Improvements made in detainee welfare information sharing following IOPC investigation into man’s death

In particular, police forces across England and Wales were urged to ensure custody staff are supported in understanding how to complete digital prisoner escort records (PERs), so that all relevant information, including any risk of self-harm and warning markers, is available to transfer and prison staff.

The improvements followed the IOPC’s investigation into the death of a man who was found hanging in his prison cell within hours of arriving from Cardiff Bay police station in December 2021.

The investigation found that the escort form lacked key information, specifically that the man had attempted an overdose the previous night, prior to his arrest, and had warning markers for self-harm.

Police custody staff incorrectly believed that such information held on police systems was automatically included on a digital PER. In fact, it needed to be manually inputted, the IOPC said.

At the end of its investigation in July 2022, the IOPC made a number of recommendations to South Wales Police, the Ministry of Justice and the National Police Chiefs’ Council (NPCC, which were accepted, to help tighten arrangements for the transfer of detainee information.

Following a nine-day inquest at Pontypridd Coroner’s Court into the death of John O’Driscoll, a jury returned an outcome of suicide.

The IOPC said issuing its investigation findings has awaited the end of the inquest.

IOPC Director for Wales David Ford said: “My thoughts are with Mr O’Driscoll’s family and friends. This sad case highlighted the need for informed and thorough assessment of an individual’s risk of self-harm and a robust means of communicating this information to all authorities with responsibility for people in custody.

“Our investigation found custody staff held misconceptions about how a prisoner escort record would be automatically populated with information about an individual’s vulnerability already held on police systems.

“It is vital that when police digital systems are implemented, officers and staff know how to effectively use them.

“I am pleased our recommendations were agreed by South Wales Police, the Ministry of Justice and the NPCC, with the learning being shared with force custody leads.

“While it may not have affected the tragic outcome in this case, it is in everyone’s interests that key welfare concerns about a detainee are readily available to all those working throughout the custody chain.”

The IOPC investigation began in January 2022 following a mandatory referral from South Wales Police.

Mr O’Driscoll was arrested just after 2.30pm on December 29, 2021, for a recall to prison and taken to Cardiff Bay police station.

“The custody record showed that Mr O’Driscoll had warning markers for suicidal thoughts and an alleged attempt to hang himself. Risk assessments were carried out by the custody sergeant and a healthcare professional,” said the IOPC.

“The custody sergeant updated the custody records and completed a digital PER form, authorising transfer to HMP Cardiff. Mr O’Driscoll arrived at the prison at around 4.30pm and underwent two risk assessments. He was placed in a cell and put on hourly checks. When prison staff checked on him at 9pm, he was sadly found dead.

“Our investigation showed that the PER form was not accurate, as it did not contain information regarding markers for self-harm, or an attempted overdose from the previous night.

The IOPC issued the following learning recommendations:

• South Wales Police should provide training for custody staff about the Prisoner Escort and Custody System (PECS) and completing digital PER forms to highlight that PECS is a stand-alone system and any existing or new information must be manually added to the PER;
• The NPCC should share the learning from this investigation with force custody leads to take steps to ensure custody staff understand that the PECS is a stand-alone system, and that any existing or new information recorded on police systems must be inputted manually onto a digital PER; and
• The Ministry of Justice should update its guidance on the PECS, relevant to police and prisons, in particular the completion of digital PER forms.

“It is imperative that the PER is reviewed before a person is transferred to make sure it is accurate and all relevant information is recorded,” the IOPC said.

Following the IOPC investigation, in respect of the inaccurate PER form, a custody detention officer in this case took part in the reflective practice review process. At a disciplinary meeting held for a custody sergeant, misconduct was found proven and they received an 18-month written warning.