Recommendations - South Wales Police, July 2022
We identified organisational learning during an independent investigation in relation to custody digital records.
IOPC reference
Recommendations
The IOPC recommends that South Wales Police provide training to custody and detention officers regarding the Prisoner Escort and Custody System (PECS) and the completion of digital Person Escort Record (d PER) forms. Any such training should highlight that:
PECS is a stand-alone system which does not interface with any police systems. Therefore, any existing or new information on police systems must be inputted manually onto the d PER.
If a detainee had a d PER created from a previous detention, the information stored in the PECS system should auto-populate a new form with the information known at the time of the previous detention. There may be occasions though where the auto-populate function fails. Therefore, it is imperative that Custody Officers review the d PER to make sure it is accurate and all relevant information is recorded.
This follows an IOPC investigation where an individual was transferred from police custody to prison. A digital person escort record (d PER) was created by the detention officer via the prisoner escort and custody system (PECS). The d PER did not contain all up-to-date warning markers and risk information of the detainee, such as the detainee had taken an overdose the previous night and had been in hospital. This was due to a misconception that officers incorrectly believed that as the detainee had previously been registered on the PECS system that the d PER would be automatically populated with information transferred from police systems. In addition, on this occasion the auto-populate function failed and did not transfer some information recorded on a previous d PER. The d PER was passed to the escort staff and in turn to the prison staff. The impact of the omitted information was that when the d PER was passed to escort staff and in turn prison staff they were not aware of the latest information concerning the detainee’s risk of self-harm. The detainee ended their own life during their first night at prison.
Do you accept the recommendation?
Yes
Accepted action:
This recommendation was discussed in the force quarterly Strategic Lessons Learned forum on 16th June 2022.
Following the group meeting it was established that the error was not a Niche system error, but human error. Therefore a Chief Inspector (Custody Services) is ensuring that training is provided to all Custody staff around completion of the PER form.
This training will ensure that all Custody staff are aware that any existing or new information on police systems must be inputted manually onto the PER form. It will also ensure that Custody staff are aware that they should always review the PER form to check that it is accurate with all relevant information recorded.
The IOPC recommends the NPCC (as holders of the national portfolio for custody and detention) provide guidance to all police forces highlighting:
The Prisoner Escort Custody Service (PECS) is a stand-alone system which does not interface with any police systems. Therefore, any existing or new information on police systems must be inputted manually onto the d PER.If a detainee had a d PER created from a previous detention, the information stored in the PECS system should give the option to select previously known information if it is still relevant and to add new information. It is still imperative that Custody Officers review the d PER to make sure it is accurate and all relevant information is recorded.The College of Policing APP contains detailed information and instructions regarding d PERs including when and how to complete them.All police forces are required to review their own local policies and training regarding d PERs.All police forces are required to review their training is sufficient regarding the inclusion of warning markers on the d PER.
This follows an IOPC investigation where an individual was transferred from police custody to prison. A digital person escort record (d PER) was created by the detention officer via the prisoner escort and custody system (PECS). The d PER did not contain all up-to-date warning markers and risk information of the detainee, such as the detainee had taken an overdose the previous night and had been in hospital. This was due to a misconception that officers incorrectly believed that as the detainee had previously been registered on the PECS system that the d PER would be automatically populated with information transferred from police systems. In addition, on this occasion the auto-populate function failed and did not transfer some information recorded on a previous d PER. The d PER was passed to the escort staff and in turn to the prison staff. The impact of the omitted information was that when the d PER was passed to escort staff and in turn prison staff they were not aware of the latest information concerning the detainee’s risk of self-harm. The detainee ended their own life during their first night at prison.
Do you accept the recommendation?
Yes
Accepted action:
In response to the recommendation the following guidance was issued via an email on the 25/10/22 to all BaSM users stating:
Following an investigation into a death in custody by the Independent Office for Police Conduct, we want to remind you that:
- Book a secure move is a standalone system. It does not share data with any police systems.
- Any existing or new information identified by staff while a person is in your custody must be added to the digital Person Escort Record (PER).
- If a person has had a digital PER created for them previously, Book a secure move will automatically populate the new digital PER with the information from their last PER. This must be carefully reviewed (and where necessary, changed). Any new information must be manually added.
All PERs must be accurate and complete before a move begins.
The digital PER must be reviewed before a person is transferred. You must make sure it is accurate and all relevant information has been recorded.
Thanks, Book a secure move team.
In addition, BaSM users will be reminded of the points set out in the guidance on the BaSM system's 'What's new' page. This will be communicated to users at the same time changes are made to the dashboards that make it clearer which sections of the PER are still left to complete.
The design changes will be mentioned on a “banner” shown on the BaSM homepage. The banner will show to every user for 2 weeks. On the banner, there'll be a link to the 'What's new' page. On this page, the guidance in the email sent to all BaSM users on the 24/10/22 will be reiterated. These comms will be issued in December 2022.
The IOPC recommends the National Police Chiefs’ Council (NPCC) shares the learning from this IOPC investigation with force custody leads, asking them to take steps to ensure:
Custody staff understand that the Prisoner Escort and Custody System (PECS) is a stand-alone system which does not interface with any other police systems. Therefore, any existing or new information recorded on police systems must be inputted manually onto a digital Person Escort Record (d PER) form.Custody staff understand that if a detainee had a d PER created from a previous detention, the PECS system should give the option to select previously known information if it is still relevant. If this option is selected then a new d PER form will be auto-populated with this information. Any new information must be inputted manually onto the new d PER.Their local policies, procedures and training are in line with national guidance as set out in APP, in particular that it is the responsibility of the custody officer who transfers the detainee to ensure that the PER is up to date and all relevant information is recorded. This should also include consideration of whether training is sufficient regarding the inclusion of warning markers and supporting information on the d PER.
This follows an IOPC investigation where an individual was transferred from police custody to prison. A digital person escort record (d PER) was created by a detention officer via the prisoner escort and custody system (PECS). The d PER did not contain all up-to-date warning markers and risk information in relation to the detainee, in particular the form did not note that the detainee had taken an overdose the previous night. This was due to a misconception that custody staff incorrectly believed that as the detainee had previously been registered on the PECS system that the d PER would populate with up-to-date information which automatically transferred from police systems. The d PER was not subsequently reviewed by the custody officer before it was passed to escort and prison staff. As a result, escort and prison services were not aware of the latest information concerning the detainee’s risk of self-harm or suicide. The detainee ended their own life during their first night at prison.
Do you accept the recommendation?
Yes
Accepted action:
This learning recommendation will be circulated on ChiefsNet for all Chief Constables to consider for wider learning and also shared with all custody leads whose details are held by the NPCC Custody Portfolio.