Following a call by Parliament’s Joint Committee on Human Rights for a national oversight mechanism to ensure that lessons are learned from deaths in prisons, Clair Hilder reflects on the growing number of cases that demonstrate the failure of our current system to protect vulnerable prisoners.
Parliament’s Joint Committee on Human Rights (the JCHR) is currently carrying out an inquiry into mental health and deaths in prison, looking at three broad themes:
- Whether prison is the right place for vulnerable offenders such as those with mental health conditions and/or learning difficulties;
- The way prisoners with mental health conditions are treated in prison; and
- How to ensure that lessons for the future are learned, errors not repeated and that good practise becomes common practice.
As well as written submissions, the JCHR has taken oral evidence from a number of witnesses and as a result considers that there is a need for a ‘national oversight mechanism with a duty to collate, analyse and monitor learning outcomes and their implementation arising out of deaths in prison’.
Sending a letter to the Secretary of State for Justice in March, Chair of the JCHR, Harriet Harman called for the Prisons and Courts Bill, which at the time was making its way through Parliament, to be amended to provide for such a national lesson-learning mechanism, similar to the one outlined in the Children and Social Work Bill in relation to the deaths of children in care.
For those who act for bereaved families at inquests following deaths in custody, the need for such a mechanism is obvious and clear, indeed it is something for which the charity INQUEST has been calling for a number of years. In their written submissions, INQUEST highlighted how bereaved families repeatedly tell them that they want change in order to safeguard lives in the future, and that the number of repeated failings are incomprehensible to families.
Currently there are numerous ways that failings are identified and recommendations made including:
- HM Chief Inspectorate of Prisons carry out inspections, publish their findings, and make recommendations;
- Following deaths, the Prison & Probation Ombudsman (PPO) carry out an investigation which involves interviewing staff, identifying issues and making recommendations;
- An inquest will be held following a death; the inquest’s conclusion can highlight failures which were probably or possibly causative of the death, and in addition the coroner can make a Prevention of Future Deaths (PFD) report should they consider that there is a risk of further deaths.
- Independent reviews are set up to look at specific issues, for example Lord Harris’ review of young people’s self-inflicted deaths in custody or Baroness Corston’s review looking at vulnerable women in the criminal justice system.
The problem is that as it stands these recommendations have very little teeth. Those directed at individual prisons do not get passed to other establishments. Recommendations are not monitored or followed up. Whilst PFD reports are now published on the Chief Coroner’s website, there is nothing to compel prisons, or other bodies such as healthcare providers, to act. The bodies at which they are directed are just required to provide a written response and no one checks that action is actually taken. As INQUEST highlighted in their submissions to the JCHR, action often peters out only to be revisited several years later by different bodies. This will likely be as a result of a further death in similar circumstances involving the same issues and failures.
As Clare Hobday- Saunders, the partner of Dean Saunders who died in HMP Chelmsford told the JCHR in compelling evidence, ‘They should actually be learning those lessons, but instead they just say it so that people will go away. That happens again and again. Those lessons are not being learned. For me, the PPO investigation was fantastic, but that bit of paper is almost irrelevant. They will look at it and say “Yes, we’ll sort it out”, but they will not. It seems to be a tick-box exercise: “We’ve had the PPO investigation and we’ll say we’ll do this, this and this. They won’t come back and check, but next time it happens will say, “There are lessons to be learned”.’
The need for PPO recommendations to carry greater weight, and for the creation of a body to follow up on recommendations, was made starkly apparent from recent cases I have been involved in involving HMP Winchester, the details of which make for gloomy reading.
Lessons are not being learned – HMP Winchester
I represent the families of Haydn Burton and Daryl Hargrave. They were found hanging at HMP Winchester four days apart.
Haydn died on 18th July 2015 and his inquest was held in September 2016. The jury at his inquest found that his death was exacerbated by inadequate implementation of suicide and self-harm prevention procedures (otherwise known as ‘ACCTs’) and insufficient communication within the prison system. They found that the failure to carry out the mandatory ACCT assessment interview and first ACCT case review within 24 hours of the ACCT being opened contributed to his death.
Following the inquest, the coroner made a Prevention of Future Deaths report noting that staff were not implementing ACCT plans in accordance with national policy, notwithstanding training they had received, and in particular that the observations conducted were inadequate. This followed CCTV evidence that the officer who conducted the last ACCT observation on Haydn walked past and glanced into the cell without breaking his stride. The officer in question gave evidence that he did not know which of the two prisoners in the cell was Haydn, such an observation therefore clearly lacked any meaningful interaction with the person identified as being at risk.
NOMS (National Offender Management Service) responded to the coroner’s report in December 2016 stating that the new Governor of HMP Winchester was committed to ensuring that all operational staff are successfully trained in ACCT procedures to enable them consistently to follow national ACCT policy. It was noted that local ACCT refresher training was due to take place on 13th and 20th December 2016 for 48 members of staff and would be delivered at least monthly thereafter.
Daryl died the day after Haydn on 19th July 2015 and his inquest was held in March/ April 2017. The jury at his inquest found that his death was as a result of suicide whilst suffering from psychosis and this was contributed to by neglect, following a failure to treat his mental health problems.
Despite there being a gap of three months since NOMS’ response to the PFD following Haydn Burton’s inquest, and almost 18 months since Daryl’s death, the evidence heard at his inquest in respect of ACCT training was woeful. A document disclosed, providing dates of officers’ most recent training, showed that of those involved and who were still working in the prison, h the most recent training was received in December 2015. The officer who was conducting ACCT observations on Daryl the day he died and who missed two observations that day had received no ACCT training whilst at HMP Winchester.
The Governor, when giving evidence, admitted that only 61% of staff overall and only around 51% of healthcare staff were trained adequately.
Following the conclusion, the coroner indicated that she remained gravely concerned and felt further steps were needed to reduce the risk of future deaths. The coroner’s Prevention of Future Deaths report, a lengthy and comprehensive document, made reference to numerous areas of concern, highlighting improvements needed to the ACCT documentation and process, the problem of officers not having the time for meaningful interaction with prisoners and poor progress relating to the speed and delivery of ACCT training.
In both of these cases the PPO investigated the deaths prior to the inquests and were critical of failings in the ACCT processes. It also expressed the worry that these deficiencies had been identified previously in investigations into deaths at HMP Winchester.
Haydn and Daryl were not the only self-inflicted deaths at HMP Winchester during 2015. There were at least two others that we are aware of, and around seven deaths in total. Nor were theirs the only ones in which ACCT training had been raised as a concern. A PFD was made about this following the inquest into the death of Sheldon Woodford which concluded in February 2016. In this case, the PPO in January 2016 urged the Governor to take urgent action.
Following Daryl’s inquest, his mother, Nicky, explained that she clung to the hope that Daryl’s death would help others. Unfortunately leaving it to prisons to implement changes has not proved successful in the past. I have little hope that without a national mechanism to push through change, recommendations from PPO and PFD reports from coroners will have sufficient impact to save lives and promote the positive change which is sorely needed within our Prison Service.
HMP Woodhill – the highest rate of self-inflicted deaths in the country
These problems are by no means limited to HMP Winchester. There are countless examples of prisons failing to act following self-inflicted deaths.
Earlier this month a judicial review was brought by relatives of two men who died in July 2015 and August 2016 at HMP Woodhill and was heard by the High Court. HMP Woodhill is the prison with the highest rate of self-inflicted deaths in the country, and the applicants are asking the Court to order the Governor of Woodhill and Secretary of State for Justice to take urgent action to reduce the risk of future self-inflicted deaths. Judgement is currently awaited.
In December 2016, a jury at an inquest into the self-inflicted death of Tedros Kahssay in January 2016 found that the failure to act following previous deaths contributed to his death. Amongst other failings they considered HMP Pentonville didn’t comply with an agreed recommendation made by the PPO following a previous death at the prison in respect of the sharing of information between the prison and healthcare staff. This failure impacted on the adequacy of the mental health assessment given to Tedros. During evidence at the inquest neither the prison governor nor the deputy head of healthcare were able to explain why this recommendation had not been implemented.
Can change happen without more resource?
Even with the introduction of a national oversight mechanism it is questionable whether, without further resources, significant change will be effective. This concern was echoed in evidence given by Andrea Albutt, President of the Prison Governors Association to the JCHR. Albutt stated, ‘I hate to keep going back to resources, but I cannot overemphasise how challenging it is in prisons under austerity measures’….’It is incredibly difficult for governors to deliver those action plans, coupled with an operating environment that is so challenging and unstable. Particularly in our remand prisons, governors are trying just to keep the lid on prisons. Unfortunately, things like action plans go on to the back burner. They are trying to unlock prisoners on a daily basis, because regimes are limited and it is so challenging.’
She went on to agree with Harriet Harman that given the inadequate resources, Governors had to manage the current crisis and whatever good ideas people had for preventing suicide would not be implemented. The level of suicides would inevitably rise; ‘you cannot think about cultural change and leadership, because it is quite overwhelming,’ Ms Albutt said. This is disturbing given the already soaring numbers of self-inflicted deaths in prisons.
Since Harriet Harman’s call for legislation on a national oversight body, the announcement of a General Election has led to the scrapping of the Prisons and Courts Bill for now and it appears this opportunity for change has been missed. It remains to be seen whether this is something which will be on the agenda for any new Government.
The JCHR’s report is awaited in due course in the hope that its’ recommendations, so important for the safety of vulnerable prisoners, are not added to the long list of those made previously but never implemented.