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Form 6.2
RESPONSE
SHERIFFDOM OF GRAMPIAN, HIGHLANDS AND ISLANDS AT INVERNESS
INV-B341-19
DETERMINATION OF SHERIFF CHRISTOPHER DICKSON
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC (SCOTLAND) ACT 2016
in the inquiry into the death of
ZACH AARON BANNER
To the Scottish Courts and Tribunals Service
1. The Scottish Prison Service (SPS), being a body to whom a recommendation under section 26(1)(b) was addressed, do respond as follows.
2. Recommendation 1 – That once normality has resumed following the Covid-19 pandemic, the Police Service of Scotland, in consultation with the current transporting agency, local Health Boards and the Scottish Prison Service, should review the contents and layout of the current PER in light of this determination and consider whether any improvements could be made to ensure, as far as reasonably practicable, that all relevant information, including, in particular, information in relation to: (i) the risk of suicide or self-harm; and (ii) the risk of harm to others, is included on the PER.
3. Response –The Scottish Prison Service have agreed with the Police Service of Scotland, to participate in the review and consideration of the above matters.
4. Recommendation 2 – That once normality has resumed following the Covid-19 pandemic, the Police Service of Scotland should consult with local Health Boards and the Scottish Prison Service as regards the system or systems of sharing medical information between police custody suites and local prisons with a view to considering whether a system, based on the HHB pilot, ought be rolled out in other parts of the country.
5. Response – The Scottish Prison Service have agreed with the Police Service of Scotland, to participate in the review and consideration of the above matters.
Court Ref: INV-B341-18
Fatal Accident Inquiry of Mr Zach Aaron Banner
Response on behalf of the Chief Constable of the Police Service of Scotland
Initial Review and actions
Following the death of Mr Banner on 3rd January 2018, an initial, local review of Mr Banner’s time in police custody between 28th and 29th December 2017 was completed which involved speaking individually with each member of custody staff (Sergeants and PCSOs) who were
on duty over that period, along with the reviewing of the National Custody System and associated documents.
As a result, a number of areas for learning and improvement where identified and addressed at a local level. This included:
At that time, there was no process in place (locally or nationally) to ensure the custody Sergeant on duty checked the accuracy and content of each PER prior to the handing over of the custody to the transporting agency which at that time was G4S. Following
that review, management advice was given to the individual member of custody staff and local instruction was circulated to all custody Sergeants to ensure the content of each PER was checked for accuracy of detail and was fully completed with all known risks prior to handing the person over to the transporting agency.
Further national guidance on the completion and checking of PERs has been circulated to all custody staff via the internal Criminal Justice Services Division weekly electronic briefing platform.
All cluster Inspectors carry out weekly custody audits using the Custody Record Inspection Form which reviews risk management and vulnerability assessment, care plan observations, medical care and the checking of PERs. If the cluster Inspector finds anything that needs addressed, they will record this on the form and take appropriate action.
A Pre-Release Risk Assessment was carried out with Mr Banner by a member of custody staff prior to Mr Banner being handed over to G4S. At that time the National Custody System did not have a specific section covering this process. This is no longer the case and prior to the subsequent FAI the National Custody System was updated and now includes a specific section to prompt the user to ask the two pre-release risk assessment questions, “Do you have thoughts of suicide or self-harm at this time?” and “Do you have thoughts of harming any other person?”. All replies are required to be recorded on the system. This section of the custody record also prompts the user to complete whether a CPN assessment is required. Only when all of these sections have been completed and the user has confirmed that the Pre-Release Risk Assessments have been completed can the custody record be closed off. This is another safeguard which is now in place.
Recommendations and Response
The subsequent FAI and published determination identified two recommendations for the Police Service of Scotland, in consultation with the current transporting agency, local Health Board and the Scottish Prison Service to consider and address.
Recommendation 1
“That once normality has resumed following the Covid-19 pandemic, the Police Service of Scotland, in consultation with the current transporting agency, local Health Boards and the Scottish Prison Service, should review the contents and layout of the current PER in light of this determination and consider whether any improvements
could be made to ensure, as far as reasonably practicable, that all relevant information, including, in particular, information in relation to: (i) the risk of suicide or self-harm; and (ii) the risk of harm to others, is included on the PER.”
Response:
Following this FAI the content and layout of the current PER is now under review at a national level.
A national Short Life Working Group (SLWG) is to be set up. The Police Service of Scotland will lead on this SLWG which will be convened and coordinated by the National Police Care Network. The SLWG will include representatives from:
The focus of the SLWG is to bring together all organisations to review the PER from both an operational and national perspective.
The SLWG will consider ways to update and improve the PER in order to enhance the handover over and passing on of essential information between all agencies, thus reducing the prospect of vital and relevant information being omitted from the PER and thereby enhancing risk management between all agencies.
In line with the recommendations from Sheriff Dickson, the group will discuss and consider what improvements must be made to ensure, as far as reasonably practicable that all relevant information is included on the PER. Specific consideration will be given to:
The revised PER must allow for sufficient detail to be added to ensure all relevant risks and other required information is passed on to other agencies. Other considerations will include:
(i) The removal of the “medium” supervision level so that the PER reflects the Police Service of Scotland’s assessment of risk as either “high” or “low”
(ii) The PER to include space to indicate whether any additional documentation has been attached
(iii) The PER to include the two pre-release risk assessment questions and answers
(iv) The PER to contain space for both the custody Sergeant and the police custody nurse to indicate they have checked the content of the PER and the time/date that they did so
Recommendation 2
“That once normality has resumed following the Covid-19 pandemic, the Police Service of Scotland should consult with local Health Boards and the Scottish Prison Service as regards the system or systems of sharing medical information between police custody suites and local prisons with a view to considering whether a system, based on the HHB pilot, ought be rolled out in other parts of the country.”
Response:
In July 2019 and prior to this FAI, Highland Health Board in consultation with the Police Service of Scotland commenced a trial at Inverness Custody Centre in which some of the above points were addressed in terms of information sharing between agencies. Evidence of this process was given at the FAI by HHB.
This process is detailed in Appendix A: ‘Standard Work Description’
The process details the natural flow of information between all agencies and is a step by step guide for all concerned.
At the conclusion of a person’s time in police custody the process involves the completion of an additional ‘Medical PER’ which is completed by the custody nurse and the content of which is endorsed by the both custody nurse on duty and GEOAmey during the handover
from the Police Service of Scotland to the transporting agency.
This additional ‘Medical PER’ is attached to the main PER and has been designed to alert the NHS prison nurse to any specific risks should that person be remanded to prison.
The good work of the local HHB should be acknowledged in this respect and the trial process has provided all agencies with a good foundation on which to progress.
This local trial process is due for review in June 2020 and the coming together of the SLWG is at an appropriate time to take forward any local learning from this process with a view to considering a wider national roll out.
As in recommendation 1 above, the national SLWG will review these recommendations and will:
i) Consider the outcomes and learning of the local HHB trial, particularly the sharing of medical information between IT systems and agencies, and consider if this could be replicated in other health board areas across Scotland
ii) Review the additional ‘Medical PER’ that has been trialled in terms of its content and layout and consider using this where there has been any healthcare involvement with a person in police custody
iii) Consider a process for when a ‘Medical PER’ was attached to the main PER, that ensures the prison nurse contacts the police custody nurse and checks the relevant health board IT system
The good working relationships already in place between all local partners, and their willingness to engage in a joint approach to address the recommendations made by Sheriff Dickson should be noted.
Peter Hindley
Inspector
Police Scotland
4th June 2020