressure on an already stretched workforce in prisons.
Recommendation 2
In line with the European Convention on Prevention of Torture (CPT), all young adults in custody must be able to spend a reasonable part of the day (8 hours or more) outside their cells, engaged in purposeful activity of a varied nature. Levels of purposeful activity must be sustained for prisoners on all levels of the IEP scheme.
Recommendation 20
From the evidence given to the panel from many sources, it is apparent that the current operational staffing levels in prisons are not adequate. Following the recruitment that NOMS is currently undertaking, Benchmarking levels should be reviewed immediately to allow for full compliance with Prison Service Instructions that concern the safety and well-being of prisoners and must include implementation of this report.
Recommendation 21
NOMS should ensure that the implementation of Prison Service Instructions is properly resourced in order that the intended benefits can be effectively delivered throughout the prison system. NOMS must have systems in place to ensure that this is happening.
Recommendation 22
Following each self-inflicted death in custody, the Minister for Prisons should personally phone the family of the prisoner who has died to express their condolences on behalf of the State and to promise that a full and thorough investigation will take place, and that any lessons from the death will be studied and acted upon to avoid similar deaths in the future.
Recommendation 23
All staff working in prisons who have contact with prisoners, including prison officers, contracted staff, and in-reach workers must receive regular mandatory training to enable them to recognise and deal with vulnerabilities, particularly mental health needs, and also in relation to the Safety and Vulnerability, Risk Assessment and Support (SAVRAS) (referred to in chapter 6) process. All staff should be subject to regular continuous professional development requirements that are subject to external moderation.
Recommendation 24
Remuneration of prison officers should reflect this professionalization, because it is otherwise unrealistic to expect to recruit and, retain a workforce capable of successfully managing complex vulnerabilities in a custodial environment.
Recommendation 25
Governors must commend every frontline member of staff who has actively implemented measures and made judgments that lead to the prevention of a self-inflicted death and that a record of every commendation and the action taken be shared with the Equality Rights and Decency Group, who must disseminate this across the custodial estate where appropriate.
Recommendation 26
The management of young adults is distinct from the management of the older prison population. The specific skills and personal qualities that are required to work successfully as a prison officer in these situations needs to be assessed and provision made for regular, progressive and monitored training.
Recommendation 27
NOMS must properly assess the impact of each PSI, both new and existing, with relevant practitioners and experts consulted as appropriate. An impact assessment must also be carried out every time a PSI is changed. If a policy decision has been made that the benefit of a PSI is required then sufficient resources must be provided to ensure its delivery.
Recommendation 28
NOMS must put in place a more effective central system for auditing the implementation of PSIs at individual establishments and to assure NOMS senior management that the Instructions are practical and are being implemented with all anticipated benefits being delivered. Primary Recommendations
Recommendation 29
There must be a legal recognition of the concept of ‘maturity’. As well as chronological age, maturity should be a primary consideration in making decisions relating to diversion, sentencing and, where a custodial sentence must be given, how and where a young adult (18-24) should be accommodated. The work to achieve this should be the responsibility of the Ministry of Justice, who should report on progress within 1 year of the publication of this review.
Recommendation 3
We recommend that the application of the current IEP scheme must urgently be reviewed so that the shortcomings associated with the current scheme be addressed and resolved. With immediate effect prisoners must not be automatically downgraded to the entry level of IEP on return to the prison following sentencing.
Recommendation 30
A multidisciplinary and cross-departmental approach must be adopted to support young adults who have entered or are at risk of entering the Criminal Justice System. The Government Departments involved should be the Ministry of Justice, the Home Office, the Department of Health, Department for Innovation, Business and Skills, Department for Work and Pensions, and Department for Communities and Local Government. The initiative should be coordinated by the Cabinet Office, with input from the Government Equalities Office. Similar arrangements should be developed in Wales under the auspices or working with the Welsh Government.
Recommendation 31
NOMS must accept that bullying wherever it occurs is a specific problem that requires specific, focussed responses. We recommend that NOMS must publish a specific Prison Service Instruction to cover the issue of bullying both from other prisoners and from staff and how custodial establishments can tackle and aim to reduce numbers of incidents. Bullying should not be subsumed into the policies that cover Violence Reduction.
Recommendation 32
Local authorities must have an explicit statutory duty to provide a corporate parenting and support role to all young people who are in NOMS custody, in addition to their existing statutory duties towards care leavers in custody. This should include providing a ‘Significant Adult’ who would be able to visit during normal visiting hours and to act as a mentor and personal advisor to these young adults.
Recommendation 33
The Review recognises that there is no simple answer as to whether young adults should be accommodated in separate institutions or mixed with older adults. All young adults (18-24 years), however, must be accommodated in small units that have the specialist staff and regime to meet their needs and that, when their maturity or vulnerability mean it is in their best interests, they should have the facilities to accommodate them in specialised wings or blocks.
Recommendation 34
All custodial establishments should have in place a process whereby a prisoner can arrange for a visit from family within three days of their arrival at the prison for the first time.
Recommendation 35
NOMS should continue its useful work on developing a tool to measure maturity effectively, the aim of which should be to better identify and support those in custody who are vulnerable because of a relative lack of maturity. This tool should be appropriately tested and made operational as soon as possible. Progress on this tool should be reported within one year of the publication of this Review.
Recommendation 36
If the YOT and other key organisations believe that due to an individual’s lack of maturity, it would be in the best interest of a vulnerable young adult to remain in the under-18 estate after they reach 18, suitable accommodation should be found for that person within the juvenile estate, recognising safeguarding issues.
Recommendation 37
YOTs and other relevant agencies should be required to remain in contact with a young adult who transfers from the youth estate to an adult or young adult establishment for at least 6 months after they reach 18, and longer if particular vulnerabilities are identified. This may extend to 21 or 24 (if they are in full-time education), comparable with the local authority duty for young adults who were ‘looked after’ before they reached 18.
Recommendation 38
NOMS should further develop its work on care leavers, in order to ensure that care leavers can be accurately and reliably identified upon arrival in Prison and that data is collected to ensure that progress through custody for care leavers is properly recorded, researched and improved.
Recommendation 39
NOMS should introduce a robust assurance process for the safe transfer of every prisoner. As part of the preparations for transfer and on completion of transfer there must be a mandatory obligation on both the sending and the receiving establishments to ensure that the full details of a prisoner’s record, including any current or former SAVRAS, is transferred. There must also be a positive duty on the receiving establishment to review and, if necessary, to act on the information provided, and also to follow up, in a timely manner, when information is thought to be missing.
Recommendation 4
HMIP must conduct a thematic review on Safer Cells, which includes an analysis of what the right number of safer cells is for each prison and YOI. The review should identify which prisons are maintaining enough cells at the correct ‘Safer Cells’ level. Once this is established, whether the prison continues to maintain the right level should become a standard part of HMIP inspection process.
Recommendation 40
As part of their response to bullying NOMS must provide (for example through an external contractor or NGO, if appropriate) a 24 hour anti-bullying helpline. This service should be provided through a free telephone hotline, so that prisoners or their families could report problems. All calls would be logged and passed to the relevant prison which would be expected to record the action taken, including consideration of urgency and appropriate management of the issues raised. On Diversion Primary Recommendations
Recommendation 41
The Review strongly supports the view expressed to us by our judicial representative that prison should be a last resort, it should not be used as the default solution when other alternatives are appropriate and available. A reduction in the prison population will enable prisons to provide an environment which meets appropriate standards of decency, safety and respect, and will assist prison authorities to comply with their human rights obligations, including the obligation to protect life. Diversion to healthcare, social care and other alternatives to custody can be a better means of addressing the complex needs of young people, and, in turn, better serve the victims of crime and society in general. It is essential that all magistrates and judges involved in sentencing decisions must be adequately trained on the vulnerabilities of young people, and the range of diversion schemes and alternatives to custody available within the local area.
Recommendation 42
Where a young adult is at risk of being placed in custodial remand for reasons that include concern that they do not have suitable alternative accommodation to which they can be remanded, the relevant local authority should either have to provide it, in something similar to the ‘Bail Hostel’ provision, or pay the costs of the custody provided through NOMS.
Recommendation 43
The scope of the Troubled Families Programme should be expanded to address early family intervention. The Welsh Government should be invited to expand their own programmes to address the same issue.
Recommendation 44
There should be a parallel Programme focussing on the needs of vulnerable young people who are at risk of entering or already have had a number of encounters with the criminal justice system.
Recommendation 45
Further funding should be made available by the Department of Health to CAMHS services (and Welsh Government equivalent) to ensure early identification of mental health issues that, if properly supported, can be dealt with more effectively at an early age. CAMHS services need to be more closely linked to educational facilities, including custodial ones, to children up to the age of 18. 45.1 Further investment is needed by the Department of Health (and Welsh Government equivalent) in Liaison & Diversion schemes, with a view to providing more appropriate services to vulnerable young people. Equal commitment should be provided to supporting Alcohol and Drug use and addiction services and services relating to the meeting of housing needs of individuals. 45.2 CCGs should consider ways to prioritise access to NHS treatment services for those diverted from custody via the liaison and diversion process. 45.3 Mental Health Assessment and Treatment Programmes must be expanded to cover all custody suites and criminal courts in England & Wales.
Recommendation 46
When a court is considering passing any form of custodial sentence upon a young adult (18 to 24) then a full written pre-sentence report must be commissioned.
Recommendation 47
It is the collective responsibility of all relevant public agencies to ensure that no young adult who is identified as requiring detention and treatment/assessment in hospital under the Mental Health Act 1983 should be detained in police or prison custody. This should be a ‘Never Event’. On Family Support Primary Recommendation
Recommendation 48
Families are integral to supporting young people in custody and can help to keep them safe from harm. They must be included, where appropriate, as a central component of the management and care of young people in custody. Secondary recommendations
Recommendation 49
Assistance should be given to families/principal carers to become more involved with their relative in custody where appropriate, including providing relevant information to help them understand the CJS, how to contact the prison, how to contact the CARO, and how to contact the Visitor Centre.
Recommendation 5
NOMS must identify and keep a record of the number of certified ‘Safer Cells’ (PSI 17/2012) both in use and available for use across the estate.
Recommendation 50
Visits and contact with family are usually a protective factor against harm and should not be withdrawn as part of punishment, IEP or because of restricted regimes.
Recommendation 51
All custodial establishments should have in place a process that will ensure that all prisoners will be able to contact a family member or a friend within 2 hours of their arrival in Prison, including following a transfer.
Recommendation 52
All custodial establishments must produce and publish information for families and prisoners on the arrangements for contacting their relatives in properly appropriate and accessible form. Arrangements should be made for this information to be widely available, for example at Magistrates’ Courts and online.
Recommendation 53
Prisons must improve their processes for receiving information direct from the families of prisoners, particularly young adults. We recommend there should be a dedicated telephone line for families/friends and others to pass on concerns about prisoners, which should be continuously available over a 24 hour period. Information received should be logged and passed on appropriately to be recorded as part of the SAVRAS. This process should be audited.
Recommendation 54
A young adult should be given the opportunity to include on the PER two personal phone numbers for friends and family, before a mobile telephone is retained by the police/ prison authorities.
Recommendation 55
NOMS should invest in new technology, such as in-cell telephony and video call facilities, (for example Skype), similar to those used successfully in other jurisdictions in order to facilitate better contact with family. If necessary, to support this, families should be assisted through provision of access to facilities at an appropriate place close to where they live.
Recommendation 56
Whenever an 18 – 24 year old is being considered for a prison transfer, the distance from the address of the family/primary carer must be considered and the transfer needs to be agreed with the recommended new dedicated young adult unit in NOMS.
Recommendation 57
Governors should place high priority on peer support systems, such as Buddy schemes, Peer Mentors and Prisoner Councils and should ensure that there is a guaranteed commitment from their staff towards these schemes.
Recommendation 58
Prison Governors should assure themselves that there is guaranteed commitment from all staff to the operation of the Listener scheme, and that Listeners feel supported and enabled.
Recommendation 59
Governors should ensure that Listener Suites are provided within their establishments and that they are a safe and supportive environment.
Recommendation 6
NOMS must develop and publish a distinct policy for management of gangs, including an identification of what strategies are most likely to deliver better outcomes in relation to the management and support of those individuals who may be perceived as being part of a gang.
Recommendation 60
Each young adult (18-24 years) in custody must be assigned to a suitably qualified and experienced staff member who will act as their personal Custody and Rehabilitation Officer (CARO) whose responsibility it will be to build a supportive relationship with them, to oversee their security and well-being, to ensure their health, education, social care and rehabilitation needs are met, and to oversee the assessment for and delivery of their Individual Custody Plan (ICP).
Recommendation 61
With a view to developing an ICP, all young adults entering custody must undergo a full multi-disciplinary holistic needs assessment within 48 hours of their arrival in custody. This process, to be known as the Safety and Vulnerability, Risk Assessment and Support (SAVRAS) process, should be co-ordinated by a CARO, who will ensure that as part of this process an appropriate assessment is made by suitably qualified practitioners (properly trained in issues of gender and cultural sensitivity) of any physical, social care, and mental health needs of, or other vulnerabilities and risks faced by, the young person. These needs will include those currently covered by the ACCT process.
Recommendation 62
The ICP should be developed by the CARO, in consultation with the young adult concerned in order to identify how, by whom and when their needs identified by the SAVRAS process, will be met.
Recommendation 63
NOMS should consider whether the ICP, SAVRAS and CARO approach might also usefully apply to older adult prisoners.
Recommendation 64
There must be parity of health care services in prisons and YOIs with those in the community and NHS England and Local Health Boards in Wales should commission the services necessary to do this and deliver what is set out in this chapter.
Recommendation 65
NHS England should commission prison mental health services in line with the recommendations of this report.
Recommendation 66
Responsibility for prevention of self-harm and self-inflicted deaths in custody should be jointly owned by both NOMS and Healthcare.
Recommendation 67
Further to the statement of the purpose of prison, the European Prison Rules (5) state the principle of approximation as closely as possible the positive aspects of life in the community; therefore healthcare must take a central responsibility in this area.
Recommendation 68
There should be a consistent approach throughout the criminal justice system to requesting consent to share medical information, which should happen at the first point of contact with the health services in a CJS setting, whether that be at a police station or at a prison, and that that consent should apply to the remainder of the prisoner’s journey through the CJS. If consent is declined it should be revisited regularly particularly if a serious health incident occurs.
Recommendation 69
All young adults should have an up to date ICP and SAVRAS that is co-ordinated by their CARO, who will be accountable for assuring the quality of the documentation, its regular review, and ensuring that its various elements are implemented.
Recommendation 7
All young adults should spend at least 8 hours a day outside of their cell and must be entitled to at least one hour of daily exercise in the open air every day. NOMS must record details of instances when a prisoner has not been able to comply with these minimum standards.
Recommendation 70
Families must be provided with sufficient opportunities to feed into the SAVRAS process, including through providing potentially relevant information on the dedicated concern line, and any such information must be recorded within the SAVRAS documentation.
Recommendation 71
All commissioning, contract and performance management policies and documents for health and mental health provision in custody should include responsibilities for SAVRAS and will include the following: 71.1 Health teams must be actively involved in the operation of the SAVRAS process, although the delivery of services through the ICP to meet assessed needs should be multidisciplinary; 71.2 Where a mental health, learning difficulty or significant social issue(s) are identified through the SAVRAS process, a full age-appropriate psychosocial assessment must also be carried out by a suitably qualified health care professional. The results will inform the content of the ICP. 71.3 Where a SAVRAS contains an element of need elevated to a crisis stage, only a suitably qualified health care professional, in conjunction with the CARO, will have the authority to terminate the services designed to meet that need.
Recommendation 72
Case Reviews of the SAVRAS and ICP will be led by the CARO and must be multi-disciplinary and where necessary must include representatives from healthcare. Where appropriate, the CARO should consider including chaplaincy, education, relevant in-reach staff, VCS and the prisoners’ families/friends. CRC/NPS probation and TTG workers should also be involved when the individual is being prepared for resettlement.
Recommendation 73
At any stage during the young adult’s time in custody, all prison staff must be under a positive obligation to notify the CARO (or the person acting on their behalf in their absence) of any concerns about an individual’s risk/vulnerability. Appropriate out of hours cover arrangements for the role of the CARO should also be made.
Recommendation 74
When the transfer is between the youth estate and an adult institution, the YJB will be accountable for the transfer of all relevant information from the YOT, including health, mental health and care leaver status.
Recommendation 75
During any transfer, where a prisoner has a SAVRAS (as all young adults will have) as part of their ICP, the receiving establishment must ensure that there must be no interruption of the ICP and/or SAVRAS as a result of the transfer.
Recommendation 76
Where a prisoner who is being transferred to another prison has been on an ACCT, and when the crisis plan of the SAVRAS has been implemented, which was closed within the last three months this must be highlighted and the Care Plan (ICP) reviewed within 24 hours of receiving the prisoner.
Recommendation 77
A record of any time a prisoner has spent on an ACCT/or the crisis plan of a SAVRAS must be recorded on System 1(or replacement) so that it is available for prison healthcare staff.
Recommendation 78
Any health assessment (both physical and mental) produced at the police station by the liaison and diversion practitioner and others at the start of a prisoner’s journey through the criminal justice system should be shared amongst specified CJS organisations (e.g. CPS, legal team, NOMS, HMPS) in order to assist them in making reasoned decisions subject to the issues relating to the sharing of data.
Recommendation 79
Department of Health, Home Office and the Ministry of Justice need to issue joint guidance to the effect that when consent to sharing medical information has been given by a person in custody, then the assumption is that that consent remains valid (unless withdrawn) throughout the criminal justice journey of the person in custody.
Recommendation 8
Any young adult where there are current concerns about their vulnerability recorded as part of their SAVRAS should not have their regime (IEP) status downgraded.
Recommendation 80
An appropriate consent form should be available which reflects the above, and in particular requesting of such consent should be a standard part of any prison reception assessment.
Recommendation 81
Should such consent not be given, the person in custody should have an informed discussion periodically with healthcare professionals to revisit the decision made.
Recommendation 82
Guidance from health organisations should be considered to reflect the duties of the State to protect life in custodial settings, with appropriate guidance given as to the disclosure and sharing of health information in such settings (including in those instances where consent is not provided).
Recommendation 83
All Healthcare staff must be trained to the minimum level of the Immediate Life Support Course of the Resuscitation Council with scenarios adapted to suit the prison environment. All prison staff must also be trained to a minimum of basic life support level.
Recommendation 84
Each prison and YOI should have an emergency medical response plan that contains the following elements: 84.1 A mandatory Medical Emergency Response exercise each year, including emergency medical codes, in conjunction with local health care providers and emergency services. 84.2 NHS needs to consider developing an appropriate health “NEVER” event in a custodial setting. 84.3 A system for checking that standard emergency medical equipment is available and in good condition in appropriate locations within the prison/YOI.
Recommendation 85
The Secretary of State for Justice should introduce legislation to create a statutory duty of cooperation for the sharing of information with the Prison Service to be placed upon those organisations that have direct engagement with the Prison Service (including health, mental health services, police, etc.). Primary Recommendations
Recommendation 86
Following a death there should be a ’Duty of Candour’ upon NOMS and its staff both towards those organisations responsible for managing the post death processes (such as the PPO and the coroner) and the families and friends of the deceased young adult.
Recommendation 87
NOMS must establish requisite monitoring and reporting systems to ensure that all custodial establishments comply with PSI 64/2011, with regard to engagement with families after a death, and to ensure the timely provision of appropriate levels of information and support and the appointment of the FLO. The FLO must not have been the young adult’s CARO. A meeting should be convened possibly chaired by Chaplaincy, in conjunction with the local Samaritans, to come together and provide support prisoners and staff following a self-inflicted death.
Recommendation 88
Families of the deceased should have a right to non-means tested public funding for legal representation at an inquest. The costs of legal representation for the families should be borne by NOMS. Secondary Recommendations
Recommendation 89
A meeting should be convened possibly chaired by Chaplaincy in conjunction with the local Samaritans, to come together and prove support to prisoners and staff following a self-inflicted death.
Recommendation 9
All light fittings within cells should as standard be tested to ensure that they are not able to bear the weight of a young adult before any cell can be signed off as being fit for purpose as a safer cell.
Recommendation 90
Parliament should have a much greater role in oversight of the inspection process and in driving change.
Recommendation 91
The Review acknowledges that NOMS cannot deliver these recommendations without significant resource investment. Although in the longer term, it is anticipated that this investment will be funded through savings delivered by earlier intervention and diversion from the CJS, the government response to this report must detail how this extra resource will be given to NOMS.
Recommendation 92
Oversight of the HMIP and PPO must be transferred from the Ministry of Justice to Parliament who would set their budgets and appoint their respective heads.
Recommendation 93
HMIP and the PPO should have a statutory duty in consultation with the NPM and the IAP present a public report annually to the MoJ on deaths in NOMS custody and the progress in addressing the underlying issues identified from previous deaths. MoJ should be under a statutory duty to publish a detailed thematic response each year to this report. This should be considered by the Justice Committee of the House of Commons.
Recommendation 94
Every two years MoJ and NOMS should produce a report for the Joint Committee on Human Rights on the extent to which prisons and YOIs are meeting their obligations inter alia under the Human Rights Act and other relevant national and international standards.
Recommendation 95
The PPO should be placed on a statutory footing and should have statutory powers to require the production of documents and to compel witnesses to participate with PPO investigations. 95.1 The PPO must look to develop standards of service for the process of investigating deaths in custody, similar to those operated by the IPCC for the securing of a crime scene, following a death in custody 95.2 The PPO should ensure that clinical reviews are independent and conducted by appropriately qualified and experienced clinicians and reviewers and should take over the management of this function by being funded to appoint a panel of suitably qualified clinical reviewers. Clinical reviews should take account of information from the families/primary carer of the deceased if at all possible. 95.3 The PPO should review the action plan produced in response to its recommendations and have the right to reject it, and require a new action plan to be produced if the PPO considers that it does not adequately address the recommendations made.
Recommendation 96
NOMS should consider each PPO recommendation and any Coroners’ jury finding and PFD reports individually, decide whether it applies only to the establishment where a death occurred or more widely across the estate, and then put in place an appropriate action plan in response to that recommendation (which may involve other establishments). Such action plans should be made public and monitored by the Equality Rights and Decency Group within NOMS to ensure that the letter and spirit of such recommendations is being followed and they should report each year to the IAP and HMIP.
Recommendation 97
HMIP should have a statutory duty (as opposed to an informal arrangement) when inspecting an establishment to review progress achieved on implementing previous PPO recommendations (using any reviews the PPO may have conducted) and any previous Coroners’ jury findings and PFD reports.
Recommendation 98
During inspections, HMIP should ensure that they take account of the views of prisoners’ families on the prison regime.
Recommendation 99
In the event of HMIP producing a poor grading for an establishment, NOMS should consider whether that prison should be placed under special measures which might include the replacement of some or all of the management team and – where relevant - the running of the establishment by an alternative provider.