How the prisons watchdog sped up its investigations into deaths in custody

Once “lost in detail”, the Fatal Incidents Investigations Team got a grip on investigative processes to deliver reports quicker to families and coroners

Credit: Paul Faith/PA

By Naomi Larsson

03 Sep 2018

One team of about 30 people in the Prisons and Probation Ombudsman is tasked with investigating deaths in prison custody, including deaths from natural causes as well as suicides. Despite the highly sensitive nature of the work – especially concerning the relatives and loved ones of those who’ve died – in 2011 just 14% of investigation reports were delivered on time.

It was a big problem for the Fatal Incidents Investigations Team at the ombudsman, but through a concerted effort in refocusing their priorities, the team transformed its performance in a few years. In 2015-16, all investigations were delivered on time – despite a 58% increase in the total number of investigations, alongside a reduction in resources.

“The investigations were very thorough, but thorough at the expense of the time. As a consequence we were missing our average targets of getting our investigations out,” says Richard Pickering, deputy ombudsman for fatal incidents.

“It's about getting structure and clarity and punchiness to the investigations. We got more of a grip on the investigative process so that they didn’t go on and on, which meant that we got fewer complaints from stakeholders such as the families and coroners, and we got more personal ownership for the individual investigators.”


Pickering adds: “There was a very rigorous managerial focus on getting structure to the investigative process, which led to staff being much more engaged with their individual investigations, and progressively getting into a position where we produced stuff to a much more timely time frame.”

He says the work had become “lost in detail”, and they had essentially lost focus on why they were doing investigations in the first place. “Our approach was so slow that coroners weren't able to carry out the inquests into deaths. Families in particular were being left unclear as to how their relatives died or why their relatives died, and the prisons within which they did die were not being held to account in the fashion that, in a timely investigation, we wouldn't have permitted.”

The drastic changes were made as a result of refocusing their efforts. A priority was identifying problems that would lead to people killing themselves, but primarily to address the concerns of the key stakeholders – the families and coroners.

Such was the team’s success in transforming their performance that they were given an award for customer service at the Civil Service Awards 2016, praised for the “sheer commitment of both management and staff” in making the changes work.

Pickering joined the team two years ago, and he says he’s now “harvesting the benefits” of the improvements, leading a team of staff who are “very proud of their performance”.

“They’re very proud of the fact that we are 100% on our timeliness, but they're also proud of the fact that the work that they generate is something that's regarded as of a high standard, worthy of national acknowledgement.”

The priorities of the team are now to maintain the performance, Pickering says. “The other challenge is not to lose quality in the drive to hit targets. It's about maintaining proper quality control in there.”

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