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Women Offender Programs and Issues

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Report on announced inspection in Canada by HM Chief Inspector of Prisons for England and Wales:
Grand Valley Institution for Women

Section 3: Duty of care

Bullying behaviour ('muscling')
 
Expected outcomes:
Everyone feels safe from bullying (muscling) and victimization (which includes verbal and racial abuse, theft, threats of violence and assault). Active and fair systems to prevent and respond to bullying behaviour are known to staff, inmates and visitors, and inform all aspects of the regime.


 
3.1 There was no formal anti-muscling policy. Many women said they had been victimized and that they felt unsafe, mainly on their houses where there was no supervision. A difficult balance between direct supervision and supporting the women's empowerment had to be maintained. Many women reported incidents to staff but the nature and extent of muscling was not monitored thoroughly enough.


3.2 In the CSC, bullying behaviour was usually referred to as muscling. We use this term in the report to refer to intimidation, victimization and harassment by other inmates, including verbal and racial abuse and threats and psychological intimidation. Such behaviour can also manifest itself in exclusion, isolation, being singled out and treated differently by other women inmates.

3.3 In our survey, 47% of women, significantly higher than the English comparator of 32%, said they had felt unsafe at GVIW. Of these, 31% had felt unsafe on their houses, 13% at the gym and 13% in leisure areas. We detected a sense of acceptance of the inevitability of muscling among women and staff. Forty-three per cent of women, against the English comparator of 24%, said they had been victimized (insulted or assaulted) by another inmate and 37%, much higher than the comparator of 14%, said they had reported victimisation.

3.4 There was no clear formal anti-muscling policy or strategy. Most CSC behaviour and conduct policies and training related to harassment by staff. This was supported by an anti-harassment coordinator and four anti-harassment officers. Inmate-on-inmate muscling had a lower profile and there was little publicity about the potential consequences of muscling on victims. The inmate handbook paid little attention to muscling, although it was a significant issue.

3.5 The anti-harassment officer completed a quick analysis of incidents between January 2004 and July 2005 and estimated that 17% of offences had been resolved informally and 49% of formal disciplinary cases were potentially related to muscling.

3.6 A number of women told us about their experience of muscling, including a serious physical assault. We reviewed a large sample of observation reports of incidents of assaults and fights between inmates, and looked at incident reports completed by the security information officer. Most incidents involved assaults that took place on the unsupervised houses. Other than to count women, officers were rarely on the houses long enough to detect problems. Each house was required to hold a monthly house meeting but staff did not routinely attend.

3.7 Women could contact the main control post from the house by telephone and officers were required to respond whenever the receiver was lifted, even if no one spoke. In some incidents, women had been afraid to be seen using this line. Concerns had been raised at one inmate committee about the length of time taken by officers to respond to calls from the houses. Other incidents had occurred during leisure and in the gym washroom.

3.8 The open environment was difficult to supervise. We heard anecdotal evidence that some women had deliberately behaved in a way that would lead to them being admitted to segregation as a way of finding sanctuary.

3.9 Many incidents were not single impulsive acts of aggression but related to problematic personal relationships. Some were associated with power struggles manifested through arguments over food and the catering arrangements. Problems associated with debt, race and the nature of offences were also evident. We were concerned that women new to the establishment could be particularly vulnerable to muscling as there was no structured support for them before they moved to live in unstaffed houses. There was insufficient peer support.

3.10 No internal survey of women's experience of muscling had been done to capture this information and devise a strategy. The information that was known was not being monitored and the exit survey organized by psychology did not specifically ask about views and experiences of muscling.

3.11 Staff demonstrated a good awareness of muscling. A risk assessment officer identified potential 'predators and non-compatibles' before they arrived at the institution. Observation reports, which included any unexplained injuries observed by staff, were highlighted at a morning staff meeting and investigated by the security information officer. Particular women were often identified as suspected bullies but the nature of the relationships and the environment made it difficult to gather evidence as some women were worried about reprisals. Requests for house moves were monitored by an assistant team leader. Staff and inmates did not routinely discuss muscling or feelings of safety at the inmate committee.

3.12 Women involved in muscling incidents, sometimes inappropriately the alleged victim, were moved to a different house. Many incidents were responded to informally, with staff working with the inmate chair in some cases. Some women were removed to segregation. There were no interventions to challenge bullies directly or to support victims. We were told that referrals could be made for participation in alternatives to violence or anger management.


  Action points
 
3.13 All incidents of muscling should be recorded and monitored to develop a profile of this behaviour across the institution.

3.14 Investigations into incidents of muscling should show evidence of action taken, and incidents should be followed up to support victims and challenge bullies about their behaviour.

3.15 There should be an annual confidential survey of women's experiences and perceptions of muscling, to inform the strategy.



Self-harm and suicide
 
Expected outcomes:
Inmates at risk of self-harm or suicide are identified at an early stage, and a care and support plan is drawn up, implemented and monitored. Inmates who have been identified as vulnerable should be encouraged to participate in all purposeful activity. All staff are aware of and alert to vulnerability issues, are appropriately trained and have access to proper equipment and support.


 
3.16 Levels of self-harm were low. Overall, there was a very caring approach for those at risk. Care was multidisciplinary, led by psychology and was particularly good on the SLE. But initial responses were too reliant on the use of segregation and protective clothing. There was no coordinated safer custody strategy to bring together all those involved.


3.17 Levels of self-harm were low. T he relaxed and open environment was a significant contributory factor to this, and helped women to deal with stressful events.

3.18 There was no single register documenting incidents but some information about those at risk was available through a system of 'active alerts, flags and needs' on the computer-based offender management system (OMS). One report recorded that 30 women currently at GVIW had disclosed some history of self-harm, seven had self-injured at GVIW since January 2004 and four of these had harmed themselves on several occasions.

3.19 One woman had killed herself in 2003 and some, but not all, of the subsequent recommendations from the coroner's investigation had been implemented. These included suicide awareness workshops for women, several of which had taken place during 2004 with women co-facilitating alongside staff and suicide prevention trainers. Recommendations that had not been implemented included 24-hour healthcare and the provision of an on-site defibrillator.

3.20 There had been few very serious or near-fatal self-harm incidents. A report by the warden on the attempted suicide of one woman analysed the action taken and considered what, if anything, could be learned from how staff had responded to the incident.

3.21 The psychology team took the lead in the care of those at risk of self-harm, and the acting senior psychologist was the suicide prevention coordinator. Three psychologists were based in the healthcare department. Much of their time was taken up with their responsibilities on the SLE and secure unit and this was reflected in the minutes of their weekly departmental meeting. There were insufficient resources to respond adequately to other needs within the general population.

3.22 All new receptions were seen within 24 hours for an intake assessment that considered the risk of self-harm. In some cases, previous information about self-harm history from the community-based parole officer was available through the OMS. Any woman who had self-injured was referred to psychology who, in consultation with the team leader responsible for her unit, decided on a care plan. The warden or deputy warden approved the plan and informed the case management team.

3.23 The usual response to an incident of self-harm was to locate the woman in the segregation unit. A psychologist decided the frequency of the watch and whether she would be observed by a closed-circuit television camera. Six of the seven women who had self-harmed at GVIW had been placed in protective gowns in cells in the segregation unit where there were obvious ligature points. No specific record was kept of the use of security or protective clothing. One woman described how this had made her feel worse.

3.24 One woman was being held in these conditions during the inspection. No thorough assessment had been made of her previous history as the relevant reports were written in French and had not been translated. These had identified her as being at potential risk of self-harm.

3.25 A good range of resources was available to help the small number of women at risk of self-harm. Behavioural counsellors provided regular support to women in the SLE and secure unit, and to those moved to the general population. Staff on the SLE also provided 24-hour support and several primary workers had been trained in dialectical behaviour therapy. Multidisciplinary team meetings were held weekly to review all new admissions and other on-going cases where there were concerns. Additional weekly case meetings were held on the SLE and secure unit. A strong group of volunteers contributed to the support of women in the institution and some, such as the Elizabeth Fry Society, helped women after release. There was, however, insufficient sexual abuse counselling (see section on programs) and the limited direct contact with inmates' families or significant others was usually made by the chaplain following a crisis. Families were not included as part of the correctional plan.

3.26 Women provided a lot of mutual support but there was little formal peer support (see section on reception). In our survey, 51% of women, against an English comparator of 72%, said they were able to speak to a member of the peer support team at any time if they wanted to.

3.27 Standing Order 843 Prevention of Suicide and Self-Inflicted Injuries (issued 1/04/05 and reviewed annually) provided guidance for staff on procedures. Incidents of self-harm were recorded in observation reports, discussed at a morning meeting and referred to psychology for follow up. Although levels of self-harm were low, the different areas that contribute to safer custody, such as links with muscling, the pressures of the early days in custody, alternative strategies to segregation and the role of peer support, were not brought together under an overall strategy.

3.28 From the training records provided, it appeared that all staff who have direct contact with offenders had received some training as part of the correctional training program, the new employee orientation program or from modules on the women-centred training or dialectical behaviour therapy course. Training for some had been some years previously and there was no refresher training. It was planned that this would be delivered through computer-based training by November 2005.

3.29 Staff carried a protective mask, gloves and ligature cutters to respond to emergencies.


  Action points
 
3.30 The records of incidents of self-harm should be improved to identify any emerging trends, and record use of segregation, protective clothing and other interventions.

3.31 The psychology-led behaviourist approach to women at risk of self-harm should be developed to involve primary workers in managing cases and a formal support scheme which should include overnight facilities where peer supporters can help women at risk.

3.32 All recommendations from the coroner's investigation into the self-inflicted death in custody should be implemented.

3.33 The resources available to the psychology department should be reviewed to ensure that it meets the needs of the entire population.

3.34 Systems should be put in place to ensure appropriate care for Francophone women at risk of self-harm and that all relevant reports are available in English before a transfer to GVIW.

3.35 Families and other significant people should be contacted and involved when a woman is at risk of self-harm, where this is appropriate and with the woman's agreement.

3.36 A safer custody forum should be developed to consider the relationship between the policy areas that contribute to feelings of safety. These include muscling, early days of custody, peer support and alternatives to segregation.


Race relations and diversity
 
Expected outcomes:
All inmates experience equality of opportunity in all aspects of prison life, are treated equally and are safe. Diversity is embraced, valued, promoted and respected.

 
3.37 Race relations were not an overt problem but there was no monitoring of outcomes for women from different racial and cultural groups. Aboriginal women were over-represented in the segregation and secure units. Aboriginal and black women's groups promoted their interests, but there was little wider promotion of cultural diversity issues. Black and Aboriginal women reported a cultural gap between themselves and the majority Caucasian staff.


3.38 Sixty-three per cent of women were Caucasian, 22% were black, 11% were Aboriginal and 3% were Asiatic. Black and Aboriginal women had support groups facilitated by a paid liaison officer. The native sisterhood group, assisted by a liaison officer and an elder, provided access to spiritual activities as well as cultural, linguistic and reintegration help and information. The black women were supported by a worker from the Black Inmates and Friends Assembly (BIFA). She was contracted for three visits a month but attended more frequently. Both groups advocated well for women and had achieved better provision of toiletries and cosmetics for black women and of sweat ceremonies for Aboriginal women. Neither the elder or black inmates' liaison officer had keys to allow them independent access through the prison. There had been important celebrations of emancipation day and treaty day in recent weeks. Although these events had been designed to include the whole population, they had been perceived by most women as special days for minorities.

3.39

We met a group of Afro-Canadian women, who said that:

•  they felt less important and had less consideration than Caucasian or Aboriginal women, not in access to resources or services but in less respectful treatment by other inmates and staff

• racist language used against them was treated as less serious than other discriminatory behaviour

• the majority of Caucasian staff did not understand cultural aspects of black inmates' communication and behaviour, which meant that they had to change to fit the cultural norms of staff

• the support of the BIFA group was important in allowing them to have a collective voice to negotiate services and to help organize special cultural events  

3.40 Although there was some monitoring at national level there was no routine monitoring in the institution of access to facilities, services or outcomes by race or cultural identity to identify trends and reassure women of equity of provision.

3.41 A review undertaken during the inspection revealed that minority groups were represented in all residential houses apart from house 12, which was a minimum-security house for which there was a significant waiting list. The 11% of Aboriginal women were over-represented in the secure unit (33%) and accounted for 16% of minor and 22% of serious charges.

3.42 There was no separate system to report or manage cultural or racial complaints. There had been two significant racist incidents, one of which had been generated by an allegation that a Caucasian woman had said in the hearing of many others that 'all niggers should die'. This had been dealt with by discussions involving the inmate committee, BIFA and the elder. Representatives were sent to each residential house to warn about the consequences of such behaviour. Although the alleged perpetrator was individually advised about her conduct, many black women felt the issue had not been taken sufficiently seriously. In another incident, black women had protested by staging a sit-down protest. There was no single person responsible for promoting positive race relations or handling complaints about racist incidents.

3.43 A cultural awareness day had been held for all women in 2005 as well as events organized by the sisterhood and BIFA. There was no attention to race relations and cultural diversity as part of the reception or induction processes. The foundation training for staff covered race and diversity but there was no ongoing education and promotion of a commitment to positive race relations and cultural diversity.


  Action points
 
3.44 A system for staff and inmates to report perceived racist incidents should be introduced with complaints about racism identified and investigated separately.

3.45 There should be ongoing promotion of race equality and diversity for staff and inmates.

3.46 The support group liaison staff and elder should be issued with keys to allow them access through the prison.

Foreign national inmates
 
Expected outcomes:
Foreign national inmates should have the same access to all prison facilities as other inmates. All prisons should be aware of the specific needs that foreign national inmates have and implement a distinct strategy, which aims to represent their views and offer peer support.


 
3.47 There was a small number of foreign national women whose immigration status was well managed. Access to information and support for women about their individual cases was good.


3.48 There were eight foreign national women: three from Jamaica, two from America and one each from Barbados, India and the United Kingdom. These women were identified during the reception process.

3.49 The administrative systems to address issues of immigration, deportation or repatriation were efficient and effective. The chief of sentence management had a good knowledge of the women's sentence and personal circumstances. There were good links with the local immigration office, which provided information about deportation status early enough for any appeals to be heard during their sentence. Immigration interviews were routinely held at the prison. One woman was appealing against deportation and was being well supported by administrative staff, including helping her contact external pressure groups and get legal advice. Foreign national women were confident that they understood their immigration status and knew whom to speak to about any related issues.

3.50 No woman had been detained in the prison on an immigration warrant beyond her sentence, although a woman could stay temporarily to make suitable travel arrangements.

3.51 All the foreign national women spoke English. We were told that where possible, those who did not or who had poor English were located with another woman able to speak their language and support them. External translators had been used for complex correctional plan and immigration interviews. The prison also maintained a list of staff and inmates with language skills that could be used.

3.52 Foreign national women received all the correctional planning, programs and privileges available to Canadian women, including access to healthcare.

3.53 None of the foreign national women believed a support group was necessary as they were satisfied with the help they got from primary workers and the chief of sentence management. Foreign national women could receive incoming telephone calls at times arranged at their convenience to help maintain contact with their families.


Family and friends
 
Expected outcomes:
Inmates are encouraged to maintain contact with family and friends through regular access to mail, telephones and visits.


 
3.54 Facilities for visits were reasonably good but restrictions placed on visitors indicated by the drug dog were disproportionate. Family days were popular and the excellent private family visiting facility was well used. No financial assistance was available to visitors who needed it. The security procedures for vetting visitors and telephone contact were restrictive and caused unnecessary delay.




  Mail
 
3.55 There was no random censorship of mail, although all mail was opened to check for unauthorized items. Legally privileged mail was logged, signed for by women and opened in front of staff. There was no limit to the number of letters women could send or receive. Stamps, envelopes and paper could be bought through the canteen or brought in through visits.

3.56 Mail was collected and distributed to the women's individual private post-boxes daily by the visits and communications officer. In our survey, 34% of women said they had problems sending or receiving mail.

  Telephones
 
3.57 Access to telephones was good with a telephone on each house. The system to check telephone numbers, similar to that for checking visitors, caused delays in women being able to contact family and friends. In our survey, 37% of women, significantly higher than the English comparator of 27%, said they had experienced problems in accessing the telephones. Women without telephone credit needing to make an urgent call could request to use an administrative telephone and have the cost of the call billed to their account. All such calls were recorded and there was evidence that this service was being offered.


  Visits
 
3.58 In our survey, 43% of women, against an English comparator of 34% and 22% at Nova, said they had been given information about visits on the day of their arrival.

3.59 All visitors had to be security cleared before their names could be added to a list of approved visitors. Women were given the relevant forms to complete during reception and, if necessary, could ask the inmate orientation team for advice about it the same day. The form was sent to the nominated visitor, who filled in their personal details before returning it for processing by the risk assessment officer. Delays frequently occurred if there were minor errors in the form or if the risk assessment officer was absent. Nominated visitors were checked with the Canadian Police Information Centre. Unlike at Nova, where staff focused on offences involving drug trafficking and family violence, applications for GVIW were likely to be refused if proposed visitors had a current, lengthy or recent criminal history. All completed applications were then brought to the fortnightly institutional review board for discussion and approval.

3.60 The whole process could rarely be completed in less than three weeks and on average took over a month. Women were understandably frustrated by the time it took to get security clearance for their visitors. There was some flexibility in special circumstances to allow visitors who had not been fully security cleared to visit but only closed visits were allowed. The institution did not regularly monitor the number of closed visits imposed but we found that there had been 33 in the previous 10 months.

3.61 Statistics of the number of visitor applications denied were unavailable but our examination of a sample of applications and the minutes of the institutional review board showed that this did sometimes happen. The most frequent reason for refusal was 'lengthy/recent criminal history' but the nature of the offence was not specified. In our survey, only 47% of women, fewer than Nova although distance was not such an issue, and significantly lower than the English comparator of 71%, said they were given the opportunity to have the number of visits to which they were entitled.

3.62 Approved visitors were sent a package of information detailing rules about visits, including searching procedures, and giving a drug tip line telephone number. Visitors could visit at any time without prior appointment unless they were visiting a woman in the secure unit or the segregation unit.

3.63 Women could have up to four visitors on a single visit. Visits were scheduled on two evenings during the week, and in morning and afternoon sessions at weekends. There was no limit to the visits that women could have within that schedule. Women in maximum security could have visits on one evening a week and on Sunday mornings. These had to be booked 48 hours in advance and the women were risk assessed to determine whether restraint equipment could be removed during the visit.

3.64 There was no family support work to actively encourage or facilitate family contact, and correctional plans did not cover the need to maintain family ties. No financial assistance was made available for visitors with significant travelling expenses. The chaplaincy offered occasional help for those travelling in the greater Toronto area.

3.65 Women were given a frisk-search out of sight of their visitors before entering the visits area. Visitors were screened for drugs using an ion scanner. Anyone with a positive reading could be turned away or offered a closed visit, or the police could be called. A drug dog was also used and we received many complaints about the dog's behaviour (see section on substance use). If the dog indicated, a threat risk assessment was carried out to determine what type of visit should be offered. If the risk was deemed low, designated seating was a theoretical option. In reality, there were too few staff to supervise and a closed visit was usually offered. All closed visits were regularly reviewed at the institutional review boards but aggregated data was not collected and there was no overall monitoring of them.

3.66 Facilities for visits were good. The area was comfortable, refreshments were available from a couple of vending machines, a few toys in reasonable condition were provided and the inmate committee occasionally organized activities for the children. An attractive patio area with seats and tables could also be used except by maximum-security women.

3.67 A separate house in the main grounds was used as a private family visiting facility where women could spend up to 72 hours with partners, children, parents, siblings or grandparents. It had been used 73 times in the previous six months and was an excellent resource to support the promotion of family ties. Women could also apply to use the house on their own for some personal quiet time for up to 48 hours.

3.68 Family days were organized twice a year, in the summer and at Christmas. These were well received, with 113 visitors attending the last event.


  Action points
 
3.69 The process of security checks on telephone contacts and visitors should be revised and speeded up especially for those visiting minimum-security women.

3.70 Financial assistance should be provided to visitors who are not able to visit due to financial hardship.

3.71 The importance of maintaining family contact should be recognized in correctional plans.

3.72 Detailed data on the imposition of closed visits should be collected and routinely aggregated to ensure that the system is operating correctly.

3.73 Visitors should not be offered restricted visits solely on a drug dog indication.

3.74 Women should not be kept in restraints during a visit.


Requests and complaints
 
Expected outcomes:
Effective request and complaint procedures are in place, are easy to access, easy to use and provide timely responses. Inmates feel safe from repercussions when using these procedures and are aware of an appeal procedure.


 
3.75 Request and complaint forms were not easily accessible. There was an over-reliance on formal requests and not all departments kept an audit trail. The timescales for investigating complaints and reporting back were too long. There was no quality assurance and no analysis of patterns or trends concerning complaints.


3.76 Details of how to make complaints and grievances were set out in the inmate handbook and on notices outside the office of the inmate committee. No comparable information about how to make a request was available, although this was covered by the inmate orientation team on a new arrival's first day.

3.77 The chief of administration services acted as the complaints/grievance coordinator and was scheduled to deliver a session about complaints to new arrivals on Thursdays, although this did not always happen (see section on orientation). In our survey, 42% of women, significantly higher than the English comparator of 30%, said they had been given information about how to make an appeal/file a grievance.

3.78 Women had to get request and complaint and grievance forms from the inmate committee office, which meant they were inaccessible when the office was unoccupied and locked. Women in the segregation and secure units had to ask staff for the forms. In our survey, only 66% of women, against an English comparator of 82%, said it was easy/very easy to get a complaint form, and 79%, compared with 87%, said it was easy to get a request form.

3.79 The wide range of different request forms suggested overuse of a formal system of requests. Requests went through the normal internal mail system and were distributed to the appropriate departments. The majority of departments logged the request for action on the central computer system so that it became part of a 'brought forward' file that could be tracked. Two departments, admissions and discharges and stores, did not log or track requests.

3.80 Women could write in confidence to the warden and place the complaint in a dedicated post-box. Women in the segregation and secure units used the usual post-box but only the warden and head of administrative service had keys to it.

3.81 Complaints were also dealt with through the normal mail system. Women used the general post-box and the admissions and discharge officer brought the complaints daily to the grievance coordinator. This included complaints about staff. The lack of confidentiality was inappropriate.

3.82 All complaints and grievances were processed through the chief of administration services, who collected complaints from a post-box to which he had the only key. Anyone wishing to speak to someone from outside the institution about their complaint was usually referred to the Correctional Investigator and the Elizabeth Fry Society. Both had freephone numbers that were given to all women.

3.83 The chief of administration services designated complaints and grievances as routine or high priority, with the timescale for investigation and reporting back set at 25 and 15 days respectively. These timescales were too long. If a complainant was not satisfied with the response, the complaint became a first level grievance stage and was referred to the warden. Appeals against first level grievances became second level grievances, which were referred to regional headquarters. Third level grievances were dealt with at national headquarters.

3.84 The chief of administration services tracked complaints through a status report that was brought to the morning briefings. There was no aggregated monitoring or routine analysis of complaints to identify trends. Regional headquarters and national headquarters carried out an annual audit and occasionally asked for information on specific areas such as timeliness or complaints about staff harassment. We had some doubts about the audit's validity and robustness since in some instances it relied on the institution selecting its own sample.

3.85 Twenty-three complaints had been submitted between 1 April and 17 August 2005. Complaints about lost or damaged personal effects were dealt with as claims against the Crown through a different process and submitted via the warden. We asked for some analysis of the complaints made during the previous 12 months, which showed that the largest proportions were about healthcare (21%) and staff conduct (33%). Such analysis was not undertaken routinely.

3.86 There was no quality assurance system to ensure consistency in responses, appropriateness and politeness of replies. We examined a sample of complaints and first level grievances and found the quality of responses varied considerably. Apart from in responses from psychology, apologies were rare and there had been no investigation into the five complaints that had been withdrawn. In our survey, 32% of women, significantly higher than the English comparator of 12%, said they had been made or encouraged to withdraw a complaint. We found no evidence of this and discovered from talking to some of the women involved that they had in fact chosen to withdraw their complaint because they had been unhappy with the outcome. It was important that when this happened it was clearly recorded.

3.87 Allegations of victimisation and/or harassment by staff were treated as a first level grievance, designated high priority (by-passing the complaints stage) and referred immediately to the warden. She took a robust line and we saw examples where some were referred to regional /national headquarters for investigation in case local preliminary investigation would be seen as compromising objective inquiry.


  Action points
 
3.88 The inmate handbook should outline the system for requests, and information should be displayed on notice boards.

3.89 In addition to the supply retained by the inmate committee, request and complaint forms should be made freely available.

3.90 Requests to all departments should be logged so that there is an audit trail.

3.91 Primary workers should take verbal requests daily to reduce the overuse of the formal system.

3.92 All complaints should be responded to within seven days, either with a resolution or interim reply explaining what was being done.

3.93 Complaints should be quality assured to ensure that responses are timely, respectful, legible, and address the issues raised.

3.94 There should be regular analysis of complaints to identify patterns and trends.

3.95 A supply of request and complaint forms should be freely available to women in the segregation unit.