PRG - 11-10-2013 INDECOM Completes Investigation into the death of Vanessa Wint at HARC.pdf

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Contact Information

Kahmile A. Reid - Senior Public Relations Officer

The Independent Commission of Investigations (INDECOM)

1 A Dumfries Road, Kingston 10

General: 1.876.968.8875 Ext. 282. D: 1.876.908.4689. M: 1.876.564.6765. F: 1.876.960.4767. E:[email protected]

FOR IMMEDIATE RELEASE

TELE: 1.876.968.8875 THE INDEPENDENT COMMISSION OF INVESTIGATIONS

1 A Dumfries Road

Kingston 10

Jamaica

REPORT ON DEATH OF VANESSA WINT AT HARC COMPLETE

October 14, 2013 - The Independent Commission of Investigations (INDECOM) wishes to advise

the public that the Commissions Report on the investigation into the death of Vanessa Wint is now

complete and the matter referred for a Coroners Inquest.

The incident occurred in November 2012 at the Horizon Adult Remand Centre (HARC).

The terms of reference established for this investigation was to determine: how Vanessa Wint lost

her life; whether or not her right to life was breached by any agent of the state; whether or not any

person or authority may be liable for her death; the necessary systemic improvements that could

prevent reoccurrence.

The investigation into this matter found that Vanessa, who was a ward of the state, succeeded in

committing suicide on Wednesday, November 21, 2012 after numerous attempts.

The Commission recognized, very early in the investigation, that there was a significant absence of

standard operating procedures and training to deal with the risk of suicide. This we believe is

inexcusable because it is widely known that there is a greater risk of suicide when a person is

incarcerated and the state has a responsibility to preserve the life of these persons.

Further, the Commission discovered, also very early in the investigation, that there was no particulartraining of the staff as it relates to the handling of juveniles. Ergo, the Commission decided to not

just consider the narrow issue ofVanessas death, but also the broader issues regarding reducing the

risk of suicides in the future.

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Having referred the matter to the Coroner, the Commission will not make public, any of the

findings on possible individual culpability of any correctional officer so as to not prejudice the

proceedings in the Coroners Court. The Coroner will have the full benefit of the Commissions

investigation in that regard.

FINDINGS

Among the findings the Commission observed, with great concern, a failure of the Department to

promulgate standard operating procedures to prevent suicides and to train staff in preventing

suicides.

The housing of juvenile wards at the HARC, a facility shared by adults (males), denied staff the

option of placing Vanessa in the Medical Centre, which would have been more appropriate given

her psychological state.

The Commission found that the State failed in its duty to safeguard the life of Vanessa Wint as they

failed to take all reasonable steps to cause her to be closely monitored in a manner that wouldfacilitate quick response should she make another attempt to harm herself or take her own life; this

considering the known fact that she had made numerous attempts.

The Commission also found that the State failed in its duty to establish and maintain standard

operating procedures to effectively detect and manage the risk of an inmate or wards suicide.

The Commission also found that Vanessas remand was irregular and possibly unlawful due to the

fact that the committal order was not endorsed by the Minister as required by the law.

To that end, the Commission recommended that the matter be referred to the Solicitor General for

the consideration of compensating the estate of Vanessa Wint for the breach of her right to life andfor negligence.

Staff training was also an area of concern for the Commission as there was no specific training of

the staff working on the female block in child psychology or in the management of juvenile inmates.

Consultation on the part of our investigators with local experts informed that dealing with juveniles

requires special training and dealing with special needs require specific knowledge.

Liability on the part of the State for Vanessas death is evident in case law (Reeves v

Commissioner of Police for the Metropolis) which dictates that it is the custodians duty to take

reasonable care to guard against suicides although suicide was a voluntary and deliberate act. This

duty arises from the level of control the gaoler exercises over the prisoner and the additional special

danger of people in custody taking their own lives.


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The Commission recommended that the Department of Corrections, by the 2nd of December 2013,

issue Standard Operational Procedures and develop training for an effective regime to detect and

manage the risk of suicide by inmates and wards to include:

1. Establishing a regime that effectively categorises the risk and provides for different degreesof attention and treatment depending on the risk. An inmate under suicide watch beingthose at the highest risk of suicide.

2. Inmates are to be frequently assessed, especially if they are, or have been, previously on asuicide watch to determine their risk of self-harm. For a ward who has been on suicide

watch previously, whenever there is extreme uncontrolled behaviour, they should be

immediately referred to a trained counsellor or psychiatrist.

3. Improving staff training on the detection of the risk factors associated with suicide and thesigns of psychiatric and mental issues.

4. Emphasising suicide prevention and providing the documented procedure and simulationtraining to make staff ready to respond to arrest a suicide in less than two (2) minutes of

report whilst, in cases of inmates or wards under suicide watch, for immediate response.5. Providing that persons who are on suicide watch be placed, under one-on-one supervision in

an approved facility, such as a psychiatric hospital or medical centre.

6. That persons who are determined to present some risk of suicide, be promptly seen by thetreating psychologist or psychiatrist who must document the kind of treatment that such an

inmate should be placed on. This entry should not divulge confidential medical information

such as diagnosis, or even medication to be given, but would clearly specify signs to look for,

types of utensils to be used by the inmate, how isolation is to be used, how their items are to

be removed if the need arises, and specify for how long this watch should continue.

7. Persons who are believed to be suicidal to be checked on every 15 minutes and persons whoare on suicide watch to be under constant supervision.

8. Inmates in need of treatment should receive it, without delay, taking into considerationsecurity measures and be kept under supervision.

9. A shift supervisor must clearly document any issues that might indicate a risk of suicide andpoint these out to the supervisor of the next shift.

10.All staff should be trained in basic first aid including CPR.11.Correctional Officers who supervise juveniles need to be cognizant of, and trained in, areas

such as child psychology in its basic form, the Child Care and Protection Actand the stages of

development of teenagers so that they can better understand and manage juveniles in their

custody.

The Commission considered and consulted local experts in the field of psychology and psychiatry

and is particularly grateful for the assistance of consultant psychiatrist with the University Hospital

of the West Indies. They assisted investigators in gaining a greater understanding the issues at play in


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this matter. Their assistance further assisted in focusing their necessary research into standards of

care (both locally and internationally) related to self harm and suicide prevention.

The Commission is also grateful for the kind cooperation of the Commissioner of Corrections and

his staff.

The Commission notes that in its report to Parliament: Safeguarding the Right to Life: Issues from

Investigations of Jamaicas Security Forces it pointed out the failure of the JCF to establish measures to

detect and manage the risk of suicide of prisoners in their custody. This investigation revealed

similar egregious failings in the Department of Corrections. It is hoped that with these

recommendations the required improvements will be made with promptitude.

The Commission also notes the genuine dedication of the staff asked to care for Vanessa and her

fellow wards but sadly, they lacked the required training and were hampered by unfavourable

conditions.

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PRG - 11-10-2013 INDECOM Completes Investigation into the death of Vanessa Wint at HARC.pdf

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