Investigations into Zonderwater and Pollsmoor Incidents: Department report

CORRECTIONAL SERVICES PORTFOLIO COMMITTEE
9 June 2006
INVESTIGATIONS INTO ZONDERWATER AND POLLSMOOR INCIDENTS: DEPARTMENT REPORT

Chairperson: Mr D Bloem (ANC)

Documents handed out:
Department of Correctional Services Presentation on the Pollsmoor incident
Department of Correctional Services Presentation on the Zonderwater Investigation

SUMMARY
The Department of Correctional Services admitted that negligence had led to the fire at Pollsmoor prison and that poor leadership had contributed to the hostage situation at Zonderwater prison. Members were concerned that the Department often reported on investigations being underway and suspensions having taken place, yet seldom reported on conclusions of investigations or actions that had been taken against guilty parties. Concerns were also raised about it always appearing to be reacting to situations that could have been prevented. Members felt that many questions relating to the Pollsmoor incident in particular still remained unanswered and warranted further investigation.

MINUTES
The Deputy Minister of Correctional Services, Ms Loretta Jacobus, explained that Minister Balfour was unable to attend the meeting as he had a prior engagement. She was pleased to inform the Committee that the Department of Correctional Services (DCS) had sent a high level delegation to deliver the briefings and to respond to Members’ questions.

DCS report into the fire at the Pollsmoor Correctional Centre
Mr Smallberger, Acting Regional Commissioner: Western Cape, briefed the Committee on the events that had led up to the fire that occurred on 4 April 2006. He gave a brief history of the inmate who had been killed in the blaze and detailed the investigation that had followed. The presentation also included a summary of the remedial measures that had since been put in place.

Discussion
The Chairperson asked why the senior management of the Pollsmoor facility was not present? One would expect that since they were there at the time of the incidents they would be in a better position to respond to Members’ questions, he argued.

Deputy Minister Jacobus responded that the DCS had put together the team believing that they would be able to adequately respond to the Committee’s questions. She suggested that the Committee could, if it felt that the team did not satisfactorily answer its questions, invite the other officials for another briefing.

The Chairperson responded that he had specifically requested the senior management of Pollsmoor to be present at the briefing. He was disappointed that they were not present because the Committee considered the situation to be very serious.

Mr N Fihla (ANC) said that since one generally learnt from one’s mistakes, Pollsmoor should have learnt from an earlier, similar incident that had occurred at the facility. He commented that generally it was best to isolate an offender who was aggressive. Sometimes one even had to remove everything in their isolation cell. It was unfortunate that there was no medical officer on duty to tranquillise the deceased. He wondered why it had been necessary to chain her to the grill when she was in a single cell and could pose no harm to other inmates.

Mr J Selfe (DA) found it interesting that despite a similar incident in 2004, the DCS only sent samples of fire resistant mattresses to the South African Bureau of Standards (SABS) after the latest incident. Concurring with Mr Fihla, he said that the DCS did not appear to learn from its experiences. The Committee felt that the Department always took action when it was too late and seldom took the necessary precautionary measures.

Ms S Seaton (IFP) thought that there was a problem with the staff at the Pollsmoor facility. She wondered how the head of the centre could leave the facility when an incident was unfolding and asked whether action had been taken against him or her.

Mr S Mahote (ANC) noted that the report indicated that there had been a failure to adhere to the requirements of the Correctional Services Act. He asked who it was that failed to meet these requirements.

Mr T Motseki, DCS Chief Deputy Commissioner, said that there was a serious element of negligence underlying the incident and that a number of officials were subject to disciplinary action. The DCS was investigating the charges at the moment. Some officials had already been suspended. He emphasised that if the DCS were to make statements prior to all processes having taken their course, these individuals might feel prejudged. Some of the negligent actions could lead to criminal charges being laid and the DCS had to allow the South African Police Services (SAPS) investigation to take its course. He reiterated that while the DCS took the Committee’s concerns seriously it did not want to make prejudgments.

Mr Motseki stressed that the DCS had specific procedures in place but that officials did not observe them. This could not be allowed. He denied that the Department always acted after incidents took place. He said that officials were moving away from their call of duty and the care of the inmates and assured Members that the DCS would act on the evidence before them.

Mr Smallberger said that all incidents of failure to adhere to the policy formed part of the charge sheet of the person who had been in charge and had given the instructions. If one gave a specific instruction that instruction needed to adhere to the framework and had to be followed up. Failing to do this constituted negligence.

Mr Selfe wondered what the “mechanical restraints” with which the inmate’s movement had been restricted referred to. To his understanding one had to follow specific procedures before applying mechanical restraints. He asked whether these protocols had been observed.

Ms Seaton wondered what the deceased had been chained to since she appeared to have been very close to the gate to enable her to accept the ‘cigarette’ from the inmate in the adjoining cell.

The Chairperson asked whether the deceased had been restrained with handcuffs as well as leg irons. Section 30 of the Correctional Services Act read that an inmate could be mechanically restrained for a number of reasons. He wondered why the DCS had chosen to focus on only one of them.

Mr Smallberger agreed that there was a prescribed framework and a number of requirements that needed to be adhered to before implementing the decision to isolate or mechanically restrain an inmate. He said that it was unfortunate that in this case, discretion was given to a person who did not adhere to these requirements. The SAPS’ investigation was still underway but the DCS would, in cases where its code of conduct was breached, continue its own investigation.

Mr Motseki agreed that when applying mechanical restraints one had to adhere to specific procedures e.g. one had to report the situation to the Inspecting Judge, the inmate had to receive immediate medical attention, etc. He agreed that these procedures had to be followed at all times. The issuing officer of such an instruction had to be aware that there were consequences to this instruction. He repeated that it would be “seriously prejudicial” to make charges when all the investigations have not yet been concluded.

The Chairperson said that the Committee was getting impatient with what was happening at Pollsmoor. So far seven people have died at the facility. He wondered what had happened to the other investigations. He urged DCS to understand that the Committee took its work very seriously and felt strongly about the incidents that had taken place.

Mr Motseki said that the Department appreciated the Committee’s concern. Despite the fact they had ensured that the correct procedures were in place, the DCS took direct responsibility for the incidents that had taken place. He said that if instructions were given one had to follow up on their implementation. When an inmate was put in isolation and restricted by mechanical means that inmate had to be under constant observation, yet in this incident everybody had moved away from the situation. This constituted a serious omission that resulted in death.

Mr Motseki added that the fact that the inmate had been mechanically restrained indicated that the presence of a medical officer was required. The act of restraint as provided for in the Act was not only in the interest of others but also in the inmate’s own interest. He admitted “it may well be that in this specific case there was an over reaction”. Since investigations were still underway, the DCS could not reveal the names of the people involved.

Mr Smallberger said that the deceased had been restrained using foot cuffs, handcuffs and a belly chain. He explained that the use of straight jackets had been discontinued in Correctional Services. The isolation section contained three single cells that were next to each other. The inmate was chained to the door so as to keep her away from the windows, which she had been breaking. The information was received from the acting head of the prison and some of it was questionable. It was clear that many of the procedures prescribed in the Act had not been followed.

The Chairperson asked why the Department had not mentioned that the deceased had been restrained by using leg irons and a belly chain in addition to the handcuffs.

Mr Smallberger responded that the report made mention of “mechanical restraints” and later said the deceased was “handcuffed to the grill”. He knew that he would be given an opportunity to explain more accurately.

Ms Seaton found it strange that someone who appeared to have been totally immobile could have set a mattress alight. She felt that further investigation of the matter was necessary.

Mr Selfe noted that it took more than three officials to move the inmate to the isolation cell. The inmate was obviously aggressive, abusive and disturbed. If medical or psychological care had been sought the tragic consequences might have been avoided. He added that the report failed to address many other unanswered questions.

Ms W Ngwenya (ANC) too raised concerns about the apparent absence of medical staff.

Ms S Rajbally (MF) wondered whether the deceased had been treated for mental illness and whether any attempt had been made to take her to a mental institution.

Ms S Chikunga (ANC) pointed out that the DCS’ estimates of national expenditure (ENE) indicated that it had a 24-hour medical service. She did not believe that this was the case and yet this claim consistently appeared on the Department’s ENEs. If it so happened that there was medical staff on duty on that day, but they were not summoned, it aggravated the matter. She agreed that a medical practitioner would have been able to sedate the deceased.

Mr Motseki admitted that the DCS struggled to address health care issues. The DCS was struggling to employ nurses and had signed a service level agreement with the Department of Health and some individual practitioners in the Western Cape. He said that even if there had been no medical staff on duty that day, it still would not explain why the deceased had not been referred to the nearest medical practitioner. Nurses had been on duty on that day, and the DCS was investigating why they had not been called.

Mr S Mahote (ANC) wondered why the Pollsmoor facility had a staff complement of only 89 officials and asked whether the facility was overcrowded. He wondered whether anyone had been guarding the isolation cell while officials were attending to the new admissions.

Mr Smallberger answered that the 89 officials at the Pollsmoor Female Centre almost met the approved establishment. The facility was overcrowded by 305. Three people had been on duty that night and two of them had gone to the scene.

Mr Mahote wondered whether the deceased had met with her case officer as she had requested.

Mr Motseki said that the deceased’s request to see her case officer could not have resulted in her violent reaction and the subsequent events. He wondered why no extraordinary measures had been put in place to deal with the situation. He felt that there had been a “very serious omission” which had cost the Department very dearly. He said that it was “not nice” to have to offer an explanation when one could not account other than on the basis of an investigation. He said that the “human factor” posed a very serious challenge.

Mr Mahote was curious as to why the master key had to be fetched and why it was not readily available to officials.

Ms Ngwenya too wondered why the master key was not easily accessible to officials and why the deceased had been restrained when she was in a single cell.

Mr Smallberger responded that the master key was kept in the “office section” of the facility and officials lost time while they went to collect it. He said that the deceased had shared a single cell with another inmate but was later segregated.

Ms Ngwenya said that as a woman, specifically a woman who had been in prison for 10 years, she was deeply moved by the incident. She reminded the Department that the Committee had asked how the new facilities that it planned to build would be different from the old ones so that such incidents did not occur. She wondered what action officials took when the deceased refused to have her meals and whether a warder had checked up on the deceased.

Mr Smallberger said that the head of the office reported that she had visited the deceased twice during that day. This also formed part of the broader charges.

Ms Ngwenya wondered how the inmate had had access to tobacco if the facility was a smoke-free zone. Mr Smallberger explained that the Pollsmoor management had declared the women’s section a smoke-free zone. The Act however prescribed that if one were to have a smoke free-zone one should also make provision for a smoking zone.

Mr Fihla said that if the Department wanted to correct its mistakes there had to be some indication that it was learning from its past experiences. He wondered whether inmates were not given certain regulations that they had to adhere to when admitted to facilities that fell under the 36 centres of excellence.

Mr Selfe requested that the Committee be given a copy of the Department’s report, which it had submitted to the Judicial Inspectorate of Prisons (JIOP) and to the Minister. He commented on the fact that the Department’s strategy was to facilitate change and implement its ideals at the centres of excellence. The DCS’ reorientation would start at these facilities. He wondered what the implication for the other facilities was, if even at the centres of excellence procedures were not followed. He reminded all present that there had been previous incidents of fire. He would have thought that the DCS would have taken measures to prevent a repetition. Only now feasibility studies were being done for fire prevention precautions to be taken. He agreed that the Committee would like to see the Department learning from their experiences.

Mr Motseki responded that one only needed to follow the procedures that were in place to avoid such incidents from occurring. He said that DCS security policy was built on six pillars including the “human factor”. He said that in everything the DCS had attempted so far the human factor had been a challenge. The DCS regretted the incident and agreed that it should not have happened. The Committee’s comments were helpful.

Deputy Minister Jacobus said that it was unfortunate to have to appear before the Committee to report on such an incident. She pointed out that the incident was a manifestation of a whole range of challenges with which the DCS was faced. Perhaps it was the case that the Department always responded to these cases after they occurred. When she had visited the female section at Pollsmoor not so long ago, two inmates had been in isolation. One of them had been segregated because she had assaulted an official who had, over a period of time, repeatedly verbally abused her. This case exemplified the difficulties the DCS was faced with. The general atmosphere was difficult to cope with and lent itself to “all sorts of behaviour”. She reminded Members that Correctional Services was not necessarily a career of choices. It was faced with numerous human resource related challenges. Medical professionals did not want to work in that environment.

The Deputy Minister admitted that overcrowding remained one of the major challenges. The Committee and the Department should find a way of working together to address the human resource, environment and overcrowding challenges the DCS was faced with.

The Chairperson said that the Committee would draft its own report and recommendations to present to Parliament. He reminded the DCS of the recommendation the Committee had made after the 2004 incident: it had recommended that the entire leadership at the Pollsmoor facility needed to be replaced. Two years later another similar incident had occurred.

DCS final report on the investigation into the incidents at Zonderwater Correctional Centre
Mr Motseki said that the events at Zonderwater raised similar issues as the one at Pollsmoor prison. Ms Madisa, Gauteng Regional Head of Correctional Services, gave a brief overview of the hostage situation that had occurred at the Zonderwater facility on 6 November 2005 and had led to fatalities among inmates as well as officials. She then detailed the findings of the investigation that followed.

Discussion
The Chairperson wondered why the senior management of the Zonderwater facility was not present at the meeting. Mr Motseki responded that the current management was appointed after the investigation had been completed.

Ms Chikunga commented that it appeared as though those who were accountable often delegated accountability. She also felt that the person who was in charge of a facility at the time of an incident should be the one called to account regardless of whether they were still employed by the Department.

Mr Motseki said that officials who had been directly affected by an incident such as this one suffered a lot of trauma and took some time to recover from it. They could not be expected to brief the Committee on the incident immediately. The DCS took measures to provide emotional support (through their wellness programme). He mentioned again that there had been leadership problems at this facility. The area manager, the deputy director of corrections and the divisional head of security were the people held accountable for the incident. The area commissioner was currently on extended sick leave. He admitted that there had been clear organisational problems but assured the Committee that measures had been taken to resolve the matters that had led to the incident.

Ms Chikunga noted that the report indicated that lack of leadership by the management was one of the reasons for the incident. The DCS allocated a portion of its budget to capacity building programmes for management. She wondered whether the management at Zonderwater had had been part of such a capacity building programme.

Mr Motseki could not definitely indicate that all these managers had been through leadership training but knew that middle management had gone through training. The last batch of senior management officials had gone through their training last week. The DCS would now be able to assess whether the training had been successful or not.

The Chairperson said that the Committee was not insensitive to the trauma people suffered when involved in such incidents. Members did however consider it very disrespectful that those officers who were involved had not yet reported to the Committee despite the incident having taken place seven months earlier. In future the Committee would like to be briefed by the people who were directly involved in such incidents.

Mr L Tolo (ANC) noted that there always seemed to be ongoing investigations and suspensions yet the Committee seldom received reports on how investigations had been concluded and on the actions that had been taken against officials who were found guilty of improprieties. He specifically mentioned the rape of two nurses at the Baviaanspoort prison and asked what had happened to this investigation. He very often could not answer the questions the public raised about these cases. He agreed that the people who were directly involved in the incidents should be called to account. He added that when the Committee had visited the Kimberley facility officials had shouted and sworn at Members when they raised questions. He wondered how firearms could have been smuggled into the facility. Perhaps the DCS did not screen their recruits adequately? He asked how the Committee could assist to solve some of these problems.

Ms Seaton said that she had requested a report on the death of Mr Horne, who had been killed while on duty. She had taken the matter up with the Minister as well but had not yet received a reply.

Mr Motseki said some investigations were still ongoing but others had been completed. If the Committee had specific cases in mind the DCS would be able to forward the status of these cases. He said that the labour relations regime caused many cases to be protracted. People had the right to sit in hearings, to appeal, to refuse to appear for cases until they received mediation, etc. The Department of Public Service and Administration’s newly introduced measures for senior managers would improve the situation: any senior manager that had been dismissed, would remain dismissed, until cases have been resolved. This did not apply to levels below that of director, but would ensure that cases were resolved more speedily.

The DCS had not been aware of the fact that the staff at Kimberley had been abusive and regretted that. Mr Motseki assured Members that the DCS took extraordinary steps to protect the Committee when it visited facilities.

Ms Ngwenya wondered why dangerous offenders were accommodated in a facility that was not designed to house them. She said that this incident shared similarities with the Pollsmoor one.

Mr Fihla added that on an oversight visit to Zonderwater he had been surprised to see how “open” the facility was despite the fact that it housed offenders who had committed serious offences. He said that prisons used to be categorised according to the risk the inmates posed. Unfortunately the DCS only realised the risk maximum-security offenders posed after an incident had taken place.

Mr Motseki responded that the Zonderwater facility was not meant for offenders who had committed serious crimes but needed to house maximum-security prisoners as well. This was partly due to the pressures of overcrowding as well as the high number of inmates who had been convicted of aggressive crimes in Gauteng. He said that in this case too there had been a “serious omission”. He agreed that once the risk posed by the inmates in a facility increased, that facility should also increase its security. It did not happen in Zonderwater’s case. The Minister had the previous year given direct instructions for the immediate installation of the CCTV cameras, turnstiles and taut wire. These measures have since been implemented.

Ms Rajbally asked whether there was a shortage of manpower at the Zonderwater facility. She suggested that the Committee should have a thorough discussion on the findings of the investigation. It could then come up with ideas and recommendations for how to address the problems the DCS faced.

The Chairperson agreed and said that all issues would be raised at that meeting. The Committee could not continuously have briefings on suspensions and investigations. It needed to see action as well.

Ms Madisa said that Zonderwater, as was the case with many other facilities, struggled with staff shortages. This particular incident occurred at the weekend when often facilities had to function with fewer officials. All inmates were aware of the fact that at weekend the facilities were short staffed. The DCS was taking measures to address the situation.

The Chairperson reminded the DCS of what the late Regional Commissioner of Gauteng, Mr S Mlombile had said to the Committee on the first report of the Zonderwater and Baviaanskloof incidents. He had said that some officials within correctional services were criminals. They paraded in the Department’s brown uniform when they should be wearing the orange uniforms of inmates. Mr Mlombile had been straightforward and honest regarding what was going on in the Department. He emphasised that the Committee could only assist if people were “open and honest” with them. The Committee would draft a “very strong report” because both cases were very serious.

The meeting was adjourned.