3. INCIDENT PREVENTION AND RESPONSE 81 Suicide attempts or instances of self‑harm that result in serious injury also need to be investigated. This is important not only to ensure that there has been no cover up of ill‑treatment, but also to determine why authorities failed to prevent them, including any shortcomings in support services and mental health-care. 82 As the Mandela Rules refer to any “custodial” death, disappearance or serious injury, the death, disappearance or serious injury of any staff member in the course of their duty, or the death, disappearance or serious injury of any prison visitor or service provider that takes place in the custodial environment, should also be investigated. 83 The requirement to report allegations of torture or other ill‑treatment is reiterated in Rule 57(3), which is dealt with in Chapter 1, paragraphs 161–162 and in Rule 71(2), which is dealt with in Chapter 3, paragraphs 84–101 of this guidance document. PROMISING PRACTICE: INVESTIGATING DEATHS OF THOSE RECENTLY RELEASED FROM PRISON [3.6] The Prisons and Probation Ombudsperson (PPO) in the United Kingdom investigates deaths in custody due to any cause, including any apparent suicides and natural causes. As part of its role, the Ombudsperson has discretionary powers to investigate the death of someone who has recently been released from custody if he/she feels there are particular lessons to be learned from the treatment of that individual. The PPO has noted that although deaths following release from custody “represent only a small proportion of our investigations, there are some specific risks associated with prisoners who have recently been released from prison. Research suggests that, relative to the general population, people discharged from prison are 40 times more likely to die in the first week after discharge and over 90% of those deaths are drug-related”.208 3 The PPO gathers evidence about what was happening to the prisoner or former prisoner before her or his death. This includes examining all the relevant records and policies, together with interviews with relevant staff and prisoners or residents, if required. The PPO also works with health authorities to commission an independent clinical review of the health-care provided to the person before their death while they were in custody. The PPO appoints a family liaison officer to support the bereaved family through the investigation process and informs them about the progress of the investigation. He or she will also offer them the opportunity to ask any questions and raise any concerns so these can be considered as part of the investigation. 208 Initiating an investigation 84 As Rule 71 makes clear, all deaths, disappearances, serious injuries or allegations of torture and other ill‑treatment need to be reported “without delay” and notwithstanding the initiation of an internal investigation. Rule 57(3) states that allegations of torture or other ill‑treatment shall be “dealt with immediately”. 85 UNCAT has clarified that the meaning of “prompt” for the initiation of an investigation by the prison director should mean “within hours, or at the most, within days” and that a relatively short delay can constitute a violation of Article 12 of the CAT.209 86 An internal inquiry can be carried out in parallel to the external investigation, provided it does not interfere with the external investigation. The fact that there may be a criminal investigation into a particular incident does not preclude the need for a prison to conduct its own investigation into that incident. In no circumstances should there be a requirement for an internal inquiry to be completed before an external investigation can be initiated. 87 In order for prison directors to be able to make reports without delay, they must be promptly informed by their staff members following any incident. If the prison director is not available, then staff should report the incident to the deputy or senior prison staff member authorized to represent her/her. This staff member should then make the report. 208. Nicola Singleton, Elizabeth Pendry, Colin Taylor, Michael Farrell, and John Marsden, Findings 187: Drug-related mortality among newly released offenders, Home Office UK, 2003 at webarchive.nationalarchives.gov.uk/20110218135832/http:/rds.homeoffice.gov.uk/rds/pdfs2/r187.pdf. 209. Report of the Special Rapporteur on torture, A/68/295, op. cit. note 57, para. 63; see also: UN CAT, Blanco Abad v. Spain, Comm. No. 59/1996, CAT/C/20/D/59/1996, 14 May 1998, para. 8.5 at www.univie.ac.at/bimtor/dateien/cat_1996_abad_vs_spain.pdf. See also: Manfred Nowak, UN Covenant on Civil and Political Rights: CCPR Commentary, 2nd edition, Kehl am Rhein, N. P. Engel Verlag, 2005, p. 434. Guidance document on the Nelson Mandela Rules 93