House of Commons - Defence - Written Evidence

Select Committee on Defence Written Evidence

Annex A

YOUTH JUSTICE BOARD FOR ENGLAND AND WALES

INTRODUCTION

1. This paper provides background on the role of the Board, the juvenile secure estate and characteristics of young people in custody, and then addresses the particular issue of duty of care. The Board would be pleased to provide any further information that would be of assistance to the Committee.

2. The Youth Justice Board for England and Wales has statutory responsibility for monitoring the youth justice system, identifying and promoting effective practice and offering advice how to achieve the statutory aim of preventing offending by children and young people. The Board is also required to commission services for young people remanded and sentenced by the courts to secure facilities.

BACKGROUND

3. The Youth Justice Board for England and Wales is an executive non-departmental public body. The Youth Justice Board comprises up to 12 Board members, appointed by the Home Secretary. There are approximately 180 staff employed by the Board. It was established under the Crime and Disorder Act 1998 to:

— advise the Home Secretary on the operation of the youth justice system, how to prevent offending by children and young people; and the content of national standards for youth justice services;

— monitor the operation and performance of the youth justice system;

— identify and disseminate good practice in youth justice and in preventing offending by children and young people; and

— since April 2000 commission and purchase places for children and young people remanded or sentenced to secure facilities.

4. The Board has had a central role in implementing the reforms to the youth justice system set out in the Crime and Disorder Act 1998 and subsequently in the Youth Justice and Criminal Evidence Act 1999. Section 37 of the Crime and Disorder Act 1998 established a new principal statutory aim for the youth justice system, "to prevent offending by children and young persons". It is the key objective of the Board to monitor the performance and develop the ability of the youth justice system to meet this aim. The Board believes that taking measures to prevent offending and re-offending by children is in the interests of the child. Addressing the basic needs of young people, including their general safety, is essential before useful work can be done to reduce the likelihood of offending and re-offending.

5. Since April 2000, the Board has been responsible for commissioning services for young people under 18 who are sentenced or remanded to secure facilities. The budget for purchasing places was transferred to the Board. The Board has established contracts and service level agreements with secure facilities providing places for young people—the Prison service, Local authority secure children's homes (LASCHs) and Secure Training Centres (STCs). Monitoring arrangements have been developed in order to measure how compliance with requirements set out by the Board are being achieved. The commissioning approach has enabled the Board to influence the standards of custodial regimes for young offenders. It is a fundamental objective of the Board that children detained in custody should be cared for safely and should be protected from all kinds of significant harm.

6. The juvenile secure estate exists to provide custodial accommodation for all young people under the age of 18 who are sentenced or remanded to custody by a court.

7. The Estate consists of four sectors: young offender institutions, prison service accommodation for girls, secure training centres and local authority secure children's homes.

8. Young offender institutions for boys comprise about 85% of the available accommodation for juveniles. About 2,600 boys are accommodated in 13 establishments (12 of which are run by the Prison Service and one by Premier). A discrete estate has been developed ensuring separation of boys from adult prisoners. The Board places older and less vulnerable young people in this accommodation. They are aged 15 to 17 plus around 370 18 and 19 year olds completing a Detention and Training Order or Section 91 order awaiting transfer to the adult estate.

9. The Board has ensured since 2003 that no girls under 17 years of age are placed in prison service accommodation. Currently 80-90 girls aged 17 at any one time are placed in prison in accommodation they have to share with older prisoners. To address this the Board is seeking with the Prison Service to develop a number of new units linked to existing female establishments but with their own separate staffing, facilities and identity, which would provide a more suitable regime for this group. The first of these units is being developed at HM Prison Downview and will be commissioned by the Board in the latter part of 2004-05. Detailed work is being undertaken to identify other appropriate sites needed and funding to develop the further units needed has been made available by the Home Office.

10. Secure Training Centres (STCs) are establishments run by private companies under contract to the Board. There are currently 194 places provided in three STCs. A fourth STC will be opening in the current financial year providing a further 80 places. The STCs originally provided accommodation for 12 to 14 year olds. The Board also place there some of the more vulnerable 15 year olds boys and 15 and 16 year olds girls.

11. Local authority secure children's homes (LASCHs) are owned and managed by Local Authorities. They provide places for children from the age of 10 and 11 who need to be held securely for welfare reasons as well as criminal justice reasons. Following a recontracting exercise the Board is expecting to reduce the number of places commissioned in LASOAs this year, while increasing places in STCs. There will be a net increase in places available for younger and more vulnerable children.

THE CHARACTERISTICS OF YOUNG PEOPLE IN CUSTODY

12. The age profile of the juvenile custodial population is shown in the table below.


Age Profile of Juvenile Secure Population at end February 2004

	Boys		Girls		Totals
Age	Number	% of Total	Number	% of Total	Number	% of Total

10	0	0.0	0	0.0	0	0.0
11	2	0.1	0	0.0	2	0.1
12	12	0.4	2	1.1	14	0.5
13	30	1.0	5	2.9	35	1.1
14	129	4.4	12	6.9	141	4.6
15	363	12.5	34	19.5	397	12.9
16	707	24.3	38	21.8	745	24.2
17	1,291	44.4	57	32.8	1,348	43.7
>=18	375	12.9	26	14.9	401	13.0
Total	2,909	100.0	174	100.0	3,083	100.0

13. Children and young people in custody suffer multiple disadvantages in terms of historic abuse, inadequate parental care, poor educational attendance and attainments, physical and mental health problems and substance misuse. They are in general terms a vulnerable group of children, who sometimes also pose a risk to other children. The statistics show that a significant proportion are likely to have been subject to harm prior to custody. Some of these statistics are likely to understate the proportion who have suffered from historic abuse as they do not for example explicitly pick up other areas of abuse, namely emotional abuse and neglect. Furthermore, we know that significant numbers of children disclose abuse for the first time when they are in custody. While the experience of being held in secure accommodation may compound vulnerability, being held in custody should not be regarded as the original cause of that vulnerability in many cases.

Education

— Nearly half of those in custody, who are of school age, have literacy and numeracy levels below those of the average 11 year-old. Over a quarter have literacy and numeracy levels equivalent to an average seven year-old.

— Between a quarter and a third of juvenile prisoners have no educational training available to them immediately before custody.

— In a survey 84% of young people interviewed claimed to have had periods of exclusion from school, and 86% had truanted.

Mental Health

— Two-fifths of sentenced males and two-thirds of sentenced females had symptoms of anxiety, depression, fatigue and/or concentration problems compared to one-tenth of young people in the population generally.

— Between 46% and 81% have mental health problems.

— 10% exhibited signs of psychotic illness.

Drugs and Alcohol

A Board study in 2003 of young people in custody identified that:

— 97% of the sample had used an illegal drug at some point in their lifetime.

— 72% of the sample used cannabis on a daily basis in the 12 months before their arrest.

— 51% were poly-drug users—that is they used two or more drugs more than once a week.

— Approximately 40% had been dependent on a substance at some point in their lives.

— 74% of the sample drank alcohol more than once a week. The majority of drinkers regularly exceeded 6 units on a single drinking occasion.

— 38% of the sample felt that their crime was related to illegal drugs; 29% thought their crime was related to alcohol use.

Family background

Various studies have found that:

— Between 40% and 49% of young people in custody have a history of being in local authority care.

— Two out of five girls and one out of four boys reported having suffered violence at home.

— One in three girls and one in twenty boys reported sexual abuse. This abuse may have lasting emotional and psychological consequences for the children concerned, which may impair their capacity to benefit from regimes which are offered.

INCIDENCE OF SELF-HARM IN CUSTODY

14. Since 1990 there have been 23 apparent self-inflicted deaths of juveniles in prison establishments. Since April 2000, when the Board took responsibility for commissioning places for children in custodial facilities, there have been eight apparent self-inflicted deaths in custody. The last apparent self-inflicted death in the juvenile secure estate was in October 2002.

15. There have been no apparent self-inflicted deaths in Secure Training Centres since the first centre opened in April 1998.

16. There have been no apparent self-inflicted deaths in Local Authority Secure Children's Homes since the Board has had responsibility for the secure estate. The last apparent self-inflicted death in a LASCH took place in 1998 at the Hillside Secure Unit in Wales. A committee of enquiry following that incident led to recommendations about both practice issues and room design being adopted across the secure estate.

17. The level of recorded self-harm in YOIs has increased in recent years. This may reflect the new reporting system (see below). But it is still clear that the levels of self-harm in custody remain unacceptably high.


Year	Reported Incidents of self-harm (juveniles in YOIs)

1998	252
1999	205
2000	288
2001	402
2002	509
2003	1,070

18. A revised method for self-harm data collection was introduced by the Prison Service in 1 December 2002. The revised form aimed to improve the consistency with which self-harm incidents are reported and improve the detail and quality of the information collected. Research had demonstrated that the previous method for collecting data, using the Incident Reporting System, significantly under-reported the actual extent of self-harm occurring in establishments. Analysis of data collected since the introduction of the new process suggests that overall there has been in the region of a 70% increase in the extent of reporting. Despite this improvement, early checks by the Prison Service of 2003 self-harm data suggests that there is still a significant amount of under-reporting and work is on-going with establishments to encourage them to report every incident of self-harm.

19. The level of recorded self-harm in the three Secure Training Centres in each of the last three years is set out below. The number of places available in STCs increased by 32 places in June 2002 and by a further 32 places in November 2003. Over the period the Board has placed increasing numbers of 15 and 16 year olds liable to self harm in STCs rather than in custody.


Year	Reported incidents of self-harm (Secure training centres)

2001-02	69
2002-03	110
2003-04	203

20. Information on self-harm statistics in LASCHs have not been routinely collected. The Social Services Inspectorate has agreed to allow the Board access to a database being developed to collect inspection information on LASCHs, including this data. Following the retendering exercise with LASCHs new contracts specify that such information should be collected once the mechanism is in place.

21. There have been no other recorded deaths of juveniles (either natural or other causes) in prison service accommodation since the Board took responsibility for commissioning secure estate places in April 2000.

22. There have been no other recorded deaths in LASCHs since 2000.

23. On 20 April this year the Board reported the death of Gareth Myatt, a 15 year-old boy, at Rainsbrook Secure Training Centre. The circumstances of the death are subject to a police investigation at the time of writing. The Board has commissioned an independent expert, recommended by the Commission for Social Care Inspection to investigate the death and this will form the basis of the Board's serious incident review. This in turn will inform the statutory investigation conducted by Stoke-on-Trent Area Child Protection Committee. There have been no other recorded deaths in STCs.

FACTORS ASSOCIATED WITH SUICIDE AND SELF-HARM

24. To inform measures to promote safety and prevent suicide and self-harm in particular it is clearly important to understand factors that are associated with these actions.

25. An overview of the issues that relate to suicide and self-harm by juveniles in the youth justice system was included in the background document used to develop the Board's Key Elements of Effective Practice guidance on mental health. The guidance notes that the risks that a young person poses need to be regularly reviewed—particularly if a young person's situation changes or new information becomes available. It is clear from research literature that risks to self, and to others are (1) contextual ie dependent on circumstances and (2) dynamic ie likely to change over time. The following extract from the source document provides guidance on the background to suicide and self-harm in relation to young people:

"Suicide and self-harm

Suicide refers to a conscious desire and act to end one's life. It is not invariably linked with mental disorder. Self-harm is seen by the young person as a solution to a problem and often not an attempt at taking life. The act of self-harm significantly raises the risk of an accidental suicide. Self-harm is distinct from a deliberate suicide act.

Asset—mental health screening tool

Research within the community has linked many factors to suicide and deliberate self-harm (DSH) in young people. These include:

— previous self-harm and suicide attempts substance misuse;

— mental disorder, especially depression and schizophrenia;

— family dysfunction and relationship difficulties;

— physical and sexual abuse;

— personal knowledge of DSH or suicide among family/friends;

— significant life event, eg bereavement, traumatic experience;

— school non-attendance and unemployment; and

— serious physical illness.

It is evident then that young offenders, given that they are more likely to experience the above risk factors, will be especially vulnerable to suicide and DSH, particularly those in custodial establishments and immediately after release.

Deliberate self-harm within prison

Self-harm is a significant issue for adolescents generally, and for those within prison, in particular. Liebling (1995) has examined factors associated with self-harm in young prisoners. In these studies, it was noted, as documented elsewhere, that all the prisoners had backgrounds with multiple disadvantages. The differences to emerge between suicide attempters and the comparison group were differences of degree. Suicide attempters were more likely to report multiple family breakdown, frequent violence leading to hospitalisation, local authority placement as a result of family breakdown, truancy as a result of bullying, experiences of sexual abuse and previous episodes of self-harm. The suicide attempters found prison life more difficult in most respects. She called this group of young people "poor copers".

Suicide within prison

Within prison, 10% of suicides occur within the first 24 hours of imprisonment, 40% within the first month and 80% within the first year. Studies on prison suicide have highlighted the importance of both individual and systemic/institutional factors. In studies of completed suicides in England and Wales (Dooley 1990; HM Chief Inspector of Prisons 1999) risk factors identified included mental illness, a history of psychiatric contact (-40%), a history of single or multiple substance misuse (30 to 70%), a history of self-harm (-50%) loss of social contact and relationship difficulties, victimisation by other inmates and difficulties in coping with the prison regime."

26. In May 1999 HM (Chief Inspector of Prisons for England & Wales published the thematic review "Suicide is Everyone's Concern". The report concluded that the findings of the inspectorate during the review and from their inspections supported research identifying that the backgrounds and criminal justice histories of both those who attempted suicide and those who did not were characterised by the same multiple disadvantages, although there were significant differences of degree. As noted above, suicide attempters were more likely to have experienced, multiple family breakdown, sexual abuse, frequent violence leading to hospitalisation, local authority placement as a result of family problems (rather than offending), truancy as a result of bullying (as opposed to boredom or peer pressure) and very short periods spent in the community between periods in custody.

27. The report noted that a history of psychiatric illness or history can be less common with people, including young people, who commit suicide in custody compared to those who commit suicide in the community. It was concluded that risk of suicide may therefore be far more a function of vulnerability as of psychiatric illness and the solution can not reside in psychiatric care alone but in a prison wide approach.

28. Of the 23 apparent self inflicted deaths of juveniles in prison service accommodation since 1990 the method in all cases was recorded as hanging. In all cases the apparent self inflicted death was of a boy two boys were aged 15, eight boys were aged 16 and 13 boys were aged 17. In eight cases the legal status was remand, with five convicted but unsentenced and 10 sentenced. In terms of latency in custody one boy was in custody for one day three boys were in custody between three days and one week; 11 boys were in custody between one week and one month; five boys were in custody between one month and three months and three boys were in custody between three and six months. A majority of self inflicted deaths of juveniles occur within the first month of entering custody.

PERCEPTIONS OF SAFETY

29. In 2003, the HM Prison Service Safer Custody Group undertook a project on perceptions of safety based on visits and surveys with young people and staff in nine establishments, including specialised prison service units, a Secure Training Centre and Local Authority Secure Children's Home. While there needs to be some caution with the findings due to the small sample size the conclusions identified included:

— an apparent association between experiences of bullying and thinking about self-harm. All those surveyed who had thought about self-harming and who had actually self-harmed said they had been the victims of negative behaviours from others;

— an apparent overlap between victim and victimiser roles. Those who had reported being victims of negative behaviour such as bullying by others were considerably more likely to have used the behaviour against others themselves than those who had never been a victim.

— The role and influence of staff was identified as vitally important. It is was identified that the most successful regimes were those where young people could expect consistent treatment by staff. The report also noted that the majority of young people appreciate it when staff show genuine concern or interest in them and take time to talk or following follow through with things they said they would do.

SAFEGUARDING CHILDREN

30. The concept of "safeguarding" encourages a more holistic and integrated approach to the task of keeping children safe from all sources of harm. In addition to self harm other sources of harm identified are bullying and peer abuse, and harm from adults. In the Joint Inspectors report "Safeguarding Children", the inspectors expressed the view that bullying was the most serious and common kind of harm to which young people are subject in YOIs.

PERFORMANCE FRAMEWORK AND MONITORING

31. The Board has a central role in developing the standards in the juvenile secure estate. A combination of formal agreements with providers, performance indicators set by the Board, guidance on effective practice, and national standards set by the Home Office on advice from the Board contribute to the framework of standards.

32. With prison service establishments a Service Level Agreement (SLA) is agreed between the Board and the Prison Service. The latest SLA is attached at Annex 1. The SLA includes measures for safeguarding children. The SLA in tuna includes a requirement that the requirements of the key Prison Service Order relating to juvenile regimes, PS04950, are met. The latest version of PSO 4950 is attached at Annex 2, but it should be noted that this document is currently subject to fundamental revision. Requirements for the SLA for 04/05 includes the agreement that safeguarding children will now be the responsibility of a single member of the senior management team in each establishment, responsible for all aspects of safeguarding children.

33. For Local Authority Secure Children's Homes the Board provides a service specification (Annex 3) that is linked to contracts with the providers. LASCHs are also under mandatory requirements of the National Minimum Standards for Children's Homes set by the Department of Health. The Board's service specification sets out key requirements in relation to safety and care including requirements for effective suicide and self harm prevention plans and policies to be in place, while not seeking to duplicate or contradict the National Minimum Standards.

34. For Secure Training Centres the operational specifications of contracts with the Board sets out requirements in relation to care including suicide and self harm prevention (Annex 4 provides an example of these). The Board requires STC providers to supply operating proposals dealing with the management of suicide and self harm risk. In addition, the Invitation to Tender requirements for new STCs includes design standards for buildings to minimise opportunities for suicide and self harm.

35. The Board sets out annual performance indicators for the secure estate facilities. These relate to key standards of the regimes including time out of rooms and involvement in education and training but also include key measure relating to safety: ensuring appropriate information is accessed and assessments for vulnerability and substance misuse take place on reception. For this financial year it is intended to include a new performance indicator seeking to improve levels of safety as. reported by young people themselves.

36. National Standards for youth justice services are issued by the Home Secretary following advice from the Youth Justice Board and in consultation with other key departments and agencies. They are the required minimum standards of practice which practitioners who provide youth justice services are expected to achieve. The standards set out a series of requirements relating to safety in. general and the prevention of self harm and suicide in particular. The standards are encapsulated within the contracts and Service Level Agreements with secure estate providers. Key standards in relation to prevention of self harm and suicide include:

Asset

— requirements to ensure assessment information is received by establishments on reception of a young person;

— assessment on reception into custody including an assessment of mental health needs as well as an assessment of substance abuse. Where withdrawal treatment is needed the young person must be referred to a specialist doctor or nurse and a drug or alcohol worker,

— key workers to be allocated to each young person to provide advice and assistance during their period in custody,

— requirements for all establishments to have procedures to identify and manage those at risk of self harm and suicide and these should be regularly monitored, reviewed and updated.

37. The Board undertakes monitoring of the secure estate to measure performance and standards against key requirements. A new performance management system for the juvenile secure estate is currently being developed. A prototype, A Safe Environment, has been operational since October 2003 (Annex 4). This approach has included the development of a new reporting system that brings together all strands of secure estate operation and performance providing a complete and coherent picture. A key area of reporting within the new framework is both the treatment and conditions of young people in secure establishments, including safeguarding measures, at each stage of the regime from reception to resettlement. The revised comprehensive reporting system includes also incident reports to YJB, including self harm, and an overview of vulnerability assessments of individuals placed in each establishment.

38. The core framework is designed to focus monitoring on the individual treatment and care of young people, framed around each stage of the custodial process. The monitoring programme and the intensity of the monitoring of individual establishments will be risk and intelligence led in the sense that judgements will be made about which performance indicators are to be monitored and the depth of examination that is required. This is designed to provide the Board with the ability to undertake more regular and intense monitoring of any establishments that are indicating high risk concerns. Following piloting, it is intended to roll out fully the new Effective Regimes monitoring framework over the current financial year. The overall aim is to ensure that performance monitoring effectively contributes to continuous and measurable performance improvement across the secure estate, working with secure estate providers to address identified concerns.

39. The monitoring functions of the YJB are backed up by independent inspection and audits undertaken by other bodies (in particular for the secure estate, Her Majesty's Chief Inspector of Prisons and the Commission for Social Care Inspection). Working together with other inspection agencies, for example Ofsted, these bodies provide an additional and independent overview of the practice and performance of individual secure establishments. The Youth Justice Board provides information and data to these inspection bodies and uses their reports to inform its work and where necessary; improve standard setting and contractual requirements.

SPECIFIC MEASURES TO PROMOTE SAFER CUSTODY

40. Since the start of the Board's responsibility for the juvenile secure estate a number of practical measures have been taken to improve the safety, of children in custody, including to minimise the risk of self harm and suicide. Key examples of measures taken include:

— the provision of 30 safer cells at four Young Offender Institutions (Brinsford, Feltham, New Hall and Wetherby). The improved design minimises opportunity for injury and removes ligature points;

— provision of funding for 24 hour health care in all establishments that take young people straight from court;

— the provision of "First night packs" for all young people entering custody. These contain phone cards, toiletries, reading material and pen and paper, sweets and a drink;

— all secure facilities have written protocols on how to deal with alcohol and drug withdrawal by young people coming into custody;

— the commissioning of a regular survey from the research section of Her Majesty's Inspectorate of Prisons (HMIP) of all young people in YOIs. The survey asks among other questions how safe they feel;

— measures have been taken to improve the transmission of information from YOTs to secure facilities and to ensure the safety of the young person when vital information is absent;

— provision of funding to end communal showering and ensure that cubicular showering is available (the programme is not yet complete);

— the Board has also funded two staff in the Prison Service Safer Custody Group to provide outreach services specifically to assist juvenile establishment develop and maintain suicide and self harm strategies;

— the Board is now commissioning advocacy services to work in the prison service estate. There are already advocacy services in STCs and LASCHs. There is a phased implementation of the new services and they are due to be completed by March 2005. At the end of this process all juveniles in custody will have access to independent advocacy services providing support to young people. By access it is meant that there will be capacity for all juveniles to contact the advocacy service at any time, at least by 24 hour telephone help-line.

CHILDREN IN YOIS AND THE CHILDREN ACT (1989)

41. On 29 November 2002, Mr Justice Munby delivered his judgement in the High Court, in relation to the application of the Children Act (1989) to children detained in YOIs. He found unequivocally "that the Children Act did apply to these children, and that duties owed by local authorities to children generally, continue to be owed to children in YOIs".

42. Following the judgement and also in response to the publication of the Joint Inspectors report, Safeguarding Children, a multi-agency review group including the Association of Directors of Social Service, Local Government Association and Youth Justice Board, in association with the Prison Service, has considered the implications and issued a report. The Board is implementing a central recommendation of that report by funding the employment of 25 local authority social workers to help fulfil local authority duties under the Children Act 1989 for children in YOIs. A significant part of the duty of these staff will be in relation to safeguarding. The review proposed that these staff should have considerable experience both at operational and management level. The Board recognises that these staff will need to ensure that they are not working in isolation from key agencies, notably social services and YOTs.

43. The Board and Prison Service will also assist the DfES in the preparation of guidance for Area Child Protection Committees (ACPCs) and YOIs, setting out the obligations of ACPCS in safeguarding children who are placed in YOIs. That was a further key recommendation of the multi-agency review.

COMPREHENSIVE REVIEW OF CHILD PROTECTION AND SAFEGUARDING ARRANGEMENTS IN YOIS

44. In light of the judgement of the Children Act judgement and the publication of the Joint Chief Inspectors Report, Safeguarding Children, a comprehensive review of safeguarding arrangements in YOIs also has been undertaken. This was conducted by Prison Service and YJB staff, under the oversight of a steering Group which included members of the Social Services Inspectorate and HM Inspectorate of Prisons.

45. The review examined arrangements in every YOI establishment holding children, in relation to:

— measures to address self harm and suicide;

— measures to address bullying and peer abuse;

— measures to address harm from adults;

— monitoring and reporting arrangements;

— measures to address historic child abuse;

— management arrangements;

— training arrangements;

— arrangements in place with local ACPCs and local authority services; and

— measures to promote a child centred culture, within which safety is seen as central and of highest priority.

46. The aim of the review was to provide an all-inclusive approach to the care of juveniles in YOIs covering all the main sources of potential harm. A report giving an overview of the whole prison service juvenile estate has been prepared providing a platform for child safeguarding improvement plans for each establishment, and the estate generally.

47. It has been agreed that subject to the availability of necessary funding, the Board and the Prison Service would establish a Child Safeguarding Taskforce to consider and address the recommendations of the Review. This has been reflected in the Service Level Agreement between the two organisations for 2004-05.

48. Key themes that have emerged from the review include the need to ensure policies on safeguarding are juvenile specific and that safeguarding policies across different areas are sufficiently linked up within establishments, including management oversight and accountability. It is also identified that policies and guidance needs to strike an appropriate balance between identifying those most vulnerable and providing a supportive overall environment which recognises the potential vulnerability of all young people in custody. In general, it was acknowledged that the biggest obstacle to progress is ensuring there is a clearly defined framework within which relevant agencies are encouraged to operate.

49. Following the review, the Board will be focusing in particular on strengthening arrangements to ensure robust senior management responsibility for safeguarding children in all units (which is being addressed in the SLA with the Prison Service for 2004-05); developing workforce and training measures for staff working with children in the secure estate; and developing the monitoring framework for safeguarding. The Board will work with the Prison Service in preparing comprehensive safeguarding policies for the Prison Service juvenile estate. The review findings will inform the current work to revise the key Prison Service Order on juvenile regimes, PS04950.

SUICIDE PREVENTION STRATEGY

50. Over the last three years Ministers and the Prison Service, with involvement from other organisations including the Board, have developed a prisoner suicide prevention strategy. This strategy is now under review. The Board welcomes the announcement that the review of the strategy will ensure that in future it will encompass a specific suicide prevention strategy for juveniles. This can be informed by the Safeguarding Review. In general terms it has been announced that the strategy will be broader and more integrated with other approaches, seeking to find the balance between policies that target the general prison population and policies that target the most at risk, based on research identified links between levels of prisoners' distress and levels of self-inflicted deaths.

BEST PRACTICE

51. While conducting the Safeguarding Review examples of good practice in relation to safeguarding in YOIs were identified. In relation to measures to address self harm and suicide by young people in custody the following examples were identified:

— proactive use of in-reach mental health care where available. This facility is highly valued by staff and young people;

— joint training with external mental health agencies;

— a dedicated Suicide Prevention Coordinator role appears to strengthen and promote awareness, practice and training in this area;

— wing-based counsellors assessing individual mental health needs and self-harmers being offered crisis intervention counselling;

— Safer Custody Governor dedicated roles to co-ordinate all safeguarding areas;

— weekly referral meeting where senior managers are made aware and contribute to care planning for individuals where there is concern;

— a lead "Nurse for Children" post;

— a "Coping with Custody" course for young people;

— additional frequent observations for first seven nights, with follow up reviews at seven, 14 and 28 days after closing F20525H (self harm at risk form);

— permanent counsellors employed; and

— Detention and Training Order clerks screening paperwork and making referrals for counselling.

INVESTIGATIONS

52. The Board has welcomed the announcement that from 1 April 2004 the Prisons and Probation Ombudsman would investigate all deaths in prison custody. Independence is a critical factor for ensuring confidence, including confidence of bereaved relatives and we believe that the process will contribute to improved understanding of these tragic events in order to reduce further deaths. The Board is in discussion with the Prisons and Probation Ombudsman office in order to ascertain the most appropriate involvement of the Board in the new process for investigations. It has been the practice with previous investigations by the Prison Service for the Board to be invited to advise on the investigation.

53. Deaths in custody in LASCHs come under the authority of the Commission for Social Care Inspection from 1 April this year. The Commission for Social Care Inspection (CSCI) expect that the local authority in which the LASCH is based to consider an Area Child Protection Committee "Part 8" Review to be the statutory inquiry into the death of a child. This review would be undertaken in conjunction with the local authority in which the child is actually resident or supervised within (eg through YOT and Social Services Department) if different from the authority that the LASCH is based in. These guidelines are set out in the inter-agency guidance Working Together to Safeguard Children 1999, jointly agreed between the Department of Health, Department for Education and Skills and the Home Office. Deaths in custody in STCs fall outside the regulations applying to LASCHs. However, the Board has sought agreement with the Commission for Social Care Inspection (CSCI) that the same review procedure will apply as applies in a LASGR. The recommendations from the "Part 8" review process will be sent to both the CSCI and the Prison and Probation Ombudsman for consideration.

54. In order fulfil its statutory functions in relation to monitoring the youth justice system, the Board has a serious incidents reporting and review system. The aim of which is to review incidents to identify systemic action or failings that the Board can correct to prevent other serious incidents from occurring. Where this includes a death of a child in custody, following a local management review undertaken by the appropriate YOT, the Chief Executive of the Board commissions a serious incident review. Using the local management review, the Board's placement reports, Prison Service Investigation (and in future the Prison and Probation Ombudsman's report) and any other relevant documents a report is drafted for recommendations and action to be considered by the Board's senior management team. The Audit Committee of the Board is then responsible for oversight and monitoring of work to meet the recommendations. Where appropriate the review reports are provided to secure estate management, the coroner, and Area Child Protection Committee (if a "Part 8" review is undertaken) and the local YOT.

SUMMARY AND CONCLUSIONS

55. The Board regards its responsibility to ensure the safe care of the children and young people detained in the juvenile secure estate as being of the very highest priority.

56. The Board seeks to discharge this responsibility through taking the following measures:

— ensuring that safety requirements are embedded in our contractual arrangements with providers of secure accommodation;

— setting clear and measurable standards for judging whether safety requirements are being met;

— undertaking rigorous monitoring activity, backed up by independent inspection and audits by other bodies (in particular Her Majesty's Chief Inspector of Prisons and the Commission for Social Care Inspection); and

— requiring urgent and robust remedial action where delivery of safe care falls short of contractual requirements.

57. The Board hopes that information provided here will be of assistance to the Committee. The Board will be pleased to provide further information orally or in writing if the Committee would find this helpful.

May 2004



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