Miscarriages of JusticeUK

Lessons Should Be Learned From PPO Investigations

Prisons and other places of detention need to learn lessons from PPO investigations so that they can make improvements, said Nigel Newcomen, the Prisons and Probation Ombudsman (PPO). Today he published the first report of an annual series, providing an overview of recommendations made in 2012-13 and the main themes identified.

The PPO makes recommendations following both fatal incident and complaint investigations in prisons, immigration removal centres and the probation service. Recommendations are nearly always accepted and action plans are required. HM Inspectorate of Prisons assesses progress on implementation when it visits a prison. Recommendations therefore have considerable potential to ensure that lessons are learned and improvements made.

From April 2012, PPO staff began collating all the recommendations made into a single database. The database enables more effective analysis of trends and identification of action points where similar recommendations have been made in a number of cases or to a number of establishments. Between 1 April 2012 and 31 March 2013, 1603 recommendations were made in 482 investigations. Formal recommendations were more often made in fatal incident investigations (93% of cases), than after complaint investigations (36% of upheld complaints).

Findings from data about deaths in custody include:

- of the fatal incident investigations with recommendations made, 95% were for prisons, 4% for probation and 1% for immigration;

- there were 322 recommendations made about healthcare, highlighting concerns such as the reliability of medical records and management of chronic diseases such as diabetes and epilepsy;

- there were 143 recommendations made about emergency responses, including the need to train more staff in basic life support techniques and improving access to defibrillators;

- there were 109 recommendations made on the Assessment, Care in Custody and Teamwork (ACCT) process to care for individuals at risk of self-harm and suicide; and

- frequent recommendations were made to prisons about the need to improve risk assessment to justify the use of restraints on escorts and in outside hospitals in investigations into deaths from natural causes.

Findings from data about complaints include:

- of the complaint investigations with recommendations made, 94% were for prisons, 4% for probation and 2% for immigration.

- formal recommendations were made most often when complaints about equality issues, adjudications and staff behaviour were upheld;

- a fifth of complaint investigation recommendations made were about prison disciplinary hearings (adjudications), normally because of a significant flaw in how the hearing was conducted or recorded; and

- around a tenth of recommendations were for the establishment to apologise - generally in writing - to the complainant.

Nigel Newcomen said: "This report is the first of an annual series, providing an overview of the recommendations made in the year 2012/13 and the main themes identified by them. Most of these themes are not new and I hope that by sharing learning in this way we can reduce the number of times I have to make similar recommendations in the future. My ambition is to encourage wider learning of lessons and so help support improvements in the services I investigate."