Independent Advisory Panel on Non-Compliance Management (IAPNCM): comments from the Prisons and Probation Ombudsman

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1 Stephen Shaw CBE Chair, Independent Advisory Panel on Non-Compliance Management c/o Emma Ross Home Office 2 nd Floor, Bedford Point 35 Dingwall Road Croydon CR9 2EF 31 May 2013 Dear Stephen, Independent Advisory Panel on Non-Compliance Management (IAPNCM): comments from the Prisons and Probation Ombudsman Thank you for your letter of 8 April and your request for comments on the prospective work of IAPNCM. The creation of an independent panel to offer advice on a new training package for use by detainee custody officers is a timely and welcome development. This paper draws together material from across my complaints and fatal incident teams. Although my office has not had to investigate a large number of fatal incidents or complaints concerned with the use of force by detainee custody officers - those that have come to us have raised some serious areas of concern. As a result, we have made repeated recommendations to what was the United Kingdom Border Agency - now merely part of the Home Office - to ensure that removals under restraint are conducted as safely as possible and, in particular, that staff training is improved. These issues arose most recently in the draft investigation report into the high profile death of a detainee on board an aircraft 1 which is currently being considered by an inquest. Cont/d. 1 Currently final reports of fatal incidents are anonymous and the convention is maintained in this paper. Mr A died while being removed in October 2011 and the draft report of the investigation was published in April We have yet to receive a response from the Home Office and it is possible that any recommendations in the report may yet be amended.

2 The paper reviews the issues that have arisen in these cases and repeats the recommendations that were made to the Home Office. I would welcome further dialogue with the panel where this might be helpful. Yours sincerely Nigel Newcomen CBE Prisons and Probation Ombudsman NN.151.jjb 2

3 General concerns 1. Training in appropriate C&R techniques Both complaints and fatal incident investigations have repeatedly stressed the need for all escort staff to be trained in special control and restraint (C&R) techniques for use when a detainee is seated (as will often be the case during a removal, either in a vehicle or on an aircraft). For example, Mr B complained about an alleged assault during his escorted removal. We found that, while escort staff were trying to restrain him in a vehicle, Mr B slipped backwards out of the vehicle and landed on the ground. He could have sustained a serious injury to the head or neck; fortunately, he did not. While the escort staff had all been on C&R refresher training and had followed approved techniques, the case highlighted the need for all escort staff to be trained in special C&R techniques when a detainee is seated and\or held in confined spaces. We also consider that the C&R techniques which are taught need to be appropriate the different contexts in which they are deployed and the range of staff involved. Training and guidance should also detail what should happen if something goes wrong, or if assistance is needed at any point. Accordingly, we have recommended that the Home Office introduce specialised C&R training for all staff conducting removals, that this should include techniques to manage safely detainees who are seated and\or held in confined spaces, and that the training is scenario-based. 2. Use of handcuffs Escorting oversees can take several hours, and involve a number of potential flashpoints. Given a limited number of escorting staff there may be a temptation to over-use cuffs. It is important that the training and guidance is clear on when the use of cuffs is appropriate and stipulates that an unfolding situation should be continuously assessed to minimise the risk to the detainee and escort staff. For example, Ms C complained that she had spent five hours with her hands cuffed behind her back on an escorted removal because the escort staff had lost the key. The escort staff said that handcuffs were applied because of Ms C s disruptive behaviour and they had lost their only key in the struggle to restrain her. The escorts sought to justify the prolonged use of cuffs by saying that Ms C had been refractory - when their own statements said she had been asleep for the majority of flight. We found that escort staff had not followed operational guidance which stated that all escorts should carry keys. Nor, once the situation was under control and the detainee compliant, was the cuffing reviewed and, at minimum, their position changed from behind Ms C s back to in front of her. 3

4 In the fatal incident investigation of Mr A, escort staff apparently believed that Mr A would calm down once the flight departed. This led them to restrain him using handcuffs in the rear stack position, bent forward at the waist, for longer than was safe. In Mr B s case, escort officers attempted to apply handcuffs to both wrists but were unable to do so. While the officers attempted to co-ordinate a manoeuvre to remove Mr B, he slipped backwards out of the vehicle. As part of C&R training, there should have been appropriate attention paid to applying handcuffs safely in a confined space. We have therefore recommended that escort staff should continuously risk assess the detainee and the unfolding situation during a removal. This should include reviewing the use of any restraints and aborting the removal if they do not have full control of the detainee. 3. Positional Asphyxia In the case of Mr A, escort staff told the police that they did not fully consider the possibility that he might be suffering from positional asphyxia. Although this possibility is included in current escort training, it must be taught in a way that ensures escort staff fully understand the risks and symptoms of positional asphyxia and can apply their training when carrying out their duties. We have therefore recommended that escort staff are fully trained in the risks and symptoms of positional asphyxia and are supervised to apply their training when carrying out their duties. 4. First aid training In Mr A s case there was evidence to suggest that the escort staff thought that he might have been feigning illness. It is vital that escort staff fully consider whether a detainee is genuinely ill. Policy and training related to the use of force and first aid should presume that a person who appears to be experiencing breathing difficulties while under restraint is genuine and is treated in line with first aid policy. We have therefore recommended that all escort staff are first aid trained and that this training makes clear that an unresponsive or unconscious patient should be placed in the recovery position and cardiopulmonary resuscitation delivered as required. 5. Risk assessment processes In Mr A s case, it was found that the risk assessment and the consequential level of escort used differed on three separate occasions, even though the risk he presented was assessed against fundamentally the same information. 4

5 Investigation into complaints have also raised questions about the number of escorting staff used and how this decision was reached, as well the question of whether health care staff should attend escorted removals. We have therefore recommended the introduction of a uniform, robust and evidence-based risk assessment process based on accurate information, which includes guidance on the consequential size and make up of any escort team. 6. Use of CCTV / Video Camera More extensive use of CCTV may help reduce the risk of escalation as both detainee and staff will be aware that an objective record of their actions is being maintained. This may also help any subsequent investigation should an allegation of assault be made by either side. Sound recording should also be sufficient on board vehicles to capture all conversations. This could extend to using a hand held recorder to record everything between disembarking from the van and take-off of the aircraft. Such a recording is made by prison staff when a planned removal of a prisoner is made. For example, Ms C complained that she was assaulted while being restrained and handcuffed in the escort van when it had stopped on arrival at the airport. The CCTV recorder in the escort van did not function when the engine was switched off. This was extremely unsatisfactory, as many incidents that may give rise to a complaint may take place when the vehicle is stationary. We have therefore recommended that CCTV footage in escort vehicles should record for the whole period the detainee is on board a vehicle and that a hand-held recorder is used outside the vehicle. 7. Working with airline staff In Mr A s case, the investigation found that the escort team did not seek help from the airline crew even though they were first aid trained and had access to a defibrillator. Training of escort staff should emphasise that, if a detainee being removed on an aircraft is seriously unwell and in need of medical assistance, support should be sought from airline crew. This in turn may necessitate negotiations between the Home Office and carriers (whose staff might also be encouraged to give evidence to any subsequent investigation). We have therefore recommended that escort staff seek support from airline crew if a detainee is seriously unwell and in need of first aid and medical assistance. 5

6 Other points Reducing detainee anxiety In some investigations, escort staff have been criticised for what they have said to detainees who speak about their fears of return to the destination country. It appears staff may have tried to allay those fears but this evidently had the opposite effect. It would be helpful if training and guidance was clear about how staff should respond in such situations. One of our Assistant Ombudsman used to work for the Home Office\UKBA and managed a team which specialised in removing long-term detainees. When a detainee disrupted a removal, one of his team would interview them to see if there was a resolvable reason for the disruption. The team would then try to seek a resolution and, in a significant number of cases, this apparently led to the detainee being removed without escorts. Post removal abandonment protocol The guidance and training should be clear on actions escort staff should take once a detainee is ordered off the aircraft by the captain. This would supplement the use of force protocol and help ensure appropriate actions to safeguard the well being of staff and the detainee and help ensure evidence is captured should an allegation of assault be made. For example, an immediate health check (at the airport if possible), including photographs of any injuries as a matter of course. Interaction with passengers The fact that, in effect, there is an audience makes the situation substantively different to that other setting where use of force is frequently deployed. Agitated passengers, or those taking pictures on their phones, may inflame the situation. Guidance and training should be clear what interaction, if any, staff should have with passengers should the detainee become noncompliant. Use of the toilet by detainee on board aircraft This has been a flash-point in some of the cases we have investigated. Current practice is apparently for escort staff to place a foot in the door thereby affording some privacy but not allowing the door to be closed and locked. Guidance and training on how and when to intervene and how to remove a non-compliant detainee from the toilet is required. Internal investigations The Home Office Professional Standards Unit s (PSU) own investigations need to be robust and ensure that they routinely involve all staff when investigating complaints about assaults and other serious matters. Our investigations have not always concluded that this has been the case. 6

7 In the case of Ms C, the Use of Force forms on which the PSU investigation solely relied were poorly completed and lacked sufficient detail. The PSU did not interview the escort staff or Ms C and failed to consider medical evidence (that might have supported or disproved her injury claims) because it was not written in English. 7