Ombudsman disappointed at continued failure to implement agreed recommendations

The Prisons and Probation Ombudsman (PPO) stepped up work in 2018-19 to ensure its repeated recommendations for improvements following deaths in custody and investigations of complaints have a stronger impact in practice.

Sue McAllister published her report for the year, which showed that selfinflicted deaths had risen by nearly a quarter and that some jails are failing to act on the same safety recommendations repeated year after year.

The report also makes clear that prisoners’ property – the largest cause of prisoners’ complaints – is regularly lost or damaged. This has been a repeated problem over many years and in the 2016-17 annual report the PPO urged the prison service to get a grip of the issue. The PPO praised the hard work, dedication and compassion of prison staff, many of them relatively new and inexperienced, in very difficult circumstances – including facing drug-fuelled violence and dealing with some very troubled individuals. But she urged HM Prison and Probation Service (HMPPS), working with the PPO, to better understand the barriers to learning lessons and making prisons safer and fairer.

“We continue to make the same recommendations repeatedly, sometimes in the same establishments and, often, after those recommendations have previously been accepted and action plans agreed to implement them.

“Where the same failings are identified time and again, organisations must address those barriers which exist, whether they are structural, cultural, attributable to insufficient resources or to other things.”

• The 2018-19 report – available here – has a number of key findings: The PPO started 334 fatal incident investigations, including 91 self-inflicted deaths, a 23% increase year-on-year, “with worryingly high numbers in some prisons.” Sue McAllister commented: “In many cases, we had to make the same recommendations as in previous years, where remedial action had been
  promised.”
• Deaths from natural causes fell by 4%, despite a continuing increase in the number of prisoners aged over 50. PPO investigations continued to highlight the inappropriate use of restraints on people who are very unwell, often immobile and presenting a low risk of escape or offending while being escorted to, or in, hospital.
• Psychoactive substances (PS) continued to present a significant challenge to prisons. The report noted: “It is difficult to give an exact figure for the number of drug-related deaths…as the term covers such a range of circumstances.
• We can say that there were 36 ‘other non-natural deaths’ in 2018/19. This included a small number of cases where post-mortem and toxicology reports were unable to establish the cause of death, but most of these deaths were drug-related. There were a further 23 deaths awaiting classification at the end of the year and experience suggests the majority of these deaths will also
  prove to have been drug-related.”
• Procedures for recording and managing prisoners’ property remained outdated and inefficient. “Prisons also vary in their capacity and commitment to have in place sensible and defensible arrangements for controlling and storing property and for dealing with complaints about lost or damaged property honestly and proportionately so that they need not be referred to this office.” The report added: “Mishandling property, and then mishandling thecomplaints prisoners make as a result, is a costly exercise.”
• The PPO welcomed the roll-out of body worn video cameras (BWVC, alongside CCTV and hand-held video cameras. But the office continued to receive complaints about use of force by staff and “we have been frustrated by the failure of some prisons to use BWVC consistently or to retain footage.”

Overall, Sue McAllister said:

“We, and others, are clear about what we do and why we do it. We have now turned our attention to building on those strong outputs to improve the impact we have so that we play our part in contributing to safer, fairer and more humane outcomes for people in prison and the other services in our remit.”