Individual at Sycamore Lodge

Investigation into the circumstances surrounding the
death of a man at Sycamore Lodge Approved Premises in
the West Midlands Probation Area, on 3 May 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
September 2007
This is a report of an investigation into the death of a man. He was found hanging in
his room at Sycamore Lodge Approved Premises in Oldbury in the West Midlands on
3 May 2007, the day after his arrival. He was 37 years old. I offer my sincere
condolences to the man’s family, and those touched by his death.
I asked my colleague to conduct the investigation on my behalf. Both she and I
would like to thank the manager and staff at the Approved Premises for their ready
cooperation during the investigation. I would also like to thank the man’s probation
officer, for her assistance.
In conducting the investigation, my investigator also examined the man’s short time
in HMP Birmingham. I would like to thank the Governor and the Governor who acted
as the liaison officer. Their help was greatly appreciated. My thanks also go to
Detective Chief Inspector from the Police Standards Unit for her assistance in
sharing information regarding the man’s time in police custody.
In the eight days prior to the man’s death, he had spent time in police cells, the
magistrates’ court and in Birmingham prison before arriving at the Approved
Premises on 2 May. During his time in police cells, the man had self-harmed. This
information was conveyed via the Prisoner Escort Record (PER) to both court and
prison staff. There is no current mechanism for this to be conveyed to staff at
Sycamore Lodge. However, the man did volunteer the information on his arrival at
the Approved Premises.
In discussion with others, the man had been dismissive about his self-harm. He
showed no outward signs of vulnerability in his dealings with a number of
professionals, including prison, clinical and court staff, his probation officer and even
his family.
I conclude that there are lessons to be learnt in terms of training staff to identify risk
and probe disclosures of self-harm. I have also identified some practical measures
that may help staff become more prepared to deal with such disclosures.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2007
2
CONTENTS
Summary 4
The investigation process 6
Key events 9
Issues
- Transfer of information 14
- Arrival at Sycamore Lodge 14
- Ligature scissors 16
Recommendations 17
3
SUMMARY
The man was taken into police custody on 25 April 2007. Whilst in custody, he was
suspected of having taken an overdose and escorted to hospital. However, hospital
staff assessed his condition as satisfactory. On his return to the police station, the
man tied a jumper around his neck. Police officers intervened to prevent harm and a
police doctor checked that he was fit to be detained.
The following day, the police completed a Prisoner Escort Record (PER) in which
they recorded that the man was an alcoholic, and had self-harmed. The man was
taken to court where he was remanded into custody and transferred to HMP
Birmingham.
The senior officer in reception at HMP Birmingham remembered the man, and had a
conversation with him. He checked the PER form and asked the man what had
happened and how he felt. The man was dismissive about the self-harm and said
that he wanted to get out of police custody. He was then seen by the reception
nurse who raised concerns about his need for detoxification from alcohol. He was
taken to the first night centre where he saw the detoxification nurse. He also
underwent an induction assessment with an officer. She too asked him about self-
harm. The man was again dismissive, insisting that he was coping with the situation.
The man saw a number of professionals in Birmingham prison. None of them
expressed concerns, other than those relating to his alcohol use. He was given
diazepam for symptomatic relief whilst detoxing.
On 1 May, the man attended a Magistrates’ Court where he was given conditional
bail. One of the bail conditions was that he reside at Sycamore Lodge Approved
Premises in the Langley area of Oldbury. However, civil servants, including court
staff, had taken strike action on that day. Consequently, staff were not available to
complete the appropriate administrative procedures and the man was returned to
prison. No one appears to have explained the reason to him.
The process was completed the following day and the man was released from
prison. He attended a health centre to arrange his prescriptions and then went to
see his probation officer. When he arrived at her office, he was upset and agitated.
He had been drinking. The man did not understand why he had spent an extra night
in prison. He also believed his former partner had taken some of his money. He
said he did not know how to get to the Approved Premises and had no bus fare. He
was concerned that if he did not get to the Approved Premises, the police would
arrest him again.
The man’s probation officer found him a map and bus route to the Approved
Premises. She also provided a bus pass. By the time he left, he had calmed down
and thanked her. They arranged to meet two days later.
The man arrived at Sycamore Lodge at about 8.00pm. A probation service officer
went through an induction with him. It was clear he had been drinking but he spoke
freely, answered all questions and was well engaged. The assessment took about
45 minutes. When asked if he had ever self-harmed, the man told the probation
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service officer that he had tried to strangle himself after his arrest. The probation
officer felt that the man had been open, was in good spirits and had plans for the
coming days.
Following the assessment, the man went to buy some tobacco. It is likely that he
also bought alcohol. He then went to his room. He was last checked at
approximately 11.15pm.
On Thursday 3 May, a resident whose window faced that of the man’s, opened his
curtains to see him hanging from a ligature tied to his window. He went to the office
to fetch help. Two staff went to the man’s room where they cut the ligature, but it
was clear to them that they were too late and he had died.
The police broke the news to the man’s family. They were later able to visit
Sycamore Lodge to see where the man had died and collect his possessions. Staff
and residents were well supported following his death.
I have concluded that there is a need for managers to satisfy themselves that staff in
the Approved Premises have appropriate and up to date training in suicide and self-
harm awareness. I also believe it would be beneficial to put in place a system for
identifying risk factors relating to suicide and self-harm amongst new residents.
5
THE INVESTIGATION PROCESS
I appointed my colleague, to investigate the circumstances surrounding the man’s
death, on my behalf. She visited Sycamore Lodge and issued notices to staff and
residents about the investigation, asking them to contact her direct if they had any
information.
My investigator collected and analysed information relating to the man provided by
Sycamore Lodge and HMP Birmingham. She also conducted interviews with staff
and residents.
My investigator contacted the police, and was told that the man’s care in police
custody had been examined by the Police Standards team. The investigator spoke
with and shared information with a detective chief inspector and the Coroner’s
officer.
One of my Family Liaison Officers contacted the man’s family, to discuss the
investigation and give them an opportunity to raise any concerns. It is clear they
were a close family, and the nature of his death had come as a real shock. The
family’s main question was whether the prison had been informed that the man had
tried to harm himself whilst in police custody, and whether this information had, in
turn, been passed to staff at the Approved Premises.
6
SYCAMORE LODGE AND HMP BIRMINGHAM
Sycamore Lodge Approved Premises (probation hostel) can house 32 people. The
residents are either on licence and classed as posing a high risk to others, or live at
Approved Premises as part of their bail conditions.
There are 31 bedrooms, accommodating 32 residents, as well as communal
kitchens, and television rooms. During the day, the hostel is staffed by the manager
(a senior probation officer), deputy manager (probation officer), two probation service
officers and administration staff. At night, a probation service officer sleeps at the
Approved Premises, and a night officer stays on duty throughout the night. There is
also a duty manager on call.
HMP Birmingham, also known as Winson Green prison, is a Victorian local prison
built in 1849. The prison has the capacity for 1450 sentenced or remand prisoners.
It serves the Crown and Magistrates' Courts of Birmingham, Stafford and
Wolverhampton and the Magistrates' Courts of Burton, Cannock, Litchfield, Rugeley,
Sutton Coldfield and Tamworth.
7
KEY EVENTS
The man was remanded into police custody on 25 April 2007. As he died soon after
contact with the police, the Police Professional Standards Unit was alerted to
examine the man’s care in police custody. The Detective Chief Inspector carried out
this review and helpfully provided my investigator with a copy of her findings.
The police custody record showed that the man was taken to hospital with a
suspected overdose. Following examination at hospital, he was returned to police
detention where he was monitored in a cell with a camera. During that time, the man
was seen to tie a jumper around his neck. Staff intervened to stop him from harming
himself. This was noted on the custody record and a self-harm marker was added to
the Police National Computer notes. A Police Surgeon was called to confirm that the
man was fit to be detained.
On 26 April, a Prisoner Escort Record (PER) form was completed. (This is a form
that identifies risk a prisoner may pose to themselves and/or others. The PER
travels with the prisoner when they leave police custody to be transferred to court,
prison or another police area.) On this occasion the PER identified the man as
having the following risk categories: medical condition, violence, drugs/alcohol
issues and suicide/self-harm. Additional information about the risk showed:
“struggles violently with officers date not known, 25/4/07 tied jumper around his neck
and medical condition alcoholic.”
The man arrived at Birmingham prison on 26 April. The senior officer was the
manager in charge of reception at Birmingham that day. At interview, the senior
officer said he remembered seeing the man and thought he seemed upbeat. He
checked that he had the appropriate documents for the man, including the PER form,
and saw the entry written by the police. The senior officer asked the man what had
happened. He replied that he did not want to be in police cells so had self-harmed in
the hope the police would move him. The senior officer told my investigator that this
was not uncommon. He explained that, as a result of overcrowding and “Operation
Safeguard” (the provision of police cells to hold prisoners when there is no room in
local prisons), some prisoners had to spend longer in police cells. Consequently,
they would not have access to the same facilities as in prison. For example, they
would not have a television, or be able to go out on association.
The senior officer said that the man seemed fine, not at all down or depressed. He
had looked for visible marks that would suggest the man had harmed himself and did
not see any.
The documents were then passed to the nurse, who conducted a reception
healthscreen with the man. In the assessment, the nurse wrote that the man had
said he drank about 15 cans of strong beer a day. He had been prescribed
medication outside of prison for his alcohol problem. He reported that he had also
been a user of heroin. He said he had not used heroin for about three months, apart
from one incident about a month before when he had required medical treatment for
an overdose. He also reported physical injuries for which he had pins and wiring in
his right knee and ankle. He also had a false eye as a result of an accident.
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As part of the healthscreen, the man was asked if had ever self-harmed to which he
replied that he had not. He was also asked whether he had any thoughts of self-
harm. Again, he replied no. The nurse referred him to see a substance misuse
nurse to help with his alcohol problem, and to the doctor regarding prescription of
medication.
The man went to D wing, the first night centre. An induction officer conducted a “first
night” interview with him. The induction officer told my investigator that she had
remembered the man from a previous time in Birmingham, and that he had never
raised any concerns relating to suicide or self-harm during that earlier period. The
induction officer thought that the man seemed fine, but that he might have been
under the influence of alcohol.
The induction booklet is a particularly robust document and required the officer to
ask the man a number of questions, and to record his response, mood and
demeanour. The man said that he had not expected to come into custody on this
occasion, but had been in prison a number of times before. He said that he was not
at all worried about being in prison, and that he expected to be in prison for a month
or more. The man openly admitted he was an alcoholic and was severely suffering
from withdrawal. It was recorded that the man said he had never been treated for
depression or committed any acts of self-harm, and did not feel at risk of harming
himself at that time.
The induction officer told my investigator that she had seen the PER form and asked
the man what had happened in the police station. The man had brushed it off saying
he did not mean anything by it. Officer A thought that he might have said that he
was trying to get the police to do something for him, but was not sure whether she
had confused the man with another prisoner.
The man told officer A that he had recently lost a family member. She asked how
this made him feel, whether it made him feel low, or might lead him to harm himself.
He replied that he was alright.
The man was given some tobacco and offered a phone call. He did not know the
phone numbers of his family. However, Officer A was able to obtain the numbers
from his brother, who was in another wing of the prison. Officer A said that, when
she spoke to the man’s brother, he had asked whether the man had been drinking.
She said that she thought he had. The man’s brother said that this was “nothing
new”. Having obtained the numbers, the man was able to phone his mother. Officer
A wrote that the man’s main concern was his withdrawal from alcohol. She found
him to be quiet, polite and cooperative during the interview.
The same day, the substance misuse nurse met with the man to complete an alcohol
assessment. He had been experiencing tremors. He told the substance misuse
nurse that he had not tried to harm himself, and had no self-harm or suicidal
thoughts. The nurse advised him to drink plenty of fluids to avoid dehydration and
referred him to the doctor to provide medication to relieve his symptoms.
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The following day, the man saw a number of professionals. The doctor assessed
him and noted his alcohol intake. The doctor prescribed a gradual reduction
programme of diazepam.
Another first night officer spoke with the man as a follow up to his induction
interview. The officer wrote, “no problems stated overnight”. Again it is recorded
that the man was not at all concerned about being in custody and did not feel at risk
of self-harm. A Chaplain visited the man and recorded no concerns about his
welfare. The man moved to K wing. He appeared to settle well and there were no
concerns.
On 1 May, the man attended a Magistrates’ Court. The magistrate released the
man on conditional bail. As part of his bail conditions, he was required to reside at
Sycamore Lodge Approved Premises, and abide by their rules. However, on that
day a number of civil servants had taken strike action and courts had been
particularly affected. Consequently, there were no staff available to complete the
administration, so the man was taken back to Birmingham prison for another night.
The man was confused and angry about this.
On 2 May, the man’s release was processed and he was released from prison in the
afternoon. The man visited his probation officer. She had been the man’s probation
officer for about 18 months. In the early days, the man had not been particularly
compliant and had breached his order. Since November 2006, they had met more
regularly.
The man arrived at his probation officers office at about 4.50pm. He was very upset,
flustered and agitated. He explained that he had been in court on 1 May and been
given conditional bail, but had spent another night in prison and did not understand
the reason for this. He had been told to go to Sycamore Lodge Approved Premises,
but said he did not have any directions or bus fare. The man’s probation officer told
my investigator that he was waving bits of paper around. The probation officer had
not received notification from court at this stage and was unaware of the
circumstances. She said she could smell alcohol on the man’s breath, but found it
difficult to quantify the level of intoxication.
The man told his probation officer that his partner had taken money out of his bank
account or cashed his ‘giro’. He asked his probation officer to call his partner on her
mobile telephone. The probation officer explained that she could not contact his
partner, as she was the victim of his offence. The man was annoyed by this. In his
probation officers view, he interpreted this as her not helping him and grew more
anxious. She asked a colleague to help. At this point, the man threatened: “if you
don’t help me I’m going to throw myself over a bridge or take an overdose.”
The probation officer’s colleague confirmed that they were not allowed to contact his
victim. She advised the man that the most important thing was to make sure that he
went to the Approved Premises. They found him a map, established which bus he
needed, and organised a bus pass for him. Once the man realised they were in fact
trying to help him, he calmed down, seemed to relax, and thanked them for their
help.
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The man was concerned that if he did not make it to the Approved Premises the
police would pick him up again. Hi probation officer agreed that the priority was to
get him there. In terms of risk to others or self, her main concern at that time was
the potential risk to the man’s partner, as he had been drinking and had accused her
of taking his money.
The man’s probation officer had no concerns about suicide or deliberate self-harm.
Although the man had earlier made threats of self-harm, she had felt this was out of
frustration and anger, and he had calmed down greatly. She had known the man for
18 months and he had never talked about harming himself. Neither had she
received information from any other source relating to this. The man also had plans
over the next few days. By the time he left, he was calm. The probation officer had
scheduled an appointment for Friday 4 May, two days later, so they could discuss
what had happened and the way forward.
The man arrived at Sycamore Lodge at about 8.00pm. As he had been expected the
day before, he explained that he had been held in Birmingham an extra night. The
Probation Service Officer (PSO) phoned the prison to check the man’s account and
they confirmed that he had only been released that day.
The PSO said that the man had complained that his false eye was sore. He found a
dish so he could soak it in saline solution. The PSO showed the man to his room,
and said he would come back and go through the induction process with him. The
PSO recalled that the man said that was fine and he just wanted to “chill”. Staff then
met in the office to conduct a handover from day to night staff.
After this, the PSO and the man went to a room to go through the induction
procedure. A large part of the induction involved going through the rules and
regulations at the Approved Premises. This took about 45 minutes. The PSO said
that the referral from court noted that the man had an alcohol problem and he was
aware that he was under the influence of alcohol at the time of the assessment.
The man told the PSO that he had been released from Birmingham at about 4.00pm.
He was upset at having spent an extra night in prison custody. He had then gone to
see his probation officer, and showed the PSO his appointment card demonstrating
that he had another appointment the following Friday. The man said that he then
went to the “Links” healthcare clinic as he was on medication and had arranged to
collect a prescription from them the following day.
The man told the PSO his medical problems. He said that he had epilepsy. He said
that he was on diazepam and temazepam and he had experienced difficulty
obtaining this in prison. The man showed the PSO some scars and tattoos. The
scars were mainly from an accident. The man explained he had been involved in an
accident and as a result had pins in his leg. He explained that he had worked on a
scrap yard and had accidentally got battery acid in his eye. This had resulted in the
loss of sight in one eye.
The man had a piece of paper with various phone numbers on it. He asked to call
his family and the PSO allowed him to use the office phone. The man spoke to a
family member who agreed to bring in some clothes for him the following day.
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The referral from court had said nothing about any self-harm history. When the PSO
asked the man if he had self-harmed, he replied that when he was taken into custody
on 25 April he had tried to strangle himself. The man explained that he had been
arrested in a park in front of his children and this had really upset him. The man
spoke quite openly with good eye contact, and was cheerful and upbeat.
Following the induction, the PSO showed the man around the hostel, gave him a
meal and cup of tea, and showed him where things were kept. The man then went
to the shop to get some tobacco. It is possible that he also bought alcohol.
Certainly, a can of beer was found in his room the following day. When he returned,
he made a cup of tea and sat in the television room with other residents. They
commented that he had been laughing and joking with them.
The man went up to his room by 10.30pm. At 11.00pm, the PSO locked the front
doors and checked all the fire doors. He also checked the toilets and bathrooms
and, along with his colleague, checked all the rooms. At about 11.15pm, another
member of staff knocked on the door to check the man was in his room and the man
opened the door. This check was simply to ensure everyone was in.
The following morning, another resident in the hostel got up and made a cup of tea.
The resident explained that his bedroom window faced the man’s window across a
courtyard. He told my investigator that he opened his curtains at about 8.48am. At
first, he wondered what the man was doing at his window, but when he looked again
he noticed there was a ligature attached to the outside of the window. The resident
went downstairs to the office and told the PSO that there was a serious problem. He
said that he told the PSO he should come and look for himself as he did not want to
cause alarm to other residents who were gathered around the office. The PSO and
the resident went to the courtyard. They looked up and saw the man hanging.
The PSO returned to the office to collect the ligature scissors, at which point the
hostel manager, came into the building. Together, they went up to the man’s room.
The PSO said that the room was locked from inside so he used his key to open the
door. Once inside, he reached up to cut the ligature which consisted of a bedsheet.
He said that the scissors were too small and the sheet was large so it had been a
struggle to cut through it. Together, the manager of the Approved Premises and the
PSO lowered the man to the bed, and pulled the noose from around his neck. There
were no life signs and rigor mortis was apparent. They left the room and contacted
the police.
Following the man’s death, the police contacted his family to break the news. The
family were later able to visit Sycamore Lodge. Staff and residents told my
investigator they felt they had been properly supported after the death.
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ISSUES
Transfer of information
The police clearly wrote on the PER form that the man had tied a jumper around his
neck in police custody. The PER transferred with him to HMP Birmingham. Several
staff at Birmingham asked the man about this, and he had been dismissive.
A number of professionals had contact with the man in his first few days in custody.
No concerns were raised, other than his alcoholism. Therefore, they judged that
there was no need for him to be subject to suicide and self-harm prevention
procedures.
No documents accompanied the man to Sycamore Lodge that would have alerted
staff to his previous self-harm on 25 April. The PER form is handed from police to
court to prison, or vice versa. It is not handed to probation staff in the Approved
Premises and would not have been in the man’s possession.
A Probation Circular entitled “Preventing Deaths of Approved Premises Residents”,
issued in September 2006, comments on this issue. It says “Approved Premises
managers should endeavour to obtain from the Prison Service, contracted prisons
and court escort services full information on risk of self-harm and suicide.” This
relates mainly to those who have been identified as being at risk of suicide or self-
harm and are also subject to specific procedures to prevent this. As the man was
not subject to such procedures, this information was not obtained.
Arrival at Sycamore Lodge
The man volunteered information about his recent self-harm during his induction
interview. Information such as this must be taken very seriously. Given his
admission, I would have expected contact to have been made with the prison to find
out much more about this.
The manager of Sycamore Lodge should remind staff that where a resident of
an Approved Premises has recently been in custody and admits recent self-
harm, further information from the relevant agency should always be sought.
The manager of Sycamore Lodge said that his expectation of staff who were told of a
recent self-harm history during induction would be to record it, and in the coming
days to inform colleagues. Most importantly, he felt that staff should take it seriously,
and carry out a high level of observations on the resident until a full assessment
could be conducted by a probation officer. A full risk assessment is conducted on
every new resident by a probation officer within three days of their arrival. In
practice, the manager of the Approved Premises felt this actually took place within
two days.
When the PSO asked the man whether he had ever self-harmed, he replied that he
had tried to strangle himself when he had been taken into custody the week before.
He repeated that he had been very upset about being arrested in a park in front of
his children. The PSO was not clear about the meaning of self strangulation and
13
was confused as to how serious this could be. The PSO said that the man spoke
quite openly with good eye contact and the PSO did not probe this any further. The
PSO said that, although he did not talk at length with the man about self-harm, even
with the benefits of hindsight he felt that the man had seemed in good spirits. He
had been making plans for the near future, such as a family member bringing him
some clothes, and he intended to collect his medication and to see his probation
officer.
My investigator found the PSO to be compassionate and committed to his work.
There is always a fully qualified on-call manager on duty. It is clear that if a
probation service officer has any concerns about a resident, they should contact the
on-call manager. The PSO said that, had he been concerned, he would have
contacted the manager. However, he had felt that the man had engaged in their
conversations and nothing had been said that caused the PSO significant concern
during the induction.
When asked about training, the PSO recalled that he had been through a day’s
training in suicide and self-harm but this had taken place several years before. He
had recently undergone training in “risk”, which was much broader than just the risk
a resident may pose to themselves.
My investigator spoke to the Assistant Chief Officer in West Midlands Probation with
oversight of Approved Premises in the area. He was keen to arrange some further
training in this area quickly. I agree that awareness training is necessary.
The manager of the Sycamore Lodge and the Assistant Chief Officer should
review the provision of suicide and self-harm awareness training.
The experience in my office has been that many people who go on to commit self-
harm have not presented in such a way as to alert staff. However, many prisons
have incorporated a suicide and self-harm risk assessment into their reception
interviews. Research has identified a number of factors common to those who have
taken their own lives. As part of the interview, prisoners are asked questions relating
to these common factors (for example, previous self-harm, history of substance
misuse, age, history of depression etc.) These factors are weighted and added up.
If the calculation reaches a certain threshold, safeguarding procedures are put in
place until the individual can be fully assessed by an appropriately trained
professional.
In an Approved Premises, extra supervision is likely to be needed only for one night,
before appropriate assessment can be made. Many of the questions are already
covered in the induction documents. A weighted system, which could help to
measure risk factors, would be simple to incorporate and would remove
inconsistency between staff.
The Chief Officer of West Midlands Probation should consider introducing a
weighted score card to assess the risk of self-harm and suicide on a resident’s
first night. The National Probation Directorate may also wish to consider
whether a national self-harm risk assessment should be devised for all
Approved Premises.
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15
Ligature scissors
The PSO found the ligature scissors difficult to use on a thick ligature, and he had to
use his height and strength to be at the correct angle to use them. Someone of the
PSO’s height and strength may not always be on duty.
The manager may wish to consider purchasing a ligature knife, often known as
a “fish knife”, such as those used in the Prison Service, which are better
designed to work effectively on a range of ligatures.
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RECOMMENDATIONS
▪ The manager of Sycamore Lodge should remind staff that where a resident of
an Approved Premises has recently been in custody and admits recent self-
harm, further information from the relevant agency should always be sought.
The National Probation Service accepted the recommendation, and said;
“All of our Approved Premises staff have been reminded to ensure hat
the prison or other relevant agency, is contacted where self-harm is
referred to by an incoming resident.”
▪ The manager of Sycamore Lodge and the Assistant Chief Officer should
review the provision of suicide and self-harm awareness training.
The National Probation Service accepted the recommendation, and said;
“All relevant staff in Approved Premises have undertaken the National
Risk Training for Approved Premises which was devised by the centre.
The training addresses risk of self-harm and suicide and how to
manage this. We will ensure that this training will also be offered to all
new staff who join Approved Premises and if required, staff will be
given refresher training”
▪ The Chief Officer of West Midlands Probation should consider introducing a
weighted score card to assess the risk of self-harm and suicide on a
resident’s first night. The National Probation Directorate may also wish to
consider whether a national self-harm risk assessment should be devised for
all Approved Premises.
The National Probation Service said;
“We cannot accept the recommendation as it is presented. There may
well be a need for a weighted scorecard to assess risk but if that is the
case then this needs to be developed centrally and used in all
Approved Premises throughout England and Wales. Of course we
would be anxious to fully implement any new risk assessment tool that
was provided by the centre.”
▪ The manager may wish to consider purchasing a ligature knife, often known
as a “fish knife”, such as those used in the Prison Service, which are better
designed to work effectively on a range of ligatures.
The National Probation Service accepted the recommendation, and said;
“We accept this recommendation and will take it forward in all our
Approved Premises with immediate effect once the knives have been
purchased.”
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