Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, written 22 Jul 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jul 2016 |
|---|---|
| Deceased | Olawale Adelusi |
| Coroner | Jeremy Chipperfield |
| Coroner area | London (West) |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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idk TOTAL POLICING DIRECTORATE OF PROFESSIONALISM Jeremy Chipperfield, Ton ayers Assistant Coroner, Deputy Assistant Commissioner West London Coroner's Court, 25 Bagleys Lane, Room 2.4 London, SW6 2QA. Buckingham Gate London Coroners’ Clerk: SW1E 6JP coroner.referrals@Ibhf.gov.uk Tel: 0208753 6800 Tel: 020 7230 0813 Our ref: 1X-224-16 Date: 9th September 2016 Dear Mr Chipperfield, | write on behalf of the Metropolitan Police Service (MPS) in response to your Regulation 28 Report to prevent future deaths dated 22™ July 2016. This followed the conclusion of the inquest into the circumstances of the death of Olawale Adelusi on 13"" November 2014 at St. Mary's Hospital, Paddington. The inquest concluded on 1® July 2016 and was held before a jury. The cause of death was recorded as misadventure. You raised one maiter of concern: 1. The absence of an effective system to ensure appropriate transmission of all information relevant to assessment of the (i) risk of self- harm or (ii) mental health of detained persons MPS Response- Preface In drafting a response _we have consulted with subject area experts, principally Chief ll Lead Met Detention a HE and , of the Met Detention Business Improvement Team. Met Detention has primacy within the MPS for policies and practices that shape how we deal with detainees whilst they are in our care. We have also consulted with the National Offender Management Service (NOMS), the lead agency in this area. NOMS have ownership of the Prisoner Escort Record (PER) form and the processes involved in the system by which risk information is shared between all parties involved in the transfer of individuals within the criminal justice system. The physical manifestation at present is the ‘PER form’, a paper record sheet, used by all participating agencies to document and manage the safe transit of prisoners between all custody environments: prison, police stations, courts or hospitals. Finally, we have also liaised with the office of Chief Constable |B, Surrey Police, who is the Nationai Police Chief's Council (NPCC) lead for ‘Safer Custody’, and the police delegate to the Ministerial Group on Deaths in Custody. Dates, relevant parties and communications have where possible been confirmed by reference to emails, meeting minutes, published policies, intranet communications or other documents. The following response is based upon a review of such documents by HEE f the MPS Directorate of Professional Standards (DPS). This response was then shared and reviewed by the parties previously referenced. As the matter of concern raised by you relates to issues of documentation this has been the focus of our review. We have not considered the evidence given by individuals during the course of the inquest itself which you will already have considered separately. Response to Concern: Absence of effective system for sharing of risk information on transfer of detainees The transmission of risk information relating to detainees on transfer within the Criminal Justice System is currently provided for by the Person Escort Record (PER)'. The PER is a paper based form and is described as: ‘the key vehicle for ensuring that information about the risks posed by prisoners on external movement from prisons or transferred within the criminal justice system is always available to those responsible for their custody. It is a standard form agreed with and used by all agencies involved in the movement of prisoners. The form highlights the risks posed by and the vulnerability of prisoners on external movement, provides assurance that the risks and weaknesses have been identified and communicated to those who are responsible for the prisoner and provides a record of events during a prisoner’s movement.” The design of the form and protocols for its use are the responsibility of NOMS, though the current form and any future versions will be agreed in discussion and agreement with all the stakeholders who use the form. The current PER was first issued in 2009 and its use adopted across all agencies during 2010. The PER is currently used by the police, NOMS, Secure Hospital Estate, the Home Office (for immigration detainees) and the escort contractors. The Metropolitan Police are therefore merely one of a number of users of the system, and whilst we can make suggestions and influence the future development of the system from this position, such changes would need to be made in agreement with all the other participating agencies, and with NOMS. The PER must be completed before any external movement or transfer of detainees. When correctly completed, the information imparted is expected to help prevent suicide, self-harm and other serious incidents from occurring, by alerting partner agencies to potential risks°. ' College of Policing Ltd., (2016). Detention and custody: Risk Assessment. Available: http://www.app. college. police,uk/app-content/detention-and-custody-2/risk-assessment/#person-escort-record-form . Last accessed 31/8/2016. ? HM Prison Service (2000), PER — user handbook ? HM Inspectorate of Prisons (2012). Thematic report: the use of the person escort record with detainees at risk of self- harm. The College of Policing guidelines require that forces ensure custody officers and staff are trained and competent to perform their role, which includes understanding the purpose of the PER process, and completing it competently.* Within the MPS this function is managed by Met Detention. The importance of the form and its correct completion are covered in initial training for all Custody staff and supervisors, and ongoing guidance for MPS staff in the completion of the PER is additionally provided through the provision of a ‘Custody Toolkit’ °, a reference source available at all times to staff via the MPS intranet. In summary correct use of the Prisoner Escort Record should provide for the effective sharing of risk information relevant to assessment of the (i) risk of self- harm or (ii) mental or physical health of detained persons to support their welfare and protect staff and members of the public when transferring a detainee. However, as identified in your Report this information is not always shared correctly or in sufficient detail between parties. These concerns have also been echoed in previous ‘lessons learned’ from Independent Police Complaints Commission (IPCC) reports, previous Coroners Reports, and the findings of an HM inspectorate of Prisons review of the PER system in 2012 °, The 2012 HMIP Report found that 33% of PERs inspected were not fully completed and where a risk of self- harm was identified the information presented was so limited that it tended to mask the potential seriousness. A principal theme of that report was the quality and thoroughness with which the PER forms were completed. The HM Inspectorate of Prison’s report suggested that this was due to weaknesses in the design and format of the existing PER, coupled to a lack of awareness by users of the importance and purpose of the PER form. In response to the findings of the HM Inspectorate on that occasion NOMS reviewed the design of the PER form to address the key vulnerabilities identified. One strand of the work was to initiate a project, ‘Moving People Safely’, one of the aims of which was to develop a digital, internet web-browser based PER, obviating many of the concerns regarding legibility or loss of paperwork attendant upon the hard copy versions of the form examined in the study. At time of writing, we are informed by NOMS that: “...Whilst the project and NOMS have a long-term ambition for an end-to-end digital product across all the journey types and sources (prison, police custody and court custody), the project team are currently delivering a part digital and redesigned paper product that integrates with the NOMS prison record system, NOMIS, and delivers core benefits around the structure and reuse of prisoner information digitally. The current iteration of the project is focused on the journeys between prison and court custody and is currenily trialling between HMP Bedford and St Albans Courts. In addition to the digital product, a revised paper PER form has also been produced and been trialled. This has more space (on the front cover) to record the forms and any additional paperwork which may accompany the PER, and includes a self- harm/ * College of Policing Ltd., (2015). Detention and custody: Custody management and planning. Available: http://www.app.college.police.uk/app-content/detention-and-custody-2/custody-management-and-planning/#custody- training-checklist . Last accessed 31/9/2016. * Policy Pages, Custody, Metropolitan Police. Custody Toolkit. ° See #3 above, ibid. suicide alert warning section as an integral part of the document. This was previously a separate document. There is also additional space to record health and social care information” We understand from NOMS that feedback on the pilot version of PER from Winchester and Bullingdon prisons and from Hampshire and Thames Valley Police has been positive. This was discussed at the National Custody Forum, chaired by the national custody lead, Chief Constable Ephgrave, and the police are supportive of using the new PER form nationally as part of an enlarged trial. The NPCC will work with NOMS and the College of Policing to facilitate this. It is hoped at time of writing that, subject to further consultation with all other partner agencies, a national roll out will be achievable by the end of this year, or early next year. The MPS stand ready to participate in this. Meanwhile, work on improvements to the system continues, as the NOMS spokesman explains: “In terms of timetables, the next digital milestone which is about to begin and ends at the end of the year will cover: 1. Training, support and testing at HMP Bedford for all live digital products 2. Research, development and testing of product versions to support all other journeys originating from HMP Bedford prison (ie Inter Prison Transfers (IPT), hospital visits) 3. Pilot testing on one or two journey types at one other location (e.g. HMP Winchester) to identify any changes to the product required to support other establishment working practices 4. Research and planning of Police Custody and off bail version of service 5. Further NOMIS integrations 6. SystemOne England health information integration.” - NOMS concludes that: “... The following milestone beginning in January 2017 will be looking to develop the police custody version of the service.” Delivery of the digital solution will depend on its successful integration with a number of different police custody systems, and engagement on this is at an early stage. For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures: e The inclusion of PER in the next training cycle for custody staff. (This is scheduled to take place between October and January). e A review of the training given to new custody staff attending their initial courses, regarding the PER process. e Areview of the guidance provided to staff via the ‘Custody Toolkit’. e The development of a Quality Assurance monitoring system to assess the quality of PER completion. As mentioned above, the MPS have also indicated to NOMS a willingness to be an early adopter of the revised hard copy PER form, and to engage with the PER digital project team to assist in the development of this solution. Discussions regarding this are ongoing at time of writing. In conclusion The MPS strives to be a learning organisation and to respond positively to well-founded criticism. It is clear that failings in the transmission of sufficient risk information between custodians when transferring detainees under the existing PER process is an issue throughout the criminal justice system, not limited solely to the police, or the MPS use of the PER form. We accept that vulnerabilities in the current process have been identified. Medium and long term solutions to these vulnerabilities, which are due in part to the construction of the existing PER process, require multi agency action at national level, driven by NOMS and supported by the NPCC and other stakeholders. The urgency of implementing these solutions has been discussed with both NOMS and the NPCC in the course of preparing this reply. The MPS is committed to supporting NOMS wherever possible in the development and implementation of these national solutions. In the interim we are implementing a range of measures targeted at improving the quality of PER completion within the MPS using the existing system. | trust that this provides the reassurance that we have considered the points you have raised fully, and have moved promptly to make such improvements in practice as are in our power to deliver. y' eputy Assistant Commissioner ; =! —=—- ———
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