DEATHS OF APPROVED Probation

PREMISES' RESIDENTS -
INVESTIGATIONS BY THE Circular
PRISONS AND PROBATION REFERENCE NO:
18/2004
OMBUDSMAN
ISSUE DATE:
PURPOSE 30 March 2004
This is an update to PC02/2004 (paragraphs 1 to 7 of that circular) dated 6
January 2004, and gives further details about the new responsibility of the IMPLEMENTATION DATE:
Prisons and Probation Ombudsman to investigate all deaths of approved
Immediate
premises' residents.
EXPIRY DATE:
ACTION
March 2009
Please could all staff note the contents of this circular, and the changes that
this new procedure will bring, and in particular please note the need for
TO:
continuing transitional arrangements this year. Please note that these new
procedures will involve case managers, staff who deliver programmes and Chairs of Probation Boards
staff in partner agencies etc, and not just approved premises staff. Chief Officers of Probation
Secretaries of Probation Boards
SUMMARY Chairs of Voluntary Management
With effect from 1 April 2004 the Prisons and Probation Ombudsman will Committees
investigate all deaths of approved premises' residents, as well as deaths of Approved Premises Managers
detainees in immigration centres and deaths in prison custody. However,
because the Ombudsman's Office has not yet been able to complete the CC:
exercise to recruit and train the necessary numbers of additional staff to Board Treasurers
perform these new duties, there will be a need for transitional arrangements Regional Managers
for perhaps the first 3 or 6 months - perhaps until October 2004 at the latest.
AUTHORISED BY:
RELEVANT PREVIOUS PROBATION CIRCULARS Liz Hill, Head of Public Protection
PC02/2004 Unit

CONTACTS FOR ENQUIRIES ATTACHED:

John Russell Tel: 020 7217 0772 Fax: 020 7217 0756
Annex A - Pro-forma for notifying
E-mail: JohnFyfe.Russell@homeoffice.gsi.gov.uk deaths to NPD, Annex B -
Colin Pinfold Tel: 020 7217 8226 Fax: 020 7217 0756 Advisory Note on Key Processes,
E-mail: Colin.Pinfold2@homeoffice.gsi.gov.uk Annex C - Flowchart

National Probation Directorate

Horseferry House, Dean Ryle Street, London, SW1P 2AW General Enquiries: 020 7217 0659 Fax: 020 7217 0660

Enforcement, rehabilitation and public protection

BACKGROUND

1. The Home Secretary has decided that with effect from 1 April, all deaths of approved premises'
residents will be investigated by the Prisons and Probation Ombudsman. This strengthening of deaths
investigations will bring more independence into our current processes, and will thus provide additional
reassurances to bereaved families, and will assist all of us in making improvements to operational procedures.
This circular is a follow-up to PC02/2004, and provides more detail on how the new arrangements will work in
practice.

2. The involvement of the Ombudsman will bring further rigour to our current processes for investigating
deaths of approved premises' residents, and all staff should be aware that the Investigators from the
Ombudsman's Office will not confine their enquiries simply to the approved premises. The Investigators
Officers will wish to collate as much information as possible, and will therefore wish to know, for example,
about what supervision a deceased resident has had from probation staff who are not employed at the
approved premises (e.g. the case manager), and about activities that a resident has attended outside of the
approved premises, as well as medical appointments etc.

TRANSITIONAL ARRANGEMENTS

3. The Prisons and Probation Ombudsman's Office have embarked on a recruitment exercise, and it is
hoped that over the next 6 months all the new investigators will have been recruited and trained. However, in
the meantime, there is a need for transitional arrangements - these arrangements may need to be in place for
about 3 or 6 months at the most. We will notify approved premises and probation areas when a date for the
transitional arrangements to finish has been established. We have agreed with the Ombudsman's Office the
following transitional arrangements;
• When a death of an approved premises resident occurs, the Assistant Chief Officer for approved premises
for the local probation area will conduct an investigation with an investigator from the Ombudsman's
Office. The ACO and the investigating officer will prepare a draft report for the Ombudsman who will issue
the final report.
• Please note that there will need to be different arrangements if a death of a resident of a voluntary
managed approved premises occurs during this brief transitional period. In these cases, it might not be
the local Assistant Chief Officer for approved premises who works with the investigating officer on
compiling the report, depending on whether or not this aspect of work is covered by a local service level
agreement between the voluntary managed approved premises and the local probation board. Therefore,
in those areas where there is currently no agreement for the local ACO to complete management reviews
into the death of a resident of a voluntary managed approved premises, the voluntary management
committees must nominate a member of the committee to be the person to assist the Ombudsman's
Investigator during the transitional period.

NOTIFICATION

4. With effect from 1 April 2004, if a death of a resident is discovered on the hostel premises or if your
approved premises is notified of the death of a resident elsewhere, the Prisons and Probation Ombudsman's
(PPO) Office must be informed, as soon as practicable, but certainly within 24 hours of that
discovery/notification by paging the Duty PPO officer as follows:
- Telephone the following number: 07693 711536
- The operator will say: "Welcome to 02 paging. Please enter your numeric message followed by hash # , or
hold for an operator"
- You should then simply key in the number of the telephone you want the person you are paging to call you
back on. Please remember to include the STD Code. When you have done that press the hash # key at
the bottom right hand corner of the telephone key pad.
- The operator will then say " Paging request accepted"
- You can then hang up.

5. On receipt of the message, the PPO Duty Officer will call the number you gave and ask for brief details
of the incident so that an investigating officer can be allocated and the investigation launched.

PC18/2004 - Deaths of Approved Premises' residents - Investigations by the Prisons and Probation Ombudsman 2
6. In the case of a probation board managed approved premises, this initial notification can be done by a
Senior Probation Officer, but it is the responsibility of the local ACO with responsibility for approved premises
to ensure that this has been done.

7. In the case of a death of a resident of a voluntary managed approved premises, different arrangements
will need to apply. Because the Voluntary Management Committees are responsible for the buildings and are
the employers of the staff of the 12 voluntary managed approved premises, it will be necessary to designate
either the SPO manager, or a member of the voluntary management committee, as the person who has the
responsibility of notifying the Ombudsman's Office (and NPD) of the death, although depending on what local
arrangements have been agreed and set up, it may be in order for the local Assistant Chief Officer to do the
initial notification.

8. It is important to note that NPD also need to continue to be notified when a death of an approved
premises resident occurs. Please ensure that notification is made within 24 hours of the death occurring, or on
the next working day, to the following section of the National Probation Directorate;

Approved Premises Section

Public Protection and Courts Unit
National Probation Directorate
Home Office
1st Floor, Horseferry House
Dean Ryle Street
London SW1P 2AW

Tel: 020 7217 0772 Fax: 020 7217 0756

NPD need to have this information so as to be able to notify Ministers, the Chief Executive of the National
Offender Management Service (NOMS), the Director General of the National Probation Service for England
and Wales and others who have a need to know. We also need to be able to continue to record this
information and produce statistics on this. Please find attached at Annex A, a pro-forma to be used for
notifying deaths of approved premises residents to the National Probation Directorate.

INFORMATION FOR THE OMBUDSMAN INVESTIGATOR

9. We have been in discussion with the Ombudsman's Office over what initial documents and information
will normally be required by the Investigator. Annex B attached describes the likely procedures and what the
likely requirements for initial information are likely to be. Please note that the Ombudsman's Office already
has copies of the Approved Premises Handbook, National Standards, Approved Premises Regulations and
copies of relevant Probation Circulars.

10. Annex C attached sets out in flowchart form how the main processes should work.

FAMILY LIAISON OFFICERS

11. The Prisons and Probation Ombudsman will be appointing a number of Family Liaison Officers. The
PPO will routinely try to contact the next of kin for all deaths of approved premises residents, to allow the
family of the deceased to make an input into the enquiry, and to involve them as much as they wish to be
involved in the process.

SUPPORT FOR STAFF

12. We know that any death of a resident is always a traumatic event, and it is important that appropriate
support is available for staff. We would also suggest that now would be an appropriate time for the support
available to staff in the event of a death of an approved premises resident to be reviewed by local probation
boards and voluntary management committees. The new investigations from next month will involve different
processes from the current procedures and will impact on staff in a different way, with perhaps the main

PC18/2004 - Deaths of Approved Premises' residents - Investigations by the Prisons and Probation Ombudsman 3
difference being that they will be interviewed by an Investigator from the Prisons and Probation Ombudsman's
Office, rather than a line manager from their probation area.

13. The Ombudsman's Office has advised us that it is likely that their investigators will almost always tape
record their interviews with staff and others. This ensures that staff and residents etc are not misquoted in any
way, and that nothing can be attributed to them that was not actually said during the interview.

PUBLICATION OF REPORTS

14. Draft copies of the Ombudsman's reports will be made available in advance so that probation areas
and voluntary management committees will have a short period of time in which they can check these for any
factual inaccuracies and make any final comments. The Home Secretary has given assurances that the
PPO’s final reports will be published and that the findings will be responded to openly and transparently. It
should be noted that the final reports from the Ombudsman can only be published with the permission of the
Coroner. However, it is clear that deaths of approved premises residents will have a much higher profile in
future than they do now.

RECOMMENDATIONS MADE BY THE OMBUDSMAN

15. The involvement of the independent Prisons and Probation Ombudsman in the process of investigating
the deaths of all approved premises residents will raise expectations significantly. There will in future be a
duty on us all to respond quickly and appropriately to recommendations made in reports by the Ombudsman.
Home Office Ministers will be examining the new reports closely, and if any procedures need to change, they
will expect any necessary improvements to be made quickly.

CONCLUSION

16. Although we have attempted to set out in this Circular in as much detail as possible how the new
procedures will work, there will no doubt be some aspects of the new procedures which have not been
covered. Please contact NPD for further advice as necessary. For general advice from the Ombudsman's
Office, the telephone number there is 020 7035 2876.

PC18/2004 - Deaths of Approved Premises' residents - Investigations by the Prisons and Probation Ombudsman 4
 ANNEX A

National Directorate

NAME OF RESIDENT

PROBATION AREA & APPROVED

PREMISES

DATE OF DEATH

GENDER

ETHNIC ORIGIN

DATE OF BIRTH

STATUS (Bailee, licencee, ROTL etc.)

OFFENCE/ALLEGED OFFENCE

DATE AND TIME WHEN OMBUDSMAN’S

OFFICE WAS NOTIFIED

BRIEF CIRCUMSTANCES OF DEATH

ANY MEDIA INTEREST

NAME OF LOCAL ACO WITH

RESPONSIBILITY FOR APPROVED PREMISES
NAME OF PERSON COMPLETING THIS FORM

Approved Premises Section, Public Protection and Courts Unit

Tel – 0207 217 0772 Fax – 0207 217 0756
Annex A of PC18/2004
 ANNEX B

Advisory note on key processes and good practice in Approved Premises

and Probation Areas in respect of Prisons and Probation Ombudsman
enquiries into the death of a resident of an Approved Premises

1. Advise the Office of the Prisons and Probation Ombudsman of the

fatality of the resident of an Approved Premises (wherever it occurs) as
soon as practicable, but always within 24 hours, by using the pager

07693 711536

to leave the full telephone number of the Approved Premises including the
STD code.

2. Advise the National Probation Directorate by telephone 020 7217

0772 if office hours or by fax 020 7217 0756 if out of office hours of the
death using the pro-forma attached to this Circular.

3. Secure CCTV tapes and secure print out of electronic case file or
photocopy of written case file to include assessments, plans and contact
entries.

4. As soon as the name of the investigating officer is known, advise

them of the location of the Approved Premises by faxing a location map
with travel details, full postal address and all relevant contact numbers by
fax to 020 7035 2860
(The Office of the Prisons and Probation Ombudsman will normally
undertake making all the arrangements for travel and overnight
accommodation although advice might be sought as to the most
convenient or recommended hotels.)

5. To accompany the above information, please further advise the

Office of the Prisons and Probation Ombudsman on the name and the
addresses of the Chief Officer and Chair of the Probation Board and the
name, office address and contact details for the Assistant Chief Officer for
the Approved Premises and, where relevant, the contact details for the
Chair of the Committee for voluntary managed Approved Premises.

Annex B of PC18/2004
6. Please arrange to have available for the arrival of the investigative
officer (as best as possible within the resources of the building) an office
or private space, if possible with telephone, for the purposes of interviews,
reading of case information and the writing of notes.

7. Commence the creation of a file for the investigating officer to

include a copy of the information requested above in point 2.
Documents that the Ombudsman's investigating officer will require include
the following:
• a building plan - either a copy of architect’s drawings if available or a
simplified hand drawn diagram,
• The Approved Premises log book with photocopies of the relevant
pages,
• A sample copy of hostel house rules together with any other house
requirements or information routinely issued to residents,
• Sample copies of the referral form and induction papers,
• Copies of policies, procedures or practice guidance including the
Sudden Death Strategy for the Area/Region,
• Any health and safety assessments, reports or inspection details
relating to the previous period,
• The Daily Register for the day on which the resident died and a list of
residents or photocopy of those listed on the register,
• A staff list to include roles/job titles,
• A list of staff who were on duty on the day of the death and the times
that they were on duty,
• Details of the daily routine/regime,
• A note of the on-site medical services to include GP and/or CPN
arrangements,
• Information about the principle partner agencies who deliver services
to residents. (For example, mental health, drug and alcohol services).

8. With regard to the resident, the following should also be included in

the materials immediately available for the investigator:
• The full Approved Premises case file to contain the licence or Court
Order, referral papers (the referral registration book/print out of the
computer record), OASys assessment, and supervision plans, risk of
harm assessment and risk management plan, risk of self-harm and
suicide assessment and management plan, Admission /induction
papers and any other documents signed by the resident. Also Minutes
of MAPPP meetings, and other meetings of significance.
• Details of the case manager and contact details – please make a
specific note if the case manager is ‘out of area’. The case manager
should plan maximum availability during the period of the investigation
and have case records and the case file available.

Annex B of PC18/2004
 • The case-contact records to include the case-managers records and
Approved Premises records if they are not integrated. (Print-out
records if they are held electronically). The contact record copy or
print out made at the first available opportunity by a manager following
the notification of the fatality. This document should be clearly
identified along with the date and time that it was obtained.
• Medication record. If no prescribed medication was held at the
Approved Premises please make a note to confirm.
• Details of the next of kin.
• Previous convictions, Pre-Sentence and Parole Reports.
• List of property recovered from the deceased’s room following
discovery or notification of the death if the police have approved
removal of personal items for safe storage.

9. Please give consideration to:

• Advising staff and residents of the arrangements,
• The initial welcome and familiarisation arrangements for the
investigator including a brief tour of the premises and a meeting with
the manager and deputy manager,
• Access to refreshments,
• Access to staff to explain any initial query – use of acronyms in
records, etc.,
• Access to photocopier,
• The issue of keys/swipe cards, etc for the investigative officer,
• Issue of personal alarm to investigator,
• Briefing on personal safety, fire and evacuation procedures.

In the event of further advice or information being required please contact the
Office of the Prisons and Probation Ombudsman directly or John Russell or Colin
Pinfold in the Approved Premises section of the Public Protection and Courts
Unit at the National Probation Directorate.

Annex B of PC18/2004

PROCESS RESPONSE TO FATALITY
OFFICE OF PRISONS AND
PROBATION OMBUDSMAN
Notification to Office of PPO
as soon as possible but
within 24 hrs
Pager: 07693 711536
Exchange information with
NPD
Ombudsman’s office
appoints Investigative
Officer
Inquiry commenced
Limited release availability
of draft report for checks
on factual accuracy (28
days)
Finalised report to Coroner
for consultation on further
release
Release of final report
Report posted on OPPO
on website
LOCAL PROBATION AREA
Notification on discovery of
fatality. Request
paramedical services, police
and enact management
procedures
Notification to
Chief Officers
¾ Secure room/area
¾ Secure CCTV tapes
¾ Secure print out or photocopy
of all case records including
assessments and contact
entries
Notify supervising probation officer
and incoming staff. Notify
prisons/courts if appropriate.
Respond to draft report released
for checks on factual accuracy,
copy response to NPD
Acknowledge receipt of final
report and review findings and
recommendations
Devise and implement action
plan with timescales to deliver
recommended changes and
improvements
ANNEX C
NATIONAL PROBATION
DIRECTORATE
Notification to NPD
Tel: 020 7217 0772
Fax: 020 7217 0756
Exchange information with
OPPO
Internal notification
including Ministers and
press office
Respond to draft report released
for checks on factual accuracy and
consider early notification to
ministers and senior officials of
significant issues
Acknowledge receipt of final
report. Draft written response to
be cleared by ministers.
Review recommendations and
findings and take action on those
of a wider significance.
Commission response from
local area
NPD reviews reports and
recommendations with HMPS
Safer Custody Group
Prepare for publication of
Annual Report by Prisons and
Probation Ombudsman