Deaths in Custody: FIR PPO Recommendations
Dear Prisons and Probation Ombudsman for England and Wales,
It is of real concern that time and time again I read in your Fatal Incident Reports (FIR) how prisons have ignored or failed to implement recommendations made in your previous FIRs - recommendations intended when implemented to reduce the number of deaths in custody by learning lessons from previous tragic incidents.
Can you please:
Q1: Tell me, for each of the following years (or as many as are available):
i. 2013/2014;
ii 2014/2015;
iii 2015/2016;
iv 2016/2017; and
v. 2017/2018
How many Recommendations made in FIRs by the PPO have been:
a. implemented
b. not implemented
Q2: Detail those prisons where FIR recommendations have not been implemented, and where the same or similar recommendations have had to be restated in subsequent FIRs at the same prison.
Q3: Detail what has the PPO
a. Can do; and/or
b. Has done
to ensure compliance with PPO FIR recommendations in future.
Thank you.
Yours faithfully,
Mark Leech FRSA
Editor: The Prisons Handbook for England and Wales
Dear Mark,
Thank you very much for your email, which is being handled under the Freedom of Information Act.
I would like to clarify the information you have requested in your first question. We do not monitor the implementation of accepted recommendations, so are unable to provide this information. However, there are two sources of information that may be of interest to you instead.
1.Action plans
When we make recommendations, we receive action plans from establishments in response. We apply categories to the action plans, based on the information provided to us at the time, to identify whether the recommendations have been implemented, partially implemented, underway or rejected. We record these responses and can provide you with the breakdown of this information, by year.
We do not have all the responses recorded on our database. In the process of putting this together, we have estimated that inputting this information will exceed the cost limit required for complying with this request. We therefore suggest, in order that we can comply with your request, that we provide you with a breakdown of the information currently held on our database. We hold this information for 46% of recommendations, for the years dating back to 2012/13, up to and including 2017/18. Alternatively, if you would prefer more complete information, we would suggest that you narrow your request to only those recommendations made in 2017/18.
2.HMIP feedback
Additionally, we share our recommendations with HMIP prior to their inspections of those establishments. Following inspections, they provide us with ratings on the success of implementation at the time of the inspection, though these judgments are not part of the formal inspection process, and we will only receive the information if it has arisen in the course of the inspection. Again, these are only valid at the time of the inspection. We can provide you with a breakdown of this information, by year.
Please could you confirm whether you would like to receive the information we currently hold for the years 2012/13 to 2017/18, and whether you would like the data from the action plans and/or the data from HMIP feedback?
Learning Lessons team
Dear PPO Mail - Learning Lessons,
Thank you for this.
It is hardly an acceptable situation that having made recommendations to reduce the number of deaths in custody that you do not monitor whether those recommendations have been implemented - there is no more serious a subject than deaths in custody.
The now-and-again approach to monitoring that is conducted by HMIP is again unacceptable when it comes to deaths in custody; there has to be a better way forward in learning these lessons. I have lost count of the number of your Fatal Incident Reports (FIR) I have read where you criticise a prison for its failure to implement previous recommendations where that failure has resulted in identical deaths in custody once again.
By then its a lifetime too late.
There are a number of ways you can correct this.
Firstly you could agree with the Secretary of State for Justice an Urgent Notification process (as HMIP now do) where, when there is a second death in custody in conditions identical to those you have previously issued recommendations about that have been ignored, that require the Justice Secretary to respond publicly.
Further, or in the alternative, you could (through the new IMB Management Board) ask that the implementation of FIRs are monitored by Independent Monitoring Boards and recorded in their Annual Reports.
What we cannot continue to have is the tragic situation where the PPO issues recommendations that prisons ignore with impunity and without consequence; or what on earth is the point of the PPO making recommendations to learn lessons and reduce deaths in custody in the first place?
There is also the not insignificant point as an independent body that the PPO does not (unlike HMIP) publish the action plans that you agree with prisons following a fatal incident; why is that?
Transparency in this vital safer custody area demands publication.
Turning to your response, yes please could you please provide me with:
1. the more complete information relating to only those recommendations made in 2017/18; and
2. In relation to HMIP, a breakdown of this information, by year.
With Sue McAllister now in post as PPO I am confident having known her for over 15 years that she will focus on these defects of implementation of FIR recommendation; what is certain is that the current lamentable and tragic situation cannot be allowed to continue.
Thank you.
Yours sincerely,
Mark Leech FRSA
Editor: The Prisons Handbook for England and Wales
@prisonsorguk
Dear PPO Mail - Learning Lessons,
Yes please send me the information that you have - its better than nothing but the fact you do not have it sends a message that the PPO is completely unfit for purpose.
It is frankly outrageous that the PPO does not monitor the implementation of its recommendations - I would remind you that we are not talking about the loss of someone's property here, but the loss of someone's life.
What has the PPO been doing for the last 15 years?
As I have asked before (and the Ombudsman played politics when replying by skirting around the issues) "why does the PPO not use Independent Monitoring Boards to monitor the implementation of PPO Death in Custody recommendations - or sign an Urgent Notification protocol with the Justice Secretary?"
I'm still waiting for an answer to that which makes any kind of sense.
Continuing to do nothing while recommendations designed to reduce deaths in custody are tossed in the trash by those who should be implementing them, brings the PPO's Office into complete disrepute.
You know me; I am not going to let you get away with this while people are dying in our prisons and the PPO looks the other way.
Yours sincerely,
mark leech
Dear Mark,
Thank you for your email. Please find attached the response to your FOI request.
Learning Lessons team
Dear Prisons and Probation Ombudsman for England and Wales,
Please pass this on to the person who conducts Freedom of Information reviews.
I am writing to request an internal review of Prisons and Probation Ombudsman for England and Wales's handling of my FOI request 'Deaths in Custody: FIR PPO Recommendations'.
The facts and figures you quote in your reply are wholly inaccurate - HMP Rye Hill for example doesn't appear once on the list of establishments where there have been non-implementation of death in custody recommendations (restraints), yet there is a plethora of these - links to some of which appear below ( and you will find a precis of them here: https://prisons.org.uk/ryehill-restraint...)
https://s3-eu-west-2.amazonaws.com/ppo-p...
https://s3-eu-west-2.amazonaws.com/ppo-p...
https://s3-eu-west-2.amazonaws.com/ppo-p...
https://s3-eu-west-2.amazonaws.com/ppo-p...
https://s3-eu-west-2.amazonaws.com/ppo-p...
https://s3-eu-west-2.amazonaws.com/ppo-p...
This is just one prison - what other establishments have you missed from the list?
I also feel your explanation as to why you cannot introduce an Urgent Notification procedure is baseless - until 2017 the PPO issued anonymised (deceased details withheld) FII reports - the PPO could simply do the same now with an UN procedure; it is not the name of the person who died that's important but the failure to implement previous recommendations that have seemingly lead to another death in custody.
It seems you have made a decision not to implement an urgent notification procedure, and then worked backwards to find a reason to justify it.
I repeat the PPO is not investigating the loss of a prisoner's luggage in these cases, but the loss of a prisoner's life.
Can I please have a full review of this request and the way it has been handled.
A full history of my FOI request and all correspondence is available on the Internet at this address: https://www.whatdotheyknow.com/request/d...
Yours faithfully,
Mark Leech FRSA
Editor: The Prisons Handbook for England and Wales
@prisonsorguk
Dear PPO Mail - Learning Lessons,
When can I expect a reply to my request for an internal review?
Yours sincerely,
mark leech
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