Independent Advisory Panel on Deaths in Custody
Minutes of the Independent Advisory Panel (IAP) Meeting held on Wednesday 2nd May 2012 in Conference Room 8, Clive House, 70 Petty France, London SW1H 9EX between 10.00am - 1:00 pm
Attendees: Lord (Toby) Harris of Haringey (Chair), Simon Armson, Deborah Coles, Dr Peter Dean, Professor Philip Leach, Professor Richard Shepherd, Professor Stephen Shute, Laura McCaughan (Head of Secretariat), Matt Leng (Deputy Head of Secretariat - Minutes), and Alice Balaquidan.
1. Welcome
The Chair welcomed the Panel members to the thirteenth meeting of the Independent Advisory Panel (IAP) on Deaths in Custody.
2. Minutes of the last meeting
Deborah Coles requested that the minutes should be amended to reflect the discussion about commissioning quarterly data on deaths in custody for IAP meetings. Action 1 / 2.5.12: Secretariat to amend the IAP minutes to reflect the discussion about commissioning quarterly data on deaths in custody for IAP meetings. The Panel agreed that the remaining minutes were an accurate record.
3. Action log
(i) Proposed process for implementing IAP recommendations
During their meeting with co-sponsors on 2 May, Laura McCaughan and the Chair raised a proposed process for implementing IAP recommendations. This followed the Panel’s concerns, raised at the strategic planning meeting, that although many of the recommendations had been agreed and accepted at Board meetings, there was no clarity as to how organisations would then implement the changes. This resulted in the Panel chasing organisations to ascertain how the recommendation would be taken forward, sometimes with the result that the organisation had decided not to pursue the work.
The co-sponsors acknowledged the Panel’s concerns that some recommendations were not being progressed as quickly as the Panel would like and discussed the various obstacles to achieving clarity in this area, including the point that the Board was not designed as a decision-making body. The Minister chairing the Board would not necessarily have responsibility for the department that would have to implement the recommendation so the meeting was mainly an opportunity to air views on the Panel’s suggestions.
Laura said she had circulated the IAP recommendations document and the Ministerial Board terms of reference to the co-sponsors for them to review recommendations specific to their departments. The co-sponsors suggested that there should be a standing agenda item at each Board, which would allow agencies to update Board members on the progress of Panel recommendations.
(ii) Organisation of IAP roundtable meeting with regulatory bodies
The Secretariat had identified a list of topics from the work plan relevant to each regulatory and investigatory body. Although there was some cross over, Laura thought there was insufficient common ground to justify a roundtable meeting at this stage. The Panel would continue to engage with each of the organisations on individual topics and consider a full meeting in due course.
(iii) Work plan for 2012/13
This would be discussed under agenda item five.
4. Feedback from IAP stakeholder consultation event – 2 March 2012
The Secretariat had drafted a document for the Panel to publish in response to ideas for further work raised by stakeholders at the conference. (This was circulated to the Panel on 3 April.) The Chair said this would demonstrate the Panel’s commitment to transparency as to how it prioritises the workplan and proposed that the response should be published on the website. Action 2 / 2.5.12: Secretariat to publish IAP response to stakeholder suggestions for new areas of work for 2012/13.
The Chair said the event had generated some useful discussions and contributions to the Panel’s developing projects. Deborah Coles thought in future that the morning session should be re-structured to ensure it was relevant and engaging for attendees The Chair thought it was important to have a Minister speaking at the event, but agreed that the event structure would need significant discussion. Panel members were content with this approach. This should be included as an agenda item in advance of the next event, planned for October 2013, to ensure sufficient time to commission contributions, to involve a range of stakeholders and to develop a creative introduction to the event. Action 3 / 2.5.12: Secretariat to include planning for the next IAP consultation event on the agenda for the IAP meeting in September 2012.
5. IAP work programme 2012/13
The Panel discussed their specific areas of responsibility in the work programme.
(i) Use of physical restraint
Professor Richard Shepherd reported that the development of the common principles on the use of restraint was a key priority. Matt Leng said the Care Quality Commission (CQC) had provided detailed feedback on the principles and had highlighted some concerns over their applicability for mental health settings. Richard said it was important that the principles were relevant to all sectors and that a meeting may help resolve concerns.
Analysis of use of force data from one police force was also underway, to estimate the prevalence of use of restraint (i.e. how many times restraint was used in a given period and compared to the number of detainees), with a view to informing a justification for requiring police forces to submit annual use of force data for analysis by a suitable police body. Matt added that he would be visiting the police force in May 2012 to interrogate the data further.
The Panel discussed the potential impact of changes to ACPO, as there may be no equivalent professional body to negotiate with about good practice and standards. It would be important for the Panel to develop relationships with Police and Crime Commissioners (PCCs), due for election in November 2012. PCCs would have a view on how forces use data to inform and improve practice around safety. The Police and Crime Panels (PCPs) – which would be responsible for scrutinising PCC activities – would also be important stakeholders. Action 4 / 2.5.12: IAP to discuss at their meeting in September 2012 how to build relationships with PCCs and PCPs to encourage data collection for purposes of preventing deaths in police custody.
Deborah asked about the progress of the UK Border Agency (UKBA) review of restraint, which was instigated to determine whether restraint techniques used by escort companies on behalf of UKBA could be adapted specifically for use in vehicles and on aircraft to make them safer. Laura said the review had been delayed for a number of reasons and the report was now with Ministers. She added that UKBA would provide an update to the Panel as soon as they had confirmed the Minister’s position. The Panel acknowledged the complexities of the review, but they were concerned at the length of time it had taken to complete such an important piece of work.
Deborah also enquired about the status of Minimising and Managing Physical Restraint, the new restraint package recommended by the Restraint Advisory Board (now the Independent Restraint Advisory Panel) for the secure youth estate. Matt said he was due to meet with the IRAP secretariat in May 2012 and obtain an update to share with the IAP. Action 5 / 2.5.12: Secretariat to update the Panel on the work of the Independent Restraint Advisory Panel and the status of their proposals to implement Minimising and Managing Physical Restraint in the secure youth estate.
(ii) Information flow through the criminal justice system
Professor Stephen Shute said he had attended a productive meeting with the General Medical Council to discuss the information sharing statement. They suggested minor changes, which were agreed by the Information Commissioner. The Panel would now write to service leaders to discuss how best to communicate the statement to front line staff.
Her Majesty’s Inspectorate (HMI) of Prisons and HMI Constabulary had completed their analysis of Person Escort Record (PER) forms in police custody. The inspectorates had agreed to widen their investigation into prisons and YOIs, and would provide oral updates to the Board in June 2012, with a final report to be presented to the Board in October. Stephen said this had been a positive partnership between the IAP and inspectorates which had added value to the Panel’s work.
In the longer term, Stephen was interested in determining the effectiveness of the Assessment Care in Custody Teamwork (ACCT) as a risk management tool. As a first step, he wanted to identify what data could be acquired from NOMS on ACCT. This would allow a scoping exercise to determine the effectiveness of ACCT for managing risk of self harm and suicide. Action 6 / 2.5.12: Secretariat to identify what data there was available from NOMS on ACCT. Deborah thought that this could be developed by reviewing Rule 43 reports to identify cases in which the use of ACCT had been raised by the coroner.
An additional long term piece of work was to examine the effectiveness of information flow between Youth Offending Teams (YOTs) and STCs and YOIs for managing risk of self harm. Deborah said she would inform the Secretariat about relevant Rule 43 reports where information flow in this area had been problematic. Action 7 / 2.5.12: Deborah Coles to inform the Secretariat about relevant Rule 43 reports where concerns about information flow between the YOTs and STCs and YOIs were raised.
(iii) Risks relating to the transfer and escorting of detainees
Dr Peter Dean said there were a number of ongoing activities in relation to Section 136 of the MHA and he was considering how to incorporate feedback in this area from the IAP stakeholder consultation event. He thought it was important for the Panel to have representation on the stakeholder reference group for the HMIC and CQC joint thematic on Section 136. This would enable the IAP to identify any further issues on Section 136 which needed focus. Matt had confirmed with HMIC that the Panel would be represented on the reference group.
In the longer term, Dr Dean wanted to identify how custodial sectors’ risk assessment mechanisms determined a detainee’s fitness to travel. He believed this work linked with Professor Shute’s information flow and the new workstream looking at commissioning and custody providers.
(iii) Cross sector learning
Deborah Coles said that high level findings from the Mendas research to understand the impact of Rule 43 reports on custodial sectors’ organisational learning would be mentioned at the Ministerial Board in June 2012. Due to delays to receiving information from stakeholders, the final report, with IAP recommendations would be presented to the Board in October 2012.
Deborah explained that she had been frustrated at the time taken to progress the IAP recommendations in relation to reducing delay in death in custody inquests. It would important to progress the reference to learning from deaths in custody in the remit of the Chief Coroner, once appointed. She added that there had been limited communication from Ministry of Justice (MoJ) about the appointment process. Laura McCaughan reported that she had considered whether the Ministerial Council co-sponsors should write to MoJ officials asking or further information about the job description and implementation timescales – in order to keep the Ministerial Board informed.
The next step would be for the Chair to write to the Parliamentary Under-Secretary of State with responsibility for this policy area. Dr Peter Dean stated that whilst he would welcome the appointment of a Chief Coroner to improve the sharing of learning, he was concerned that unless more funding was made available to coroners, issues around workloads and inquest delays would continue.
(iv) Near deaths
The Chair said that the intention of this project would be to identify the mechanisms used to capture learning from near deaths. The Chair said it would be important to determine any differentiation in definition of near deaths amongst the custody providers, noting that NOMS used a high threshold for near deaths to be considered in terms of Article 2. Professor Richard Shepherd said that asking for data on acute admissions to hospitals from custody could be used as a way of identifying those cases in which detainees were seriously harmed. Action 8 / 2.5.12: Secretariat to identify whether data on the number and type of acute admissions could be collated. Deborah Coles suggested that a useful starting point for this work would be to contact the Youth Justice Board (YJB) about their near death reporting mechanisms. The Chair asked whether custody providers had any formalised incident reporting system for near deaths. Laura McCaughan said the Secretariat had produced some of this information last year in the presentation about reporting and learning systems. This could be updated with each sector’s mechanisms for capturing information and learning on near misses and near deaths in custody. This work would be scheduled for later in 2012/13 as it was not a priority on the IAP work programme Action 9 / 2.5.12: Secretariat to produce document for the first Panel meeting in 2013, detailing the sector’s mechanisms for capturing information on near deaths in custody, and how they report and learn from these cases.
(v) Article 2 compliant investigations
Professor Philip Leach said he was continuing to pursue recommendations made to the Ministerial Board in June 2011. The Department for Education and MoJ officials would be attending the next Ministerial Board to discuss the recommendation that deaths in secure children’s homes should be investigated by PPO.
Professor Leach reported that efforts to improve timeliness in clinical reviews had had little effect so far. PPO and Offender Health had commenced pilots in the North West and South West SHA clusters. They would run until September in order to provide the NHS Commissioning Board with a working model for the commissioning and delivery of clinical reviews in support of PPO investigations – with the aim of improving quality and timeliness.
In conjunction with Simon Armson, he was devising a specification for research into the quality, timeliness and independence of Strategic Health Authorities (SHA) commissioned investigations into deaths of detained patients. Laura McCaughan would be meeting with the patient safety team at West Midlands SHA to scope the data they hold and to develop the research specification. Deborah Coles said that INQUEST was hosting an event involving legal experts in June 2012 to examine investigations of patient deaths whilst detained under the MHA. Deborah agreed to share further information about the event with the Panel. Action 10 / 2.5.12: Deborah Coles to provide further details to the IAP about INQUEST’s seminar on investigations into deaths of patients detained under the MHA.