Recommendation 124

This recommendation is assigned to CSNSW.

Recommendation

That Police and Corrective Services should each establish procedures for the conduct of de-briefing sessions following incidents of importance such as deaths, medical emergencies or actual or attempted suicides so that the operation of procedures, the actions of those involved and the application of instructions to specific situations can be discussed and assessed with a view to reducing risks in the future.

Context

The Commissioner considered there would be value in holding debriefing sessions following incidents of importance. Recommendation 124 is directed at ensuring jurisdictions establish procedures for debriefs to assist to avoid similar incidents in future but also to provide support and reassurance for those affected.

Status: Implemented

After action reviews are conducted following deaths, medical emergencies, assaults, fires, use of force, major disruptions, and accessing roofs.
Reviews are chaired by the Governor or officer in charge (OIC) and occur after reports are submitted, focusing on operational matters, identifying good practices, deficiencies, and lessons learned.
Staff involved in incidents must submit detailed incident or witness reports to the Governor or officer in charge as soon as possible before ending their duty.
Following a death, CSNSW investigators review adherence to policies and procedures, requiring additional reports and records as needed to recommend changes.

Detail of implementation

After Action Reviews

CSNSW conducts after action reviews following a:

Death (see part 5 Post incident support in Custodial Operations Policy & Procedures (COPP) section 13.3 Death in custody)

Medical emergencies (see part 3 Post incident in COPP section 13.2 Medical emergencies)

Assaults (see part 10 After action review in COPP section 13.4 Assaults)

Fires (see part 8 in COPP section 13.5 Fires)

Use of force (see part 11 After action review in COPP section 13.7 Use of force)

Major disruptions (see subsection 10.2 After action review in COPP section 13.13 Correctional Centre Command Posts)

Accessing roofs (part 3 Post-incident in COPP section 16.17 Removal of inmates from roofs or other heights)

An after-action review is chaired by the Governor or officer in charge (OIC) for all staff involved in the incident. The review should not occur until after officers have submitted their reports and are no longer required by police or CSNSW investigators to assist with enquiries. A review must follow the order in which events occurred and remain specific to operational matters.

An after-action review provides all employees who were directly or indirectly involved in the incident with the opportunity to discuss and evaluate the incident response (timeliness, effectiveness), identify good practices and responses, identify deficiencies and lessons learned and make recommendations to improve the response and management of any future incidents.

A review provides the Governor or OIC with an opportunity to identify the root causes of any failures so that Local Operating Procedures (LOPs) and correctional centre practices can be improved. The Governor may refer any systemic issues identified to the relevant Director, Custodial Operations. Following this, if required the Director can look at implementing new processes, LOPs and updating policies and procedures.

Following the incident, an incident/ witness report must be submitted to the Governor or OIC by all staff who:

responded to the incident;

last saw the inmate alive;

witnessed an incident or event possibly related to the death (e.g. inmate complained of feeling unwell the previous day); or

were significantly involved in the management of the incident.

An Incident/witness report must contain a detailed account of the officer’s involvement including any actions taken, decisions made or directions given. The report must be submitted as soon as possible and before ceasing duty.

CSNSW Investigation Report

Immediately following a death in CSNSW custody, the correctional centre contacts the NSW Police Local Area Command and the CSNSW Duty Officer. The Duty Officer contacts the Director of the CSNSW Investigations Branch who arranges to deploy investigators. The Investigators attend the centre and commence enquiries immediately. While the Investigations Branch Report is finalised in the short to medium term, the investigation itself commences immediately.

The CSNSW Investigator speaks to staff involved and does a review of the CSNSW’s adherence to its own policy and procedures. This includes a review of the inmate’s management while in custody and the incident response. Investigators may request additional reports or copies of records including CCTV and video footage. These must be provided by the correctional centre as soon as practicable.

Investigators must have a thorough understanding of those policies and procedures as well as an intimate knowledge of the correctional system and correctional centre routine to identify where breaches have or have not occurred and, where appropriate, recommend change.