Individual at Altcourse

Investigation into the circumstances surrounding the
death of a man at Fazakerley Hospital whilst in the custody
of HMP Altcourse, Spring 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2009
This is the report of an investigation into the death of a man who was found hanging
in his cell at HMP Altcourse at 1.00am. Nursing staff attempted to resuscitate him
and a pulse was re-established. He was then moved by ambulance to the local
hospital, Fazakerley, where he was put on a life-support machine. The decision was
made to remove the machine two days later and he died at 12.35pm in the presence
of his family. He was only 21 years old.
The man had arrived at Altcourse just a week earlier as a remand prisoner facing a
very serious charge. If convicted, he would have been given a long custodial
sentence. He was ambivalent about having vulnerable prisoner status and, at his
own request, in the evening, six days later he gave it up and moved briefly to the
prison’s Induction Unit. However, some of the other prisoners there were aware of
the charges the man faced and he was assaulted, sustaining minor injuries. Staff
immediately escorted him back to the First Night Centre, where he resumed
vulnerable prisoner status. Less than six hours later, he was discovered hanging. I
offer my sincere sympathy and condolences to his family and friends for their loss.
The investigation was undertaken by two of my investigators. A clinical review of the
healthcare provided to the man was commissioned by Liverpool Primary Care Trust
and I am grateful the review. I would also like to express my thanks to the Director
of HMP Altcourse and his staff for their co-operation, in particular the then Head of
Safer Custody, whose assistance was invaluable to my investigators.
I make five recommendations covering healthcare issues, family liaison and the
procedure for moving a vulnerable prisoner onto normal location. This investigation,
like many before it, also draws attention to a failure in information sharing.
Information about the man’s risk of self-harm was in the hands of the police but not
entered on a Prisoner Escort Record. It was not, therefore, available to staff at HMP
Altcourse.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2009
2
CONTENTS
Summary 4
The investigation process 5
HMP & YOI Altcourse 7
Key findings 9
Issues 16
Recommendations 22
3
SUMMARY
The man was remanded in custody charged with rape. It was his second time in
HMP Altcourse. He requested vulnerable prisoner status, and this was granted. He
remained on the First Night Centre whilst waiting for a vacancy in the Vulnerable
Prisoners’ Unit.
At the initial risk assessment, the man told staff that he had no history or current
thoughts of suicide or self-harm. He described himself as having a short temper and
as getting angry and frustrated very quickly. Over the next few days, staff submitted
a referral to the Mental Health Inreach Team because the man said he was
“paranoid” that other prisoners would discover the charges he was facing. Staff also
referred him to counsellors because he said that he felt deeply ashamed of his
offence. He asked the staff to telephone his mother to let her know where he was,
as he was too ashamed to talk to her.
Six days after his arrival, the man asked to be removed from vulnerable prisoner
status and signed a disclaimer. He moved to the Induction Unit but was assaulted
shortly after his arrival. Staff immediately returned him to the First Night Centre
where he was again designated as a vulnerable prisoner. A nurse examined his
injuries but none was serious enough to require treatment. A prison custody officer
asked the man how he was as she locked him up for the night. He told her that he
was fine and to stop worrying about him.
At 1.00am the following morning, a prison custody officer saw that the man’s cell
light was still on and decided to check on him. The officer saw the man hanging and
called for assistance and for the healthcare team. Staff commenced cardio
pulmonary resuscitation (CPR) and established a pulse. Paramedics arrived and
transferred the man by emergency ambulance to Fazakerley Hospital. Sadly, he
never regained consciousness. His life support machine was switched off and he
died in the afternoon two days later. He was aged 21.
After the man’s death, staff and prisoners were offered support.
I make five recommendations.
4
THE INVESTIGATION PROCESS
1. After the man’s death, my investigator opened the investigation three days later
when she visited the prison. She met the Director, the Controller, the Chairman
of the Independent Monitoring Board (IMB), a trade union representative and the
prison’s family liaison officer. She saw the man’s cell in the First Night Centre
and was given copies of his prison records. The investigators returned to
Altcourse three more times to conduct interviews with wing and healthcare staff.
2. A clinical review of the healthcare provided to the man was commissioned by
Liverpool Primary Care Trust. I am grateful for the review.
3. The objectives of the investigation were to:
• Establish the circumstances and events surrounding the man’s death,
including the care provided by the prison and relevant outside factors;
• Examine any relevant health care issues and assess clinical care,
together with the National Health Service;
• Examine whether any change in operational methods, policy, practice
or management arrangements would help prevent a similar death in
the future;
• Ensure that the man’s family had the opportunity to raise any concerns
and that these were taken into account in the investigation and the
report;
• Assist the Coroner’s inquest.
4. One of my family liaison officers spoke to the man’s family to ask if they had any
concerns that they wanted to be included in the investigation. She and an
investigator subsequently visited the man’s family, during which meeting the
family raised a number of issues relating to Altcourse staff’s knowledge of the
man’s emotional and mental health, his cell moves, the family’s contact with the
man and staff, and events immediately before and after his death. I hope that
this report goes some way to answering their questions.
5
HMP ALTCOURSE
5. HMP Altcourse is a privately run prison, located on the outskirts of Liverpool. It
opened in December 1997 and is managed by G4S Ltd. (At the time of the
man’s death, it was run by GSL which is now part of G4S.) Healthcare services
are provided by Primecare.
6. Altcourse receives both sentenced and remand adult male prisoners from the
courts in. It also takes young offenders, on remand, who live alongside adults on
all the units other than the Vulnerable Prisoners’ Unit (VPU). There are seven
house blocks that are named after the fences in the Grand National steeplechase
course:
• Bechers - remand and short term prisoners.
• Canal - medium to long term sentenced prisoners.
• Furlong - Induction and Detoxification Units.
• Melling - short term sentenced prisoners, and voluntary drug testing
unit.
• Reynoldstown - sentenced prisoners carrying out full-time education
and vulnerable prisoners.
• Valentines - medium to long term sentenced prisoners.
• Foinavon - mixture of prisoners wishing to take part in vocational
training courses.
7. A gymnasium, education block, chapel and the Healthcare Centre form a central
spine of the prison with accommodation blocks on either side. One side of the
prison houses mainly remand prisoners, along with the VPU and prisoners on the
enhanced level of the Incentives and Earned Privileges Scheme. The other side
holds the Induction Unit and accommodation for sentenced prisoners.
8. All prisoners spend their first night at Altcourse in the First Night Centre. The unit
has space for 28 prisoners and staff check the men every 30 minutes while they
are there. On the second day, prisoners move to the Induction Unit or the
Vulnerable Prisoners’ Unit. Induction for vulnerable prisoners is provided on the
Vulnerable Prisoners’ Unit. The First Night Centre is on the floor above the
Healthcare Centre.
9. Altcourse has 16 volunteer prisoner carers who offer support to prisoners who
ask to see them. They work in Admissions, the Induction Unit, the First Night
Centre and the VPU and may visit prisoners on other units when needed. G4S
also employs a team of trained counsellors who provide services to both
prisoners and staff.
10. The Independent Monitoring Board’s most recent report covers July 2007 to June
2008. The report describes the period as “a dynamic and excellent year”.
However, of particular relevance to the man’s time at Altcourse is the Board’s
view that:
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“… the continued verbal abuse of VP [vulnerable] prisoners whilst in transit
between their place of work and residential unit from other prisoners
continues to give the Board concerns.”
11. The Board also raises the issue of prisoners remaining in the First Night Centre
after their first 24 hours in prison whilst waiting to move to a suitable location.
They highlight the efforts to address this issue and the recent opening of a new,
Opt-Out Unit to ease the situation.
12. The most recent inspection by HM Chief Inspector of Prisons, Ms Anne Owers,
was an unannounced, short inspection carried out from 17 to 19 September
2007. In her subsequent report, Ms Owers commended “the quantity and quality
of time out of cell for prisoners at Altcourse, which placed its regime among the
best of any local prison in England and Wales”. She also noted, “Altcourse
remained an impressively respectful prison, with well maintained and clean
accommodation, and very good staff-prisoner relations.” However, she was
concerned that:
“Anti-bullying measures had been re-examined and were being actively
pursued, but more work needed to be done to challenge those who bullied
and to support those who had been the victims of bullying. There had
been a worrying increase in levels of violence.”
Like the IMB, Ms Owers noted that the First Night Centre held men who could not
be accommodated elsewhere in the prison.
13. The previous two deaths at Altcourse were in 2006. The issues I raised in my
reports are different from those surrounding the man’s death.
7
KEY FINDINGS
14. The man was arrested on suspicion of rape. He told police custody staff that he
was suffering from “severe depression and paranoia” and that he had taken 20-
25 paracetamol tablets the previous evening. The custody officer referred the
man to the police doctor for a medical examination. Prior to the examination, the
man was constantly observed by police officers.
15. A police doctor examined the man and assessed that he was fit to be detained
and interviewed. After the examination, the man was placed on general
observation, set at 60 minute intervals.
16. The man left police custody at 9.00am two days after his arrest. The police
officer who completed the Prisoner Escort Record (PER) did not note any of the
self-harm concerns they had about the man. The only information box marked
was the one that identified him as a drug user. Therefore, the information about
the man’s mental health and alleged overdose of paracetamol was not passed on
to the GSL staff. Nor were they aware that the police had kept him on constant,
then hourly observations. The man was remanded into custody to appear at
crown court.
17. When the man arrived at Altcourse, he went through the admissions process
during which several staff interviewed him. Staff ask all prisoners on arrival
whether they want vulnerable prisoner (VP) status. When the duty Prisoner
Custody Officer (PCO) asked the man if he wanted VP status, the man replied
that he did. The PCO notified the manager of the Vulnerable Prisoners’ Unit
(VPU) of his request and then interviewed the man while he completed the
paperwork. The PCO asked the man if he had a history or thoughts of self-harm,
to which the man replied that he did not. This is in stark contrast to what he had
told the police after his arrest. However, because the police had not put the
information on the PER form, the staff at Altcourse had no knowledge of the
man’s recent history. The man told the PCO that he did not want to share a cell
with a sex offender, which was noted on the form.
18. The duty nurse in Admissions then interviewed the man and completed the First
Reception Health Screen. The nurse is a Registered Mental Nurse (RMN) and
interviewing and assessing new prisoners is one of his main tasks. He told my
investigators that he could not recall the man individually. However, by referring
to the forms he completed while he interviewed him, he described their
interaction.
19. The man told the nurse that he used drugs socially and listed cannabis, cocaine
and “pills”. The nurse explained to my investigators that when a prisoner says his
drug use is social rather than a problem, he does not refer him to the
Counselling, Assessment, Referral, Advice and Throughcare service (CARATs),
the drug counselling service. The nurse recorded that the man said he had no
previous history of self-harm and no intention to harm himself. He also said that
he had no mental health problems and had no contact with psychiatric services.
Finally, the nurse completed the healthcare section of the Cell Sharing Risk
Assessment. He asked the man if he had any problems with sharing a cell with
8
another prisoner. The man initially replied that he had not, but then repeated that
he did not want to share a cell with a sex offender.
20. Whilst he was in Admissions, the man waited in the holding area with the other
prisoners rather than being put in a separate room as is the case for some of the
other VPs. The duty manager of the VPU, arrived in Admissions and interviewed
the man in private. She discussed his options of going to the VPU or onto normal
location. She set out the risks he faced if he decided to try normal location. The
man told her that he had been on normal location in Altcourse on a previous
occasion. He said that once a prisoner was in the VPU, the stigma meant that he
could not then go onto normal location. He decided not to request VP status and
the manager made a note of their discussion and the decision in the man’s
record.
21. From Admissions, all prisoners move to the First Night Centre which is above the
Healthcare Centre. A PCO was interviewing the new prisoners and allocating
cells when he read the nurse’s note about the man not liking sex offenders. He
spoke to the man about his decision not to request VP status. The man said that
he was happy with the decision and was content with the cellmate allocated.
22. The following day, the prison doctor assessed the man. The doctor prescribed
Aqueous cream for a shaving rash. He noted that the man was a heavy drinker
but was not withdrawing at the time. He assessed the man’s mental state and
concluded that there was no risk of deliberate self-harm.
23. Another PCO interviewed the man to complete an Initial Risk Assessment form,
required because he faced a charge of rape. The man spoke about his earlier
offence and previous time in Altcourse, but said he could not remember much
about the current offences. He gave the PCO some details but told her that his
information came from the police. In answer to whether he had any history or
thoughts of self-harm, the man replied that he did not. He told her that he was
“paranoid” about everybody discussing him and the charges against him. In the
section of the form headed “Vulnerability”, the PCO wrote “RMN referral”. She
told my investigators that, after the interview ended, she completed a referral
form for the RMN team. However, the form was not in the man’s records and
there is no record of the referral ever reaching the team.
24. The subject that the PCO and the man spent most time discussing was the VPU.
The PCO had worked on the VPU and she discussed the unit, the regime and the
opportunities for work and education that would be available to the man. She told
my investigators that the man appeared to be interested in learning about the unit
on which he would stay in Altcourse.
25. Also on the Friday, the man learned that details of the charges against him had
appeared in his local newspaper, to which some prisoners had a subscription.
(My investigators were unable to discover how the man had learned of the
newspaper article.) He again asked for VP status and the same manager of the
VPU interviewed him in the First Night Centre. The man told her that he was “a
bit paranoid” and fearful of other prisoners finding out about the offences, as the
paper had named him. The manager granted him VP status but, as there was no
9
space to accommodate him in the VPU, he had to remain in the First Night
Centre in the meantime. Several other prisoners in the First Night Centre were
also waiting for places in the VPU and staff kept them apart from the other
prisoners as far as possible. The VPU manager told the man that, whilst he
waited for a space, he could go to the VPU for association and to meet staff and
prisoners there.
26. The following day, a PCO interviewed the man as part of the induction process
and completed the Initial Assessment Plan. (A blank copy of the form appears at
Annex 3.) He began by asking whether the man had any history or thoughts of
harming himself. The man replied that he did not and that his major concern was
the embarrassment he had caused his parents. After telling the PCO that he
could not remember much as he had taken a large amount of drugs and alcohol,
he then provided quite a lot of information. He also said that he had suffered
from paranoia and depression in the past but that he currently felt fine. He
repeated that he felt ashamed and was concerned about the impact on his family.
He said to the PCO that he was “going to go guilty”, which the PCO understood
to mean that he would plead guilty to the charges when he returned to court.
27. The PCO asked the man if he wanted to speak to a carer but he did not.
However the man agreed to be referred to the counsellors. He also told the PCO
that he had not contacted his family since arriving at Altcourse and did not know if
they knew where he was. He accepted the PCO’s offer to telephone his mother.
After the interview ended, the PCO completed a referral form for the man. Later
that evening, he rang the man’s mother. During the call, the man’s mother
warned the PCO to be aware that the man was good at “blagging” people. The
PCO took this to mean that the man could be manipulative and recorded the
information in his wing history sheet. He then told the man that he had made the
call and that he might now get some mail from his family.
28. For the next two days, the man remained in the First Night Centre. Around
11.00am on the following morning, a female PCO offered the man the opportunity
to go to the VPU for association. He refused, saying he “did not want to do the
walk”. He told the PCO that he did not want to be “branded” as a VP, particularly
as he knew some of the other prisoners and did not want them to know he was a
VP. He said that he wanted to try normal location. It was not a confidential
conversation as the man was lying in his bed at the time and his cellmate was
present. During the discussion, the cellmate encouraged the man to try normal
location. The man was aware of the risks of going to the Induction Unit and then
to a normal location unit but he was very keen to make the attempt. The PCO
told the man that she was not sure it was a good idea because, as he knew,
details of the charges he faced had been featured in the local newspaper.
However, he was sure he wanted to try. The PCO said she would speak to a
manager about the request but she was unable to do so before her shift ended at
1.00pm.
29. Before the PCO ended her shift, she briefed another female PCO about the
man’s request and the need for a manager to decide whether he could move to
normal location. The second PCO spoke to the Induction Unit manager, who was
unhappy about accepting the man. He told the PCO to get the VPU manager’s
10
agreement before moving the man. The PCO was unable to speak to the duty
VPU manager, until late in the afternoon. When she told him of the man’s
request, he replied that the decision was for the individual prisoner so long as he
signed a disclaimer first. The PCO then arranged with the evening manager on
the Induction Unit that the man would move to the Induction Unit that evening.
30. As the PCO escorted the man out of the First Night Centre, she asked if he was
sure he wanted to move and whether he understood the implications. He replied
that he did, and he wanted to go to normal location as he did not want to be
classified as a VP. The man arrived on the Induction Unit around 6.00pm. The
prisoners were on association and the unit was busy and noisy. A male PCO
gave the man a short briefing about the unit and told him which he was allocated
to. The man entered the cell and asked his cellmate which bunk was his. He
then put his bag on the bed and left the cell. (The cellmate was released from
prison before my investigators arrived at Altcourse so they did not interview him.
However, they interviewed the violence reduction manager who spoke to the
cellmate over several days after the assault and gathered the following
information.) The cellmate, who was on a detoxification programme, went
upstairs to collect his evening medication. When he returned to the cell, the man
was lying on his bunk. The cellmate went to sleep and was not aware of
subsequent events.
31. About 30 minutes after the man’s arrival, a female PCO was at the officers’
console at the top end of the unit when she noticed a group of prisoners clustered
round a pool table. She went to investigate and saw that they were reading a
copy of the man’s local newspaper. The paper contained a large article about the
charges facing the man, as well as his name and a photograph. The PCO took
the paper from the men as her male colleague arrived to give her assistance.
The male PCO telephoned the manager who told him to move the man back to
the First Night Centre immediately.
32. The male PCO and another male colleague then went to collect the man. When
they entered his cell, he said, “Boss, I’ve just been jumped” (a prison term
meaning assaulted). The PCO saw red marks on the man’s face that he
described to my investigators as “reddening, like grazes”. He said that the man
was “a little bit shaken but more calm than other prisoners who have been
assaulted”. The cellmate was awake by this time but he denied seeing anything
when the PCO questioned him.
33. The man collected his bag, which he had not unpacked, and the two prison
custody officers escorted him to the gate leading off the unit. As they did so, they
passed a group of prisoners who verbally abused the man. The staff identified
one of the prisoners who appeared to be a ringleader and the female PCO locked
him in his cell. The unit manager interviewed him later that evening and, after the
prisoner admitted swearing at the man, the manager told him that his behaviour
was totally unacceptable and punished him. I am satisfied that appropriate action
was taken.
34. The male PCO opened the gate leading into the foyer of the unit and the man
and a carer moved through the first gate and waited at the second. The PCO
11
collected the man’s file from the office which is off the foyer. The carer had been
to the unit to speak to a prisoner and was on his way back to his own unit. As the
two men waited briefly in the foyer, the carer said to the man, “Are you okay,
lad?” The man replied, “Yeah, I am fine. I am alright.” But the carer told my
investigators that he thought the man “looked lost” and assumed he was being
moved off the unit because he had been bullied.
35. Once the carer went off to his unit, the PCO asked the man who had assaulted
him. The man replied that he would not tell him because he did not want to be
seen as “a grass” (informant). The PCO said that if the man gave him the names
of those responsible, he would start the procedures to have the men punished.
He told my investigators that the man replied, “I knew this would happen, but I
thought I would give it a go - coming to normal location. I deserve it anyway.” In
the First Night Centre, The PCO put the man in a cell on his own and then briefed
the manager, who was in the unit at that time. The PCO told my investigators
that nothing that the man said or did indicated that he should have opened an
Assessment, Care in Custody and Teamwork (ACCT) plan for him. (ACCT is the
arrangement used throughout prisons in England and Wales to support and
monitor prisoners thought to be at risk of suicide or self harm.)
36. The manager spoke to the man in an interview room and asked how he was.
The man said that he was “fine”. He refused to give the names or descriptions of
his attackers, telling the manager, “I’m not a grass.” He also refused to give any
details about the attack and said that he did not want the police informed. The
manager asked the man if he felt like harming himself and the man said he did
not feel like that. The manager told my investigators that the man appeared quite
calm and composed. He accepted that he had to return to VP status.
37. The female PCO who had escorted the man to the Induction Unit spoke to him
once he had returned to the cell. She saw bruising on his nose and a scratch on
his arm. The man said he had been in his cell when some other prisoners came
in with a newspaper. There had been too many of them for him to fight off. She
took him downstairs to the Healthcare Centre where a nurse examined him. The
nurse noted a mark on his cheek and asked if he had any other injuries. The
man said his head, so she examined his scalp behind the ears. She asked him
to remove his shirt and noted red marks across his shoulders and arm. The skin
was not broken and the nurse’s opinion was that he would be bruised the
following morning. The man also told the nurse that he had bitten the inside of
his cheek so she examined his mouth. None of the injuries needed medical
treatment. Although, the nurse noted the man’s manner and behaviour, she did
not carry out a formal mental health assessment.
38. The nurse asked the man what had happened and he told her he had been hit.
He said he did not see his attackers. He appeared fairly calm and sat quietly
during the examination. The nurse told my investigators that his manner gave
her no cause for concern. The man returned to the First Night Centre and the
nurse transferred her notes to the medical computer system. The computer
automatically added the time of the entry as 7.37pm.
12
39. The man was allocated a double cell, although he was on his own. (His former
bed space had been allocated to a newly arrived prisoner when he moved to the
Induction Unit, so he could not return to the same cell.) The PCO gave him fresh
bedding and again asked if he was alright. The man replied, “Yes, Miss. Stop
worrying about me. I’ll be alright.” He refused painkillers. He spent the rest of
the evening lying on his bed watching the television. Later, he collected some
hot water and returned to his cell. As the PCO locked him up for the night, he
told her to “stop fretting”.
40. At night, all prisons operate with a much reduced staff. During night patrol state,
only the duty operational manager (codenamed Oscar 1) carries a full set of keys
to unlock all gates and cells. Staff who are designated as Oscar 2 have keys
which allow movement through the prison. Wing staff and nurses do not have
access to keys allowing them free access around the prison and have to be
escorted. However, prison custody officers are each issued with a cell key in a
sealed pouch for use in emergencies. The staff instructions are that during the
night state, a cell may only be unlocked by a single member of staff where there
is, or appears to be, immediate danger to life.
41. The First Night Centre is a small unit and at night only one member of staff is on
duty there. The night PCO began his shift at around 8.45pm and was briefed by
the staff going off duty. They told him about the man’s move to the Induction
Unit, the assault and his return to the First Night Centre. The night PCO checked
all the prisoners on the unit at around 9.30pm and, although in interview he could
not recall what the man was doing, he noted that he seemed fine.
42. At 1.00am, the night PCO checked the occupant of the cell next to the man’s cell.
As he passed the man’s cell, he realised that the light was still on, so he looked
through the observation hatch. He saw the man hanging by a sheet from the
rung of the ladder at the end of the bunk beds. The PCO pressed the emergency
button on his radio and told the prison custody officer in the control room that
there was a Code 1 medical emergency. He then began to take his cell key from
the sealed pouch. The control room officer alerted the duty operations manager
and other staff of the emergency by radio.
43. The duty operations manager was in his office when he heard the message. He
and another PCO arrived at the cell while the night PCO was still removing the
key from the pouch. The manager opened the door with his key, went in and
lifted the man up. As the night PCO entered he took out his anti-ligature knife,
intending to cut the sheet. However, the whole sheet was twisted round the
man’s neck and was too thick to cut through. He helped lift the man while he and
the others removed the sheet and then they laid the man on the floor.
44. Two nurses were in the Healthcare Centre when they heard the Code 1 call.
They took the emergency equipment bags and ran up the stairs to the First Night
Centre. The discipline staff had opened the doors so they were not delayed.
They arrived just as the prison custody officers were putting the man on the floor.
The female nurse assessed the man, who appeared unconscious and she began
to give oxygen through a mask. The male nurse noticed a letter lying on the desk
addressed to the man’s family and passed it to the manager. The nurses began
13
cardio pulmonary resuscitation (CPR) and the manager called for an ambulance.
The control log timed the call at 1.03am and the ambulance arrived at the prison
gate seven minutes later. The general duties staff had opened the internal gates
to allow the ambulance to move through the prison to the First Night Centre as
quickly as possible.
45. As the female nurse set up the defibrillator (a machine that treats victims of
sudden cardiac arrest by delivering a shock to the heart), the paramedics arrived.
She briefed them and they took over the man’s treatment. They succeeded in
establishing a faint heartbeat. Once they had stabilised him, they strapped him
into a support chair and took him to the ambulance where they continued to treat
him. The manager arranged for two prison custody officers to escort the man in
the ambulance, which left the prison at 1.40am and arrived at the hospital at
1.42am.
46. Any prisoner required to remain in hospital, who has not been released from
custody on temporary licence, is escorted and monitored by prison custody
officers under the ‘Bedwatch’ procedures. This usually means that two officers
remain at the prisoner’s bedside and record any significant changes or events.
Subject to a risk assessment process, the Director decides whether the prisoner
should be handcuffed and the number of officers required to stay with him. The
duty director instructed staff not to handcuff the man after the paramedics told
him that the man was unlikely to survive.
47. Members of the Care Team offered support to the staff who had been involved in
finding and resuscitating the man. Managers ensured that all carers were on
duty over the next few days and the Inreach Team and counsellors were also
assigned to the units. Case managers reviewed all prisoners on open ACCT
plans and provided additional support where required.
48. The prison’s family liaison officer contacted the man’s family at 7.30am, having
tried for several hours to get in touch. He met them at the hospital later in the
day. The man remained in a coma on a life-support machine for two days. He
was taken off the life-support machine and died at 12.35pm with his family at the
bedside.
14
ISSUES
Health
49. When the man arrived at Altcourse, the Admissions nurse assessed his health
needs. The man told him that he had never harmed himself, nor had any contact
with psychiatric services. The following day, the doctor examined the man and
assessed his mental state as being at “no risk of deliberate self-harm or
attempted suicide”. The doctor also noted that, although the man was a heavy
drinker, he showed no symptoms of withdrawing from alcohol. He prescribed
cream for a dry skin.
50. Five days later, after the assault, the man was examined by a nurse in the
Healthcare Centre but his physical injuries did not need treatment. However, the
clinical reviewer notes that no mental health assessment was carried out after the
assault.
The Head of Healthcare should ensure that a brief mental health
assessment is completed and the findings recorded after a prisoner has
been assaulted.
Missing mental health referral document
51. When a PCO interviewed the man in order to complete an Initial Risk
Assessment form, she discussed suicide and self-harm with him. The man
denied having harmed himself in the past and said he had no thoughts about self-
harm at the present time. However, he did talk about being “paranoid”, thinking
that everyone was talking about him and the offences he was alleged to have
committed. The PCO noted the information on the form and, after the interview
she completed a referral form to the Mental Health Inreach Team. However,
although she remembers putting the referral into the internal post, there is no
trace of the form in the man’s records. Had the referral reached the team, there
is no guarantee that the man would have been assessed by the time he died, as
the following two days were the weekend.
The Director and Head of the Mental Health Inreach Team should review the
referral process to ensure that all forms reach the team.
The telephone conversation between a PCO and the man’s mother
52. A different PCO interviewed the man and completed the Initial Assessment Plan.
During their conversation, the man said that he had not contacted his family since
arriving at Altcourse. Later that evening, the PCO telephoned the man’s mother.
He told my investigator that she had said that he man could be manipulative,
which he then noted in the wing record.
53. When the man’s mother discussed her conversation with the PCO with my staff,
she said that she had not said any such thing. She had told the PCO that the
man was very good at hiding his feelings and wanted the staff to be aware of
that. She had also urged them to watch him.
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54. Clearly, the two descriptions of the telephone call are at odds. There is no third-
party account of the conversation. I have, therefore, set out both statements but
can offer no further comment on what occurred.
Decisions about Vulnerable Prisoner status
55. As each prisoner arrives at Altcourse, the manager in Admissions asks if he
wants vulnerable prisoner (VP) status. The man said that he did, so the duty
manager of the Vulnerable Prisoners’ Unit, spoke to him whilst he was still in
Admissions. After a discussion about the implications of being a VP, the man
said he would try normal location. However, the following day, after a further
discussion with the same manager, the man asked for VP status. Having made
sure that the man understood the consequences of being a VP, she granted it.
56. Unfortunately, the care and individual attention that the female manager gave the
man was not mirrored when he asked to come off VP status. The man asked to
try normal location six days after his arrival. A PCO discussed it with him whilst
he was in his cell with his cellmate present. Thereafter, both she and a second
PCO telephoned managers to obtain permission for the man to move to the
Induction Unit. The VPU manager that day was a man. He did not think it was
necessary to speak to the man who died, but focussed on ensuring that the man
signed a disclaimer accepting the risk.
57. At interview, the male manager accepted that it would have been better if he had
interviewed the man face-to-face before allowing him to move to the Induction
Unit. The male manager told my investigators that he has now changed his
procedures and will always speak personally to a VP who requests a move to
normal location. The Director has now stopped the practice of men having to
sign a disclaimer as it has no legal standing or usefulness.
The Director should ensure that all prisoners requesting to move from the
VPU to normal location are interviewed by a manager before a decision is
taken.
The impact of the charges on the man’s risk of self-harm
58.The man arrived at Altcourse on remand, having been charged with rape. Prison
staff were aware of the charges, particularly as they were at the centre of why the
man asked for VP status. The health screen form that the duty nurse completes
in Admissions lists a number of offences that trigger an automatic referral for a
mental health assessment. The offences with which the man was charged were
not on the list, so no referral was made at that point. However, it is good practice
for all staff to be aware of offences that may increase a prisoner’s risk of self-
harm and monitor those prisoners more closely.
The man’s changes of mind over being a Vulnerable Prisoner
59.When he arrived in Altcourse, the man asked for VP status and then changed his
mind. The following day, he again asked for VP status and changed his mind five
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days later. He understood that if the prisoners on normal location knew of the
charges he was facing, they might make life difficult for him. He had been in
prison before and knew how other prisoners often regard VPs. He told a PCO
that he “did not want to do the walk” to and from the VPU that would identify him
as a VP. He told another member of staff that he did not want to be “branded” a
VP. Because of the charges he was facing, the man had the dilemma of needing
VP status but wanting very much to be on normal location.
60.The female VPU manager told the man the day after his arrival that his arrest and
the charges against him had been reported in his local newspaper. When a PCO
discussed trying normal location before he moved to normal location, he told her
that he did not want to be identified as a VP. Knowing all this, the man still
wanted to try normal location and staff agreed to the move.
61.It appears that he spent less than an hour in the Induction Unit before returning to
the First Night Centre. During that short time, some of the other prisoners
assaulted him physically and made threats. He once more asked for and was
given VP status. Afterwards, a nurse examined the man in the Healthcare Centre
and noted red marks on his face, shoulders and arms, although none required
treatment. In addition to the physical consequences, the man was faced with the
psychological blow of knowing that it was impossible for him to be on normal
location for the foreseeable future. Furthermore, if convicted, he faced the
prospect of serving a lengthy sentence.
62.Once a prisoner has VP status, it is difficult for him to move to normal location.
Even if he is transferred to another prison, he may well meet men who knew he
was a VP at his previous prison. An alternative can be to move the VP to a
prison in a different part of the country. However, this makes it more difficult to
maintain family links, an important part of the resettlement process.
63.When the man arrived at Altcourse, he told two members of staff in Admissions
that he did not like sex offenders and did not want to share a cell with one. Many
of the men in the VPU are sex offenders, and only a minority are there for other
reasons. While the man waited for a place on the VPU, he had the opportunity to
go to the unit for exercise and association. He refused, preferring to make do
with the more restrictive regime in the First Night Centre. However, that was only
a temporary location and he knew that he would move to the VPU as soon as
there was a space for him. He would then be living and working alongside other
VPs, many of whom would be sex offenders. From what he said in Admissions,
this would have been very unwelcome.
Prisoners in the First Night Centre awaiting places in the VPU
64.When the female VPU manager gave the man VP status, there were no places
available on the VPU. The man, along with several other VPs, remained in the
First Night Centre waiting to be transferred to the VPU once there was space for
him. This meant that the First Night Centre accommodated both normal location
prisoners and VPs, and staff had to keep both groups separate. Whilst my
investigators were in the prison, the First Night Centre also held prisoners who
were too vulnerable to be accommodated elsewhere, even the VPU.
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65.Both the IMB and HM Chief Inspector of Prisons have raised concerns about
prisoners, other than newly arrived men, being in the First Night Centre. For the
man who died, it meant that he was in a unit where he spent most of the day in
his cell, rather than being in the VPU where the men spend much more time
unlocked. My investigators raised the issue with the Director when they met to
brief him on their findings. The prison has now opened a new unit called the Opt-
out Unit that has freed up space in a number of other parts of the prison. The
First Night Centre now only accommodates men who are newly arrived at
Altcourse. Like the IMB, I welcome this development and urge the Director to
ensure that the First Night Centre remains focussed on its specific role.
The assault on the man
66.The other prisoners on the Induction Unit identified the man almost immediately.
They had a copy of the newspaper which contained an article about the charges
facing him. Information from the man’s family indicates that there were also men
from his home town in Altcourse at that time knew of the charges.
67.One of the prisoners in the Induction Unit later told staff that he had told the man
that he had better get off the unit. The prisoner maintained that he said this by
way of advice. However, depending on the tone of voice he had used, it could
have just as easily been taken as a threat. Several prisoners went into the man’s
cell and assaulted him. The man did not name his attackers, staff did not see
other men entering his cell and there is no closed circuit television footage
available. His cellmate was detoxifying and appears to have taken his evening
medication and then slept through the incident.
68.As the man could not, or would not, identify his attackers, the Violence Reduction
Manager investigated the assault. He and another manager spoke to a number
of prisoners who were on the wing that evening. Several provided information but
nothing that could prove who had committed the attack. The Violence Reduction
Manager described his enquiry in detail when my investigators interviewed him.
The transcript can be found at Annex 20.
69.As staff escorted the man out of the unit, a crowd of prisoners shouted abuse at
him. A PCO heard one particular phrase and identified the prisoner who had
‘advised’ the man to leave the unit as being the person who said it. Although the
prisoner denied using the words reported by the PCO, he did admit to using a
different phrase. (Both phrases were abusive.) It is little wonder that the carer
described the man as looking lost. However, in the letter to his family found in his
cell, the man did not refer to the assault or his time in Altcourse. His focus was
the charges he was facing and the impact on himself and his family.
Family liaison issues
70After the paramedics told staff that the man was unlikely to survive the duty
director began the procedures for a death in custody. The process includes a list
of people and units that must be informed. At 3.30am the prison’s family liaison
officer (FLO) received a telephone call asking him to take on the role of family
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liaison officer for the man’s family. Staff provided him with two telephone
numbers so that he could telephone the family and inform them that the man was
in hospital. The FLO rang both numbers but neither was answered. The FLO
went into the prison and continued to try to contact the family. When the man
arrived at Altcourse, he had said he lived at his mother’s address and this was
noted in his records. Directory Enquiries might have been able to provide a
landline number for the address. At 7.30am, the FLO managed to contact man’s
father, who said that he would inform the rest of the family.
71.The family’s immediate concern was to be with the man in the hospital. Before
they could break the news to their own extended family, other prisoners had
passed the information to their own relatives. This meant that the news spread
round the community very quickly. When the Prison Service press office released
a statement, as is normal practice, the local media featured the news prominently.
The man’s family were upset that, because of the speed with which the news
became public, they were unable to break the news personally to all their
relations. It would be helpful for next of kin to be advised at an early stage that a
press notice will be issued and, as details may appear in the press and media, to
suggest that they might want to contact other family members quickly.
The Director should include in the Family Liaison policy a requirement for
the FLO to inform the family that the Prison Service press office will release
a statement.
72.Talking to my investigators, the FLO said that it was the first time he had carried
out FLO duties when the prisoner was still alive. His FLO training from the Prison
Service had not covered the special circumstances nor did the FLO policy contain
procedures for deciding whether to break the news to the family by telephone or
in person. He also identified the need for the FLO to have detailed information
about recent events in the prisoner’s life as soon as possible so that it can be
passed onto the family. I agree with his assessment of the need for clear
procedures to cover the specific circumstances surrounding the man’s death.
The Director should expand the FLO policy to include procedures for
liaising with the families of prisoners in hospital who are not expected to
survive. (The NOMS Safer Custody and Offender Policy Group may also
wish to consider if there is a need for national guidance on this issue.)
Conclusion
74.The man who died was a young man facing a charge of rape. He knew that if he
was convicted, he would receive a long sentence that he would probably have to
serve as a vulnerable prisoner. Many VPs are sex offenders. The man told staff
that he did not want to share a cell with such offenders but was facing the
prospect of many years living and working alongside them. His dilemma was that
he needed vulnerable prisoner status for his own safety but wanted very much to
be on normal location. He moved to normal location in the Induction Unit but was
only there for a very short time before he had to leave for his own safety. A few
hours later, he took the action that led to his death.
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75. Information about the man’s risk of self-harm was in the hands of the police.
This information was not contained in the Prisoner Escort Record and was not
therefore available to staff at Altcourse.
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