In addition to the regular monitoring by the CTAs, police custody is the subject of thematic
research by the Inspectorate VenJ, IGZ and IJZ. The main research question is: How is custody
taken care of by the police and at what places? The preparations for this research were made
in 2013, the inspections were performed in 2014 and the report will be published in 2015.
The CTAs will include the findings and recommendations of the Inspectorate VenJ in their
investigation activities.
Cross-sector
The IGZ in 2014 carried out investigations into incidents. Collaborating with the Inspectorate
VenJ, the IGZ conducted investigations into reports on malpractice by professionals,
and each case of a person dying while in custody was subjected to an investigation. Such
investigations are conducted in accordance with a set procedure and are carried out by an
independent multidisciplinary research committee. In addition, the IGZ further developed its
own risk-oriented supervision, introducing a dashboard featuring a risk assessment, based
on monitoring information from various sources, on the institutional level. Its supervisory
activities in 2014 mainly focused on medication safety, suicide assessment and evaluation,
documentation, and the transfer of information.
In addition, supervision of aspects of patient safety has led to institutions tightening up their
policies. The electronic patient record was introduced in the penitentiary institutions and
special facilities sectors so as to improve the exchange of information.
The attention paid to patient safety in the institutions is monitored through announced and
unannounced inspection visits. A number of penitentiary institutions received unannounced
visits in connection with an incident investigation. This resulted in the IGZ observing highrisk situations as concerns medication safety. In consequence, the IGZ not only requested the
institutions concerned to immediately implement measures to improve the situation, but
also reported the matter to the penitentiary institutions sector board. The board responded
by drawing up an action plan and starting up an audit to assess whether the improvements
in the quality of pharmaceutical care in penitentiary institutions are properly implemented.
The board will report on the matter to IGZ in 2015.
The various supervisory activities carried out in 2014 have resulted in an improvement of the
quality of the health screenings performed in penitentiary institutions. The IGZ, in performing
its supervisory activities, found an improvement in the staff of the detention centres acting
methodically in cases of mental vulnerability.
In addition, IGZ and Inspectorate VenJ established a joint consultation for the handling of
notifications in 2014. During this reports consultation, agreements are made on the carrying
out of incident investigations following incidents. The reports submitted in 2014 covered
a wide range of issues: malpractice by officials (including sexual harassment and abuse of
authority), natural deaths and suicides, medication safety and somatic care. In consequence
to a disciplinary complaint issued by the IGZ, the regional disciplinary committee for the
healthcare sector has clarified the standards for the actions to be taken by medical staff in
case of suicide.
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