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learning point ISSUE NO 18 MARCH 2021 Cascading learning, improving confidence Securing the real benefits of a learning based culture Improving custody observation outcomes Examining the issues facing officers monitoring vulnerable detainees
Contents
3 Reviews
Cascading learning,
improving confidence:
securing the real benefits
of a learning based culture
5
Get connected
Find out more about the
work we do at pirc.scot WELCOME
6 Investigations
Improving custody
Welcome to Issue 18 of Learning Point, our best practice
bulletin dedicated to fostering a culture of learning and
observation outcomes:
examining the issues facing improvement within policing in Scotland.
officers monitoring
vulnerable detainees It’s hard to believe that it is over a year In a similar vein, in this issue, we explore
since the entire country was plunged into opportunities for organisational learning
lockdown as the world grappled with the and improvement through cascading
8 Get in touch
Speak to us about the
devastating effects of COVID-19. Looking
back, few could have predicted that, a year
lessons learned during the complaints
process and the complaint handling
topics in this issues or join down the line, we would still be living under reviews carried out by our Review Team.
our mailing list similar restrictions to our everyday life.
Elsewhere, the work of our Investigations
However, with the roll out of the Team highlights issues faced by officers
vaccination programme and deaths and in charge of monitoring vulnerable
hospitalisations reducing each day, there is people in custody, drawing attention
light at the end of the tunnel. to key opportunities for change and
improvement in procedures.
While we move towards a more ‘normal’
and familiar way of life, we recognise that I hope that you find this issue useful and
there are continuing pressures for frontline wish you all good health.
services, including policing, as they
navigate through the ongoing pandemic.
These will not necessarily diminish as
restrictions ease.
To continue to promote and support Michelle Macleod
a culture of continuous improvement Commissioner
through learning, earlier this month,
ten years on from the original guidance
published by the Police Complaints
Commissioner for Scotland (PCCS), we
published renewed statutory guidance
on the handling of complaints about the
police in Scotland. We hope that it will
serve as a blueprint to Police Scotland, the
SPA and other policing bodies in Scotland,
pirc.scot improving service delivery and public
confidence through effective complaints
handling.
2 • learning point • issue 18 • march 2021
Reviews:
Cascading learning,
improving confidence.
Almost ten years ago our predecessor, the Police
Complaints Commissioner for Scotland (PCCS),
issued the first Statutory Guidance on the handling
of relevant complaints, From Sanctions to Solutions,
2011. The guidance was the first of its kind in
Scotland, focused on promoting good complaint
handling principles and moving away from a blame
culture to one of learning and improvement .
The guidance served as a useful compass for opportunities to improve service the complaints process. To promote
for good complaint handling and enabled delivery and to identify individual or continuous improvement of service
the development of new and improved organisational learning. It is more delivery, any identified learning requires
complaint procedures over the years. concerned with “What can we learn from to be effectively shared and cascaded
Earlier this month, the PIRC published this? How can we improve?” and less internally and externally. This will also
new and revised statutory guidance with “Whose fault is it? What sanction is prevent similar incidents from
which continues to emphasise and appropriate?”. re-occurring and ultimately will reduce
support a culture of learning. the number of complaints of a similar
Integral to embedding this culture nature. Shared externally, and specifically
A culture of learning and improvement are the mechanisms put in place with the complainer, the learning and
makes the main focus of any by the organisation to capture and improvements identified through the
complaint handling enquiry a search share any learning identified through complaints process will provide a high
level of reassurance for the public,
increasing public confidence in the
police complaints process and policing
"Handled well, complaints provide a low cost and important in general.
source of feedback and learning for organisations to help drive Significant strides in changing the
improvement and restore a positive relationship with customers organisational culture and the perception
of the complaints process internally
who feel let down by poor service. Handled badly, they erode have been made by Police Scotland over
public confidence and trust in public services." the last few years. It is evident, from our
complaint handling reviews (CHRs), that
– Scottish Public Services Ombudsman in more and more cases, police complaint
handlers are identifying and capturing
3 • learning point • issue 18 • march 2021
learning, whether it is organisational POLICE SCOTLAND’S STANDARD OPERATING PROCEDURE ON
learning to improve internal processes, COMPLAINTS ABOUT THE POLICE, PARAGRAPH 6.13.1 STATES:
or individual learning to improve subject
officers’ performance. This is a positive
and encouraging trend and we hope that “The complaints process promotes a culture of learning.
Police Scotland will continue to build on
the progress made so far. Continuous improvements is the primary objective of
the complaints handling process. Complaints provide an
However, in some recent CHRs,
we identified instances where opportunity to measure current performance, assess public
valuable learning was not effectively expectation and improve service delivery.”
communicated to the complainers or
police officers and police staff.
reassurance to the complainer was there was a significant delay in the
missed when the organisational learning custody staff implementing cleaning
was not communicated in the final procedures. Police Scotland upheld the
response letter. complaint and apologised unreservedly.
Furthermore, the enquiry officer
In PIRC/00161/19, a member of the public identified organisational learning to
These examples demonstrate made a number of complaints following prevent reoccurrence of such events,
that, even when learning her detention in police custody. The demonstrating good complaint handling
complaints focused on the lack of dignity practice. During our review, however,
is identified and captured afforded to the applicant by the custody we could find no evidence that the
during the complaints staff during her detention. The complaints organisational learning was shared or
were upheld and individual learning was cascaded internally, resulting in the
process, it is not always identified for the officers involved, which opportunity to prevent similar incidents
cascaded or shared was explained to the applicant in the in the future being lost.
final response. However, as a result of
appropriately, and valuable these complaints, the enquiry officer also These examples demonstrate that, even
opportunities to raise took the opportunity to refresh guidance when learning is identified and captured
provided to custody staff regarding the during the complaints process, it is not
public confidence, provide care and welfare of female detainees in always cascaded or shared appropriately,
additional assurance and police custody. A reminder of the relevant and valuable opportunities to raise public
Custody Standard Operating Procedure confidence, provide additional assurance
improve service delivery (SOP) provisions relating to access to and improve service delivery are missed.
are missed." sanitary products, female staff and
shower facilities was circulated, as well
as further guidance for conducting cell
In PIRC/00135/19, a member of the checks and to raise awareness among
public complained about the quality of a custody staff of the need to protect
criminal investigation. The complaint was prisoners’ dignity and avoid unnecessary
upheld as it was deemed that the criminal anxiety during strip searches or changing
investigation into an allegation made of clothing. During our review, we saw
by the complainer was insufficient. The evidence that this learning was effectively
complaint enquiry established that the shared and cascaded internally,
information provided by the complainer demonstrating good complaint handling
to investigating officers was recorded practice. Regrettably, the complainer
on some police systems, but not others, was not advised of the issuing of further
which precluded additional enquiries guidance about custody procedures in
being carried out. The complaint enquiry the final response letter and was unaware
correctly identified organisational of the improvements made directly as a
learning for the Criminal Investigation result of her complaint.
Department (CID) to review local
practices in relation to the recording and In PIRC/00504/19, a member of the
sharing of information and intelligence. public complained about her experience
However, an opportunity to increase in police custody. The complainer
public confidence and provide further became unwell while in her cell and
4 • learning point • issue 18 • march 2021
Apology
Many straightforward complaints
can be resolved by way of an
apology, and it is often all the
complainer is seeking. Similarly,
when members of the public apply to
An important part of us for a CHR, they commonly state that
they are doing so as they would like to
effective complaint handling receive an apology from the police.
is apologising when things
While Police Scotland’s complaint
have gone wrong or when handling procedures state that the
the standard of service response letter to the complainer should
always provide a clear apology if failings regret that you felt
provided has fallen short of have been identified, over the last year, there was a need to complain about my
what would reasonably be we have observed a noticeable increase officers” and “I am sorry if you took any
in complaint response letters which offence at the comment made”. While
expected. recognise shortcomings yet offer they may be well-intentioned, phrases
no apology. like these can give the impression that the
When used well, apologies can be apology is conditional and that the police
a powerful tool. They enable the Police Scotland’s procedures recognise are unwilling to take responsibility for any
police to acknowledge and learn from that any apology should be unambiguous failings established.
shortcomings and allow the complainer and sincere. The choice of language
to see that the police have recognised used is important as it can affect the Further guidance on apologies has been
that their failings have had a negative complainer’s perception as to whether produced by the Scottish Public Services
impact on the person. In short, apologies an apology is genuine. In this regard, it Ombudsman and is available at
are an opportunity to make amends. is best to avoid using phrases such as “I www.spso.org.uk.
Get connected
pirc.scot is home to a whole library of
publications, including our investigation
reports and complaint handling reviews.
There's also a section dedicated to
information for police officers and police staff.
There you have access to the library of previous
issues of Learning Point, our published audits and
statutory guidance.
Additionally, you can find information and FAQs about
what you need to know if you are involved in a PIRC
investigation or complaint handling review.
Find out more at pirc.scot/for-police >>
5 • learning point • issue 18 • march 2021
Investigations:
Improving custody
observation outcomes
Recently, the PIRC investigated an incident where a woman
sustained a serious injury while under constant observations in
police custody. The investigation identified a number of issues
relating to the implementation of constant observations and
noted that similar concerns had previously been identified
during other PIRC investigations into serious injuries and deaths
in custody. Here, we explore the key issues around observations
in custody and outline areas for service improvement.
People who are identified by police Remaining vigilant at all times during
custody staff as being high risk prisoners, the monitoring of prisoners is absolutely
due to having sustained injury or having paramount. However, studies have
other identified vulnerabilities, such as shown that carrying out a repetitive or
suicidal thoughts or the intention to self- tedious task over prolonged periods of
harm, may be placed under increased time can cause vigilance decrement – a Research indicates that
levels of scrutiny and monitoring while reduction in vigilance over a period of after 30 minutes, target
in police cells. In the most serious cases, time. The monitoring of CCTV, particularly
a person may be subject to constant where the images produced are of poor detection performance
monitoring by officers or custody staff quality or lacking in scale or sound, is one decreases by 15% during a
using in-cell CCTV or by physically such task that can result in this gradual
observing the person. loss of focus. monotonous task and after
about 90 minutes it may,
In some custody suites across the Police Research indicates that after 30 minutes,
Scotland estate the quality of CCTV target detection performance decreases in some people, diminish
images is poor. Officers or staff tasked by 15% during a monotonous task and considerably... put simply,
with undertaking constant observations after about 90 minutes it may, in some
using CCTV may have to watch several people, diminish considerably. In respect a person may be looking at
prisoners at one time often on small of CCTV monitoring, put simply, a person the [CCTV] screen but not
screens, making it difficult to determine may be looking at the screen but not
if a person becomes unwell or suffers actually seeing what is happening. actually seeing what
injury. On many occasions, audio, which is happening.
may alert monitoring staff that something Vigilance can, however, be improved
is amiss, is also unavailable. through training, prolonging the time that
6 • learning point • issue 18 • march 2021
someone dedicated to such tasks can AREAS FOR FURTHER COMMISSIONER’S
undertake observations effectively. INVESTIGATION AND RECOMMENDATIONS:
IMPROVEMENT:
In a number of investigations undertaken The Commissioner has recommended to
by the PIRC, prompt action by monitoring The issues identified in a number of Police Scotland that it:
officers has undoubtedly saved the lives PIRC investigations that merit further
of people who became unwell in police consideration by Police Scotland include: • Urgently examines the issue of
custody or who attempted to self-harm, officers tasked with constant prisoner
illustrating the impact that well trained • Officers undertaking constant monitoring to ensure that officers
and alert officers can make through observations for prolonged periods are effectively briefed about prisoner
effective and early intervention. of time, occasionally whole shifts, vulnerabilities by custody supervisors
without being allocated appropriate and receive necessary and appropriate
Following the findings of a recent PIRC breaks, or breaks not being recorded. breaks.
investigation into a death in custody, • The issue of vigilance decrement, i.e. • Considers placing a maximum
Police Scotland Custody Division attention significantly declining with time limit on the period an officer
established a short life working group the passage of time. or member of staff can undertake
(SLWG) to consider improvements in • Lack of effective briefing of officers constant prisoner observations to take
custody processes. The Commissioner assigned such duties, including account of vigilance decrement – a
has commended the decision by Police recording that sufficient briefings have reduction in vigilance over a period
Scotland to urgently examine this high been given and received. of time in those tasked with CCTV
risk area of policing and considers it
• Using junior or inexperienced officers monitoring.
important that the findings and learning
to undertake such tasks without • Examines, within current financial
from a number of PIRC investigations are
effective training. constraints, CCTV equipment used
taken account of when considering any
• Overall lack of training of all staff for prisoner observations across its
necessary improvements.
assigned constant monitoring duties. custody estate and, where possible,
• Quality of CCTV monitoring upgrade it to provide enhanced
equipment. monitoring facilities.
• Considers increased training for Police
Custody Security Officers (PCSOs)
undertaking CCTV monitoring.
In a number of investigations
• Ensures that where operational officers
undertaken by the PIRC, are utilised to undertake prisoner
prompt action by monitoring monitoring, they receive necessary
and appropriate training to enhance
officers has undoubtedly their observation skills.
saved the lives of people • Tasks the Custody Division SLWG
to seek opinion and feedback from
who became unwell in police operational Divisions and officers to
custody or who attempted ensure their experience of custody
processes, including monitoring
to self-harm, illustrating duties, are reflected and taken account
the impact that well trained of when determining what changes
and improvements should be made.
and alert officers can make
through effective and early
intervention.
Find out more about our investigations
and complaint handling review outcomes
at pirc.scot
7 • learning point • issue 18 • march 2021Get in touch
If you have any queries about the topics covered in this issue, or
would like to speak to a member of our team, please contact us
at enquiries@pirc.gov.scot.
If you would like to be added to our mailing list please email
communications@pirc.gov.scot.
Hamilton House, Hamilton Business Park, Caird Park, Hamilton ML3 0QA
T: 01698 542 900 E: enquiries@pirc.gov.scot | @PIRCNews | pirc.scot
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