Corporate report

Summary report to end 2023 – Independent Restraint Review Panel (IRRP)

Published 14 May 2024

Applies to England and Wales

1. Foreword

IRRP was formed on the basis of recommendations set out in Charlie Taylor’s report June 2020.  I was asked whilst Chief Executive Officer of the Youth Justice Board to get the Panel started and after my retirement from the YJB in May 2021, to continue as Chair on an interim basis pending a recruitment process for a Chair. 

Following an open competition, I was appointed by Ministers as the first Independent Chair to IRRP for a 3 year period from 1 Jan 2023.

This report serves to provide a summary of our work during establishing IRRP, the approach we have taken since, how it has developed and our findings in taking the work forward. 

My focus has been on establishing an effective working approach for IRRP which delivers practical improvement for children and by influencing attitudes towards the use of restraint, avoiding use where possible, de-escalation and looking systemically to learn from incidents.  As I set out within, much has changed over the period since IRRP was established.  IRRP is just one part of a complex set of initiatives and circumstances, but we believe that our involvement has contributed positively.  Subject to agreeing a methodology with the Youth Custody Service I plan during 2024 to survey governors, Directors and key users of our findings, to inform our future approach.  We have reviewed and refreshed the Terms of Reference for the work of the Panel with the Youth Custody Service to reflect our experience to date.

Whilst we have looked at numerous restraints, and at the use of pain inducing techniques, our focus has been as much on antecedents to restraint, de-escalation and opportunities to reduce the trauma for children associated with restraint when it is otherwise unavoidable.  By focussing on behaviour management, alternatives to restraint and de-escalation we hope to see force used less and when it is unavoidable, that it is minimised and less traumatic for all.  Our approach has sought to secure ‘buy in’ from prison managers and staff to achieve this and to listen to the children in custody.

From early on, support from Governors and Directors has been constructive.

2. Our approach and how it has developed

In determining our approach, we set the expectation that each IRRP should:

• include the Governing governor or Director.
• be conducted in a manner which encourages learning, participation and ownership, without shying away from calling out concern.
• look beyond the point that restraint/force is used so as to identify opportunities to minimise its need.
• identify good practice.
• listen to the children.
• examine all use of pain inducing techniques but not be limited just to these.

Our Panels started with a core group including, for example, safeguarding, MMPR, HMIP, psychology and other experts.  As interim Chair, I was overwhelmed by offers from across the wider MoJ to join and support IRRP, finding myself having to stand people down rather than the reverse.  As our work has developed, local authority support for the panel’s work has also been secured.  For most panels, a senior local authority representative now attends. 

Covid also impacted on what was safe and so the number of attendees at each IRRP was limited and social distancing rules were carefully followed.    

Over time, we have reduced standing Panel numbers to around five members, always including a medical expert, MMPR expertise and, wherever possible, senior local authority representation.  For each establishment, Governors and Directors have included operational, healthcare and safeguarding staff. Other than when Covid restrictions required this, we have placed no restrictions on establishment numbers attending.

We encourage all present at IRRP to suspend their “day job” affiliations and to challenge natural defensiveness, so that discussion and review is focussed on what might be learned from each review.  Challenging though this can be, particularly for operational staff, this has largely been achieved. Front line operational staff are some of IRRP’s strongest supporters.

After every IRRP, establishments produce action plans in response to what has been discussed at IRRP.  As we have returned to establishments, we have seen changed attitudes towards behaviour management, much more focus on de-escalation, improvements in support for children and strengthened attention on safeguarding.  Operational staff and their managers have embraced the objectives of IRRP, largely treating our independent challenge as a learning opportunity.   

3. Some Establishment Context

IRRP’s work started during Covid when for the children, regimes and movement were severely restricted. Children were living within small groups/bubbles and largely accepted this as the norm.  In turn, staff adjusted to this atypical operating model.  For new staff, they had no experience of what was in place prior to the pandemic.

As Covid restrictions were lifted and mixing increased, we saw tensions between groups that had previously been separated.  More significantly, we noted reticence amongst some staff about how and when to intervene.  This was more obvious amongst newly appointed staff with staff and children reflecting that those appointed during the pandemic were particularly unsettled/unsure.  There was, additionally in the early days of IRRP’s work, doubt amongst staff within the Secure Training Centres about when to intervene and what legally they could do. 

Both Rainsbrook and Oakhill STCs went through difficult periods of operation early on in our work, including in respect of MMPR usage, staff confidence and competence.  Rainsbrook was subsequently decanted.  Under new leadership, Oakhill has over the intervening period addressed this.

The decant of Rainsbrook, the introduction of girls into HMYOI Wetherby and more recently into Oakhill STC all involved significant local change which impacted on local dynamics. 

The holding of 18 year olds beyond the point where they would previously have moved on has also impacted on behaviours, sometimes creating tensions or impacting upon dynamics.  Some 18 year olds in the children’s estate tell us they are frustrated that they can’t get to what they call “proper jail” or that education provision doesn’t fully meet their needs.  We have also heard 18 year olds talk about the immaturity of those they are living with and how this winds them up.  In focus groups where there are older young people, we have sometimes seen age related power hierarchies in play which add to the already complex behaviour management challenges.

4. What children have told us

As an integral part of each IRRP visit we meet with children to listen to their views on restraint.  We do this with a promise of anonymity to encourage their participation.  Our focus groups have varied in size from single children through to around 8 in a group.  We try to ensure that the groups are diverse and representative.  We try hard to ensure that all can give us their views and to feel safe doing so.  To explain our work, we have produced a short film which is being made available to children before our visits.  Children told us that being restrained hurts. 

It has been striking that children generally have limited expectations about their rights/treatment. They often express limited confidence that complaints will be taken seriously or that their views can effect change – although when probing this, often there was acknowledgment that some things have changed through management/staff action on their representations.

Whilst they see most staff as fair, almost everywhere, there has been talk of individual staff who are perceived to be quicker to initiate restraint and then slower to de-escalate.   When asked what makes a good member of staff, they talk about those who treat them as people, who are fair and who do what they say they will do.  Children will often name those they consider to be good staff.

Children accept that restraint may be necessary if there is a fight, or if somebody is at risk of injury.  When they are the victim of an assault, they consider being restrained to be unfair.   

Now, almost universally, the children talk about Barnados in very positive terms.  When we started IRRP, this was not the case. Barnados is a contracted service, providing advocacy support for children in custody.

Children generally see de-briefing reviews after a restraint as a form-filling exercise rather than a meaningful interaction.   Paperwork we saw would suggest this to be the case in some instances.  Revised central guidance intended to broaden the staff group leading each review has been issued by the Youth Custody Service intended to strengthen the quality of de-briefing.  We have also seen some exceptional debriefs which positively changed behaviours and demonstrate the value of meaningful follow up.

5. IRRP findings

We have reviewed a good number of incidents since IRRP was formed.  These have included all those where pain inducing techniques were recorded, a sample of incidents where serious injury warning signs were identified eg. a child being injured or stating that they cannot breathe and some incidents which based on paper records appeared to potentially have lessons which might be learned.  Since IRRP was formed, the Youth Custody Service has revised its policies on the use of force, started to roll out a new syllabus on MMPR and it is now the expectation that force should be the last resort, used at the lowest level and PIT should be by exception and in response to emergencies.

In the majority of cases, we saw good levels of care and professionalism from staff, alongside sometimes extreme bravery in the face of the levels of violence they faced.  In some instances, we also saw children intervene to protect others at risk – both children and staff.

As Covid restrictions were lifted and mixing increased we saw occasional examples of staff reticence to intervene proactively as signs of tensions were emerging, with the result on occasions that what might have been de-escalated earlier, proved more challenging.  As establishments adjusted regimes, we often saw far more staff arriving at incidents than were needed which in turn had the potential to create confusion and escalate behaviours.  This has been actively addressed by establishments.  Staff confidence and competence, particularly amongst newly appointed staff, appears to have grown since, although still sometimes appears to be lacking.

Looking at the antecedents to many incidents, with the benefit of hindsight, there were sometimes opportunities potentially to have defused tensions before these flared up.  We have seen many examples of staff creating space, listening and responding and actively managing behaviour, which doubtless avoided incidents.  Children have told us of occasions when staff helped them deal with frustrations which could otherwise have escalated.

A consistent IRRP observation is that management of incidents is not always clear with the person who should be managing and directing, instead getting involved directly in the restraint or lack of clear incident management.  We have also seen incident management which is well executed throughout.

PIT is used rarely and in most instances, we have observed it to have been used in accordance with guidelines, where it was reasonable to believe there to be a genuine risk of serious injury or to life.  But we still see instances, where PIT is used to gain compliance, where alternative measures could have been tried.  We have also identified a small number of instances where PIT was used but not recorded as having been used.

Whilst there has been improvement, we have noted numerous instances when healthcare staff were either not present during restraints, where if present their advice was not actively sought, or where they could have been more proactive in providing advice.  We have also seen exemplary healthcare provision and focus on the well-being of children whilst being restrained and clear concern for the child after the restraint has ended.

We have tried hard not to assess situations with the benefit of hindsight, but we have seen instances where earlier intervention, better planning or alertness to the child’s perspective may have avoided the need for force or where earlier de-escalation might have been feasible. 

Early on, it was a concern to us that body worn camera footage was often not available.  Whilst there are still times when footage is not clear, cameras have not been switched on or where the system fails, BWC footage is now generally available for all incidents.  For IRRP it has proved invaluable.

We have observed multiple instances where once a restraint had started, the staff involved became task focussed, missing and responding to de-escalating behaviour or seeking to create and test opportunities to reduce or remove holds.  This is being worked on as part of local refresher training and post-incident reviews with staff.

Generally, we see SIWS being acknowledged by and responded to by staff.  There have been concerning exceptions, but these are unusual and have usually been identified by local quality assurance processes before IRRP has picked this up.  A SIWS normally leads to a pause while staff check the well-being of the child.  Often, after this pause, we see staff reapply holds rather than testing the opportunity to de-escalate, for example by not reapplying a head hold at that point. 

Pauses at stages of relocating a child is a focus of our reviews so that lower levels of holding, including potentially releasing holds, can be tested.  This might for example include when the child is at the foot of a stairway or before entering their room.  As our work has developed, we have seen more focus of this but too often, opportunities are not explored.  

We have seen some excellent post-incident de-briefing work done both with children and staff.  But, with children, de-briefing is sometimes cursory.  YCS has revised its guidance on de-briefing to allow a wider group of staff to be involved.

IRRP’s findings are fed back to establishments and more broadly influence guidance – nationally and locally.  Our feedback is used by local managers, MMPR co-ordinators, in staff training and to individual staff.  We also contribute as a member of the Expert Advisory Panel on the Use of Force. We receive a response from the Youth Custody Service to all reports and also share our findings with a range of other parties, including HM Inspector of Prisons as the main regulator of prison services.  In turn, HMIP sometimes report on incidents that we have identified.

Colin Allars
Independent Chair IRRP