Individual at Winchester

An investigation into the circumstances surrounding the
death of a man who was a prisoner at HMP Winchester,
in January 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2008
This is an investigation into the circumstances surrounding the death of a
man in January 2007. The man was serving a sentence at HMP
Winchester when he collapsed during a management and prisoner
representative meeting. Sadly, he died soon afterwards. The man was in
his early 70s and had a history of heart disease.
I would like to extend my condolences to the man’s family, and to all those
touched by his death.
The investigation was undertaken by one of my Assistant Ombudsmen.
We would like to thank the Governor of Winchester and his staff for their
co-operation during the investigation.
I asked Mid-Hampshire Primary Care Trust to carry out a review into the
clinical care that the man received whilst he was at Winchester. A panel of
five clinical staff carried out this review. I am grateful to the PCT for their
assistance.
I make five recommendations taken from the clinical review and two other
recommendations of my own. At draft report stage the Prison Service
accepted all of the recommendations.
This version of my report, published on my website, has been amended to
remove the name of the deceased and the names of staff and prisoners
who were involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2008
CONTENTS
1. Summary 4
2. The Investigation Process 6
3. HMP Winchester 7
4. Key findings 9
5. What other prisoners said 18
6. Issues considered 21
7. Recommendations 30
SUMMARY
1. The man was born in the 1930s and was therefore already an elderly
man when he was sentenced to 18 months in prison in September
2006. The man suffered from arthritis and heart disease and took
several medications for his heart condition.
2. The man moved onto West Hill unit within HMP Winchester at the end
of October after having spent a period in healthcare and on normal
location. West Hill unit is a category C unit than is run independently
from the main prison. It is a more relaxed environment than the main
residential units. The man was described by both staff and prisoners in
West Hill as ‘a bit of a character’ and as someone who would ‘speak
his mind’ and ‘call a spade a spade’. They also said that he would
sometimes get wound up and angry about things. However, the man
was a much liked man on the unit and he enjoyed doing art and drama
in the education classes run on the wing.
3. The man was recategorised to category D on 8 November. This meant
that he would have been able to transfer to an open prison (the
minimum security category of prison; one without a high fence or walls
and one where prisoners are often trusted to work in the community
during the day). However, due to some medical appointments at local
hospitals his transfer was put ‘on hold’.
4. In early January, a Home Detention Curfew (HDC or ‘tagging’) board
met to discuss whether the man was suitable to be released with a tag
later that month. Because of negative reports from the home probation
team, from the police and from the prison based probation officer, the
Head of Residence did not grant the man early release. The
information that was the main driver behind the decision not to grant
HDC concerned two charges, one of which had been dropped
altogether and the other of which had not yet come to trial. My report
considers these facts in light of the other information available about
the man and the Prison Service Order about HDC. Amongst other
things, I asked the national policy unit with responsibility for Home
Detention Curfew to look at the paperwork and they said that “the
proper procedures were followed and the decision to refuse release
was entirely appropriate”. The man lodged an appeal against his HDC
refusal, but that appeal had not been heard by the time of his death.
5. One morning in January 2007, the man represented his landing at a
regularly held prisoner representative meeting. Several other prisoners
from other landings were also there, as well as the governor of the unit
and representatives from the kitchen, canteen and gym. The man
complained about the food that was served and in particular about the
poor quality of the potatoes. He became quite heated during his
discussions with the Unit Governor and then collapsed onto the
prisoner sitting next to him. Medical help was called immediately, but
the man stopped breathing shortly after and the medical team of both
nurses and the doctor were unable to resuscitate him. A post mortem
indicated that the man died of ischaemic heart disease due to coronary
artery atherosclerosis (hardening of the arteries that supply the heart).
6. My investigation was hampered by not receiving any staff or prisoner
statements from HMP Winchester. I make a recommendation about
this matter.
7. The clinical review panel considered the response to the man’s
collapse to be appropriate and timely and that the outcome could not
have been avoided. They make five recommendations, three of which
relate to chronic disease management within the prison.
THE INVESTIGATION PROCESS
8. The investigation was opened in January 2007. On that date, my
investigator wrote to the Governor of HMP Winchester and asked him
to display notices to staff and prisoners about the Prisons and
Probation Ombudsman’s investigation into the death of the man. One
prisoner came forward from these notices and asked to speak to my
investigator. He subsequently moved prisons, but was interviewed
there by another of my investigators.
9. A liaison officer was appointed by the Governor. I am grateful to him
for his assistance during the investigation. The liaison officer arranged
for the main prison records and the man’s medical record to be sent to
me. My investigator subsequently visited Winchester on 20 March
2007 and spoke to some of the staff and prisoners who had known the
man. Unfortunately, the prison did not ask staff or prisoners to
complete any witness statements at the time of the man’s death. This
only came to light during my investigator’s visit. She asked the liaison
officer to ensure the staff who were present at the prisoner
representative meeting, or those from the medical team who tried to
resuscitate the man, make a statement as soon as they could, recalling
as much detail as they were able. These statements have not been
forthcoming and are the subject of one of my recommendations.
10. The Clinical Governance Manager for Mid-Hampshire Primary Care
Trust, was invited to arrange for a clinical review to be carried out into
the medical care that the man had received during his time in custody.
The clinical review was sent to my office at the end of June 2007.
11. The Coroner was informed of the Ombudsman’s investigation. He
kindly agreed to send me a copy of the post mortem report and the
police witness statements that had been taken from two members of
staff. I will send the Coroner a copy of this final report and hope that it
will assist him with his enquiries.
12. The man’s next of kin, his wife, was contacted by one of my family
liaison officers. She asked that my office talk to a friend of her
husband and said that he was acting on her behalf in matters
concerning her husband’s death. This gentleman did not wish to be
visited, but did raise several questions and concerns about the man’s
death. I have addressed these questions in the family issues section of
this report.
13. At draft stage the report was sent to both the man’s family and the
Prison Service for their comments. The Prison Service accepted all of
the recommendations made in this report and I have included their
comments in the recommendations section.
HMP WINCHESTER
14. Winchester prison is located just outside the main city centre. Most of
the prison is of a Victorian radial design and has a maximum capacity
of 697.
15. West Hill is a category C unit within the category B prison. Prisoners
are more trusted and are given keys to their own rooms (these can be
overridden by staff keys). It acts as a resettlement unit and offers
various work programmes. West Hill is not integrated with the rest of
the prison in that it has its own distinct staff group and its own visits
area. West Hill sometimes transfers prisoners on to open
establishments such as Ford and Standford Hill. The unit can
accommodate 127 prisoners in total, 87 within the main unit and 40 in
an adjacent building called ‘The Hearn’. The Hearn takes those
prisoners who are the most trusted, those likely to get release on
licence and those who work outside the prison. The main unit
comprises a mixture of single and double cells. The man was in a
double cell on the landing called ‘Alfred 1’.
16. Her Majesty’s Chief Inspector of Prisons, Ms Anne Owers, last
inspected Winchester in December 2004. Ms Owers published her
report in February 2005 and commented that:
“Resettlement continued to be a very strong area of work. A
specialist resettlement team provided a range of services; and
now had the benefit of a separate resettlement unit in the annex
at West Hill. However, this was not supported by a strong
personal officer scheme among residential staff, and we
remained unconvinced that there were effective partners in this
enterprise.”
17. In relation to catering, Ms Owers said, “the standard of food was
acceptable and we received no complaints about it”. However, she
made a recommendation about the completion of regular food surveys
and suggested the results could inform the menu choices offered.
18. The Independent Monitoring Board at Winchester published their
Annual Report for 2005 – 2006 in January 2007. They said of the West
Hill unit:
“This reporting period has been difficult for West Hill and the
Hearn Unit. To many it was perceived to be a resettlement
establishment, one where many, if not all prisoners from the
Hearn would be working in the community after Release on
Temporary Licence. Alas this has not been the case. Too few
applications have been successful. West Hill is perceived by
staff and prisoners alike as an extension of the main prison, a
cat C overflow.”
19. The IMB went on to comment that the personal officer scheme in West
Hill “seems to be working well”. Although the prisoner representative
meetings were not always held regularly, “they are well run with the
prisoners participating fully”.
KEY FINDINGS
20. The man was sentenced to 18 months imprisonment at Winchester
Crown Court on 8 September 2006 for cultivating cannabis plants and
conspiracy to supply a class C drug. He was one of four defendants in
the case. The Prisoner Escort Record (PER) form which is completed
by the contracted company responsible for taking the man from court to
Winchester shows him arriving at the prison at 5.46pm.
21. The nationally used form ‘First Reception Health Screen’ was
completed by a Heath Care Officer (HCO) in reception. The man said
that he had been in Winchester before during February and March
2006. He said he was taking several prescribed medications. It was
noted that he was allergic to penicillin. The man indicated he had
concerns about his physical health due to his replacement ankle joint,
angina and a double heart by-pass. The HCO noted that the man was
walking on crutches, was breathless and had arthritis. The screening
form goes on to indicate that there were no mental health concerns
about the man and that he had never seen a psychiatrist nor tried to
harm himself. The HCO decided to admit the man to the healthcare
centre and to refer him to the doctor because of his physical health
problems. The Cell Sharing Risk Assessment, a form used to help
identify those prisoners who may not be suitable for sharing a cell with
another, indicates that the man was regarded as a ‘low risk’ to others
and could therefore share a cell. A decision was made to
accommodate him in the healthcare centre initially. The officer
completing the form incorrectly recorded his current offence as
“firearms”.
22. After going through the reception process, the man was put into one of
the cells in the healthcare centre. The first entry in his medical record
was that the man had been given Nicorandil and Co-proxamol. He was
told that he might not be able to continue with this latter medication as
it was being discontinued. The man apparently replied that it was the
only painkiller you could take with ‘ulcers’. The nurse informed him that
this was not the case and noted that he was mobile with his crutches.
The following day, the man was told that he would not be prescribed
Co-proxamol, but could take Paracetamol instead. Over the next few
days, staff noted that the man seemed settled and that he was
compliant with his prescribed medication.
23. A ‘Secondary Health Assessment’ form was completed on the man,
giving his height and weight and noting that there was a history of heart
disease in his family. His blood pressure was recorded as 149/90 and
his pulse 75. Unfortunately, the form is poorly designed and does not
have a place to record the name or signature of the person completing
it, nor somewhere to record the date of its completion. It is not
therefore clear when this form was filled in.
24. The man was seen by the doctor on Monday 11 September. The Co-
proxamol was replaced with Paracetamol.
25. On 21 September, the man was deemed suitable to go onto normal
location within the prison. The medical advice was for him to be
located “on the flat” (that is, on the ground floor) and a Discharge Care
Plan was written reflecting this. It was noted that the man had suffered
no incidents of angina or breathlessness since being in the healthcare
centre. The Discharge Care Plan indicated that “poor mobility, angina
and breathlessness” were the problems and that the short term goal
was for the man to know where to go to collect his medication. The
longer term goal was to maintain his care within the main prison.
26. The man was due to have a hip block at a hospital in the area on 11
October 2006. The appointment was cancelled by the healthcare unit
at the prison on 9 October. There appears to have been some
confusion over its re-booking. The man’s wife sent a letter into the
prison with an appointment for 1 November. A subsequent
appointment given for 22 November may have been sent directly to the
man at Winchester, and so this date also had to be rearranged. A
provisional appointment date was set for 6 December and it was noted
in his medical record that the man would need to have an x-ray first.
27. The man’s security category was assessed on 24 October and he was
given a security category of C. This was due to the fact that his current
offence involved drugs. He was consequently recommended for West
Hill unit.
28. The man attended the local hospital on 27 October for an x-ray of his
lower leg. The results of that x-ray indicated that he had internal
fixation of his distal fibula and an ankle joint prosthesis. There were
unfortunately no previous films for comparison purposes. On his return
from the hospital, the man was moved onto West Hill unit and
underwent their own induction programme.
29. The man raised a couple of issues during his induction on West Hill.
The first was a rates bill that he asked for someone to look into for him.
The second were his medical problems. He told the officer that he had
heart trouble, arthritis and stomach ulcers. The officer noted that the
man said he did not like anyone smoking near him and that he “can’t
climb stairs very well”.
30. West Hill unit adopts a policy of issuing medication in possession. The
man was prescribed several medications. He now held and took these
himself:
Lisinopril – is used to treat high blood pressure. Lisinopril is in a class
of medications called angiotensin-converting enzyme (ACE) inhibitors.
It works by decreasing certain chemicals that tighten the blood vessels,
so blood flows more smoothly.
Omeprazole - Prescription omeprazole is used alone or with other
medications to treat ulcers (sores in the lining of the stomach or small
intestine), gastroesophageal reflux disease (GERD), a condition in
which backward flow of acid from the stomach causes heartburn and
injury of the oesophagus (tube that connects the mouth and stomach),
and erosive oesophagitis (swelling and wearing away of the lining of
the oesophagus). Omeprazole delayed-release capsules are also
used to treat conditions in which the stomach produces too much acid.
Omeprazole is in a class of medications called proton-pump inhibitors.
It works by decreasing the amount of acid made in the stomach.
Nicorandil – used to treat angina. The pain of angina is caused by too
little oxygen reaching the heart when its workload increases, such as
during exercise. This is usually a result of hardening of the arteries
(atherosclerosis) that supply blood to the heart. The condition is also
known as coronary heart disease. Nicorandil decreases the workload
of the heart and also improves its blood and therefore oxygen supply.
Simvastatin – Simvastatin is used together with lifestyle changes (diet,
weight-loss, exercise) to reduce the amount of cholesterol (a fat-like
substance) and certain other fatty substances in the blood.
Simvastatin is in a class of medications called HMG-CoA reductase
inhibitors (statins). It works by slowing the production of cholesterol in
the body.
Clopidogrel – Clopidogrel is used to prevent strokes and heart attacks
in patients at risk. Clopidogrel is in a class of medications called
antiplatelet drugs. It works by helping to prevent harmful blood clots.
31. The man put in an application to do some work and to attend art and
drama classes. It was felt that he was unfit for most types of work so
he was allocated to the ‘stamps workshop’ and to start the education
classes he requested. A unit Senior Officer (SO) described the man as
the sort of man who acted as a spokesperson for the younger
prisoners. He said that the man was pretty mobile and that, even
though his cell was on the ground floor, he seemed to have no problem
going up to the education area on the upper floor. The SO said that he
had had to have a few conversations with the man about his attitude
and that at times he was too quick to speak his mind and got ‘heated’.
He recalled that the man received regular visits from his wife and
daughter.
32. Because he was an old age pensioner, the man asked to be given the
flu injection on 31 October 2006. This request was reviewed on 3
November and a note was made that they were awaiting dates for
injections. His medical record indicates that the man received the flu
injection on 23 November.
33. An early review of the man’s categorisation took place on 6 November.
He was recommended for category D status based on the fact that he
had not come to the attention of staff and that he “complies with
instructions”. The recommendation was approved by the Head of
Security on 8 November, who said that the man’s “custodial behaviour
had reduced his risk”. An entry by a prison officer in the man’s wing
history sheet on 16 November indicated that he had no “burning
problems or issues to raise” and that the man was welcoming his
transfer to Ford open prison in the near future. A medical record entry
on the same day indicated that the man was “happy to stay on medical
hold to get seen at hospital”. This meant that the man would not be
transferred out of Winchester until his medical appointments and follow
ups had been completed.
34. On 6 December, the man attended a foot and ankle clinic at the local
hospital.
35. The man had a GP appointment on 14 December. There is a
reference on his medical record that he had been on Clopidogrel since
his admission in September and questions whether he should still be
on it. The entry goes on to note that the man, “had a MI [myocardial
infarction – heart attack] 15 years ago. Has a history of peptic ulcers
therefore not on aspirin but is on clopidogrel.” The GP indicated that
there was a risk of bleeding from either aspirin or Clopidogrel. He said
that the man understood this. The entry went on to say that the man
would prefer to stay on Clopidogrel. His prescription for this drug
therefore continued. This was the last time that the man was seen by a
doctor prior to his death.
36. There are various entries in the man’s wing history sheet during
November and December which indicate that he was, at times, abusive
towards staff and did not always follow the rules of the unit. He was
given an Incentives and Earned Privileges (IEP) warning at the end of
December. (IEP is a system that operates in all prisons and links
rewards such as in cell television, the amount of private cash that can
be spent in the canteen and visits entitlements to behaviour and
attitude in the prison.)
37. Over the Christmas period, the man took part in the drama production
on West Hill entitled Always Look on the Bright Side. All of the
prisoners my investigator spoke to said that the man thoroughly
enjoyed the drama classes he attended.
38. On 7 January 2007, the man was given a second IEP warning for
continuing non-compliance with the rules of West Hill and abusive
outbursts. The SO, who gave the warning, indicated that the man
would not be given a single cell until his behaviour improved and that
his next “offence” would result in a move to the basic (lowest) level of
entitlements.
39. The man’s Home Detention Curfew (HDC) date was 25 January 2007.
He was told he had been refused the ‘tag’ on 10 January. The reason
given was that he was a ‘potential threat to public safety’.
40. Before a decision is reached by a governor grade (operational
manager) about whether a prisoner is to be released on HDC, the
views of prison staff, prison probation, home area probation and the
police are sought. Their views are taken into account and considered
alongside information such as the number of previous convictions,
outstanding charges and the risk predictor information for future
offending risk.
41. The section of the paperwork detailing the views of prison staff
included comments from both an officer and a wing SO from West Hill.
They commented that the man did not have any adjudications against
him. However, the man had not completed any offending behaviour
courses as he did not feel that he had any drug or alcohol problems to
address. The officer went on to say that the man’s behaviour was
generally good, but that he had a short fuse if he did not get his own
way. The SO was stronger in his comments and said that the man had
several incidents of not complying with unit rules, two Incentives and
Earned Privileges (IEP) warnings and was argumentative. He
expressed doubts about the man’s ability to comply with any HDC
conditions.
42. Hampshire Constabulary did not recommend the man’s release on
HDC. Their report indicated that there were several other matters
where he was either found not guilty or charges were not brought
against him. The report indicated that there was information that the
man was fraudulently claiming benefits for a vulnerable adult that had
been living at their address, but who had moved on over a year
previously. The officer compiling the report felt that the man’s
sentence did not reflect the extent of the crime for which he was
responsible.
43. The home probation report from the Hampshire Probation Area
indicates they did not recommend release on HDC either. The basis
for this was Crown Prosecution Service (CPS) papers that stated that
the man had solicited an individual to murder a witness (in the case for
which he was serving his current sentence) and that a police search of
his property had found a sawn-off shotgun. The Probation Area
acknowledged that the man had not been found guilty of these
offences but felt that they gave sufficient grounds for recommending
against early release on the grounds of public protection.
44. In light of the comments from the probation office and those from wing
staff, a Probation Officer from the prison probation team also felt that
the man would not be a suitable candidate for HDC on the grounds that
he would be a potential threat to public safety.
45. The governor making the decision about HDC took all of the above
information into account. He also considered the man’s history of no
previous convictions and his risk predictor profile for both a
reconviction and re-imprisonment (he scored ‘low’ on both). He
decided not to authorise release on HDC on the grounds that the man
was a ‘potential threat to public safety’. The Head of Residence
notified the man of his decision to refuse HDC on 10 January. This
meant that his release date would now be 8 June 2007.
46. The man lodged an appeal against the HDC decision that same day.
He said that he had only been convicted for ‘growing cannabis and to
supply’ and that he would have gone to Ford open prison as a category
D prisoner except that he was on a medical hold at Winchester. The
man went on to describe the situation at home and the medical needs
of both his wife and himself. The Head of Residence sent an interim
reply on 18 January stating that he had received some new information
from the man’s solicitor and that he would reconvene a board to
consider the facts as soon as the information had been clarified.
47. The man’s security category was recommended for change from
category D to category C on 18 January 2007. The reason given was
“information from probation and police that suggests the man is a
threat to other drug associates”. The upward recategorisation was
approved by the Head of Security on 22 January. This meant that the
man was no longer eligible to transfer to an open prison.
The day of the man’s death
48. The man was to attend the prisoner representative meeting on a
morning in late January 2007. As he was to raise questions about the
quality of the food, it is relevant to quote from the report of the prison’s
IMB for the year ending 2006. In their report, the IMB comment that:
”… the standard of food from the kitchen in the main prison has
been high and the Board receives very few complaints. This is a
remarkable achievement considering the age and condition of
the kitchen, its equipment and its location.
“West Hill and the Hearn Unit also receive cooked food from the
main prison, although funding has now been approved to create
a ‘finishing’ kitchen in West Hill … The prison buys food from a
variety of sources. Some 26% is bought from Leyhill prison and
there have been problems with the quality of its produce; the
potatoes in particular, are poor.”
49. The prisoner representative meeting usually starts shortly after
10.00am and is attended by a representative from each landing, the
Unit Governor, a kitchen staff representative, one of the gym staff,
someone from the canteen and an administrative member of staff. The
meeting is held every month and provides an opportunity for prisoners
to raise issues that affect their day to day life on the unit. This meeting
was the first occasion that the man had attended; he was just ‘filling in’
for the usual representative who was on a course that day. There were
eight prisoners at the meeting.
50. The minutes from the last meeting were reviewed and the discussion
then moved on to the quality of the food. It began with talk of the new
kitchen. The man asked to raise a few comments. He talked
specifically about the potatoes and cauliflower. He described the
potatoes as being black and that everyone on the landings complained
about them tasting horrible. He said the cauliflower was hard. The
man said he wanted to visit the kitchens for himself to see how food
was being prepared. The kitchen representative answered the man’s
questions and said that queries needed to be put to kitchen staff on the
day they occurred and that the food complaints book should be
completed. However, he said he did not object to the man visiting the
kitchen if the Unit Governor agreed. A prisoner who was present told
my investigator subsequently that the Unit Governor “fobbed the man
off” though and would not allow him to go. The prisoner said the
conversation between the man and the Unit Governor got more heated
at this stage. He recalled that the man may have sworn, but said the
Unit Governor remained calm and professional in his approach. In her
police statement, the administrative member of staff present said that
the man was getting quite wound up and was ranting and, although he
did not raise his voice, he was talking over the Unit Governor. In her
police statement the prison officer attending the meeting said that the
man spoke with a raised voice but was not shouting. She went on to
say that she could “not see why the man was agitated, there was no
argument, he appeared to just wind himself up.”
51. Whatever the exact sequence of the discussion, the man stopped
talking quite suddenly and appeared to slump in his chair and then fall
to his right onto the shoulder of the prisoner next to him. The
administrative member of staff said she could hear that he was having
difficulties breathing. People immediately got up and laid the man on
a row of chairs. One prisoner said that he thought someone said ”Call
a doctor” and then the other prisoners present were ushered out of the
room.
52. The prison officer present said she went over to the man but that, when
she could get no response, she ran out of the room to the unit office in
order to contact the healthcare centre. The unit SO was sitting in the
SO’s office in the wing when the officer entered. She said that she
needed healthcare as the man was having “an episode or fit”. The SO
said that the officer said something like “it’s a code 2 incident”. The SO
then left the room and the officer rang healthcare and gave them basic
details of what had happened. The SO went into the meeting room
and saw that the man was in the recovery position, lying on a row of
armchairs. He said he knew the man was not having a fit. Another
officer and the SO together checked the man. The officer made a
“code 1” radio message (code 1 is the code used to alert medical staff
of a life threatening emergency), and also asked for an ambulance.
The SO said the man’s breathing became very laboured and that he
was making snorting and snuffling sounds. The man then stopped
breathing. The staff shook him and the man took a few more breaths,
then stopped again. A nurse had just arrived at this point.
53. The healthcare centre received the code 1 radio message around
10.15am. A nurse went to the scene immediately. She also relayed a
message that an ambulance was required. The man was lying on his
right side on the chairs and, although not responding to the nurse, was
initially taking shallow breaths. The nurse decided to move the man
onto the floor and then inserted an airway. Using an ambubag, she
and the officer who had made the ‘code 1’ call (a trained first aider)
commenced cardio pulmonary resuscitation (CPR). She checked for a
pulse but could not find one at this time and so continued CPR. The
were two other nurses present. A defibrillator machine was attached to
the man. Following its guidance, the man was given two shocks, but
there was no output. A prison GP arrived about 10.25am and oversaw
the CPR and defibrillator process. The medical team agreed to stop
their efforts at 10.35am, about 15 to 20 minutes after CPR had first
commenced.
54. Two paramedics arrived after the doctor had certified the man’s death.
They told the ambulance to stand down.
55. The staff who had been involved were taken to one side and asked if
they were okay. Members of the Care Team within the prison came
and spoke to staff and the Governing Governor also came over later in
the day to talk to staff. A debrief was held at around 4.15pm. During
the debrief, the officer who had helped with CPR said that he felt there
should be defibrillator machines in all residential areas so that time was
not lost trying to access one. One of the nurses said that this had
already been discussed with the head of healthcare and that two more
machines were on order. The unit SO said he had spoken to some of
the prisoners who were at the meeting when the man died to see if
they were feeling okay. There was a service that afternoon in the
association room for the prisoners.
Informing the man’s wife of her husband’s death
56. By coincidence, a nurse who had been involved in the efforts to
resuscitate the man attended the same church as him and his wife.
She suggested that the prison contact a lay preacher from their church
and ask whether he would be able to go along with a governor to break
the news of the man’s death. The lay preacher agreed to this and they
went to see the man’s wife at about 2.00pm that afternoon to break the
news of her husband’s death.
57. A previous cell mate of the man spoke to his wife during her visit to the
prison on a few days after his death. He also spoke at the memorial
service held for the man and said that lots of prisoners from West Hill
attended the service.
58. The Governor wrote a letter of condolence to the man’s wife in late
January. He also wrote to other family members and reiterated that a
family liaison officer was able to assist with any information or advice
that they needed. The prison offered assistance with the funeral
expenses, an offer that was taken up by the family.
WHAT OTHER PRISONERS SAID
59. My investigator spoke to four of the man’s fellow prisoners. The first of
these moved onto West Hill unit at the end of November when the man
was already there. The two men shared a cell. The prisoner described
the man as very lively and enthusiastic and someone who liked to do
things his own way. He said the man was the sort who would speak
his mind. He said the man missed his wife terribly and would speak to
her on the phone every morning and night. The prisoner told my
investigator that the man was meticulous about taking his medication
and that he never missed a dose. He said that, on the day the man
died, he had got up and followed his normal routine and that at no
stage did he complain of feeling unwell – he said the man had seemed
fine. The prisoner was not at the prisoner representative meeting that
morning. After the man had died, the prisoner said that he thought the
prison was very good and remembered the chaplaincy service
speaking to the prisoners. He also thought some Senior Officers (SOs)
had been supportive.
60. The second prisoner moved onto West Hill in August 2006 and then
The Hearn in February 2007. He was a member of the prisoner
representative meeting and said that he knew the man “a little bit” from
just being around the landings. He described the man as someone
who was fun to be around and who made friends easily. He also said
the man was quite forthright and would “call a spade a spade”. The
prisoner said that the issue about the quality of the potatoes, discussed
at the prisoner representative meeting, had come up before. He said
that many prisoners thought the quality of the potatoes was very poor.
The prisoner described how the conversation between the man and the
Unit Governor became more heated when the latter would not agree to
the man going to visit the kitchens. However, he said that the Unit
Governor stayed calm and professional. Nevertheless, the prisoner felt
that the Unit Governor should have just ended the discussion and that
the situation might have contributed to the man’s collapse. After the
man had died, the prisoner said that he talked to an SO about what
had happened. He felt it would have been useful for him to have
written a statement about it all. The prisoner suggested that the man
should not have been allowed to go to the meeting because he “got too
irate too quickly”.
61. The third prisoner is the prisoner who asked to speak to my
investigator about the man’s death and who had subsequently been
transferred to another prison. He had worked in the library at West Hill
and said that the man was a regular visitor to the library in the months
leading up to his death. He described the man as a strong character
who “spoke his mind”. The prisoner said that he thought the man was
always slow when climbing the stairs to get to education or the library
and that he would get out of breath. The prisoner attended the meeting
at which the man died. He recalled that the man brought up the
subject of the kitchens and the poor standard of food but he did not
specifically remember that an issue over potatoes came up. He said
the kitchen staff did “not know how to handle the criticisms” and that
the Unit Governor responded by “belittling” the man. The prisoner
thought that the man then repeated his point about poor catering and
that the Unit Governor “fuelled the fire”. He said after a couple more
exchanges the man collapsed onto the wing representative sitting next
to him. The prisoner thought it might have been the prison officer who
attended the meeting who called for an ambulance and remembered
another officer coming into the room and asking all the prisoners to
leave. He said that, as he was walking down the corridor outside of the
room, the medical team were running in. He also thought he passed
the chaplain. The prisoner said he heard on the “grapevine” that the
man had died. He did remember the Governor putting up notices to tell
prisoners what had happened. The prisoner said that prison staff were
offered care and support but that the prisoners were not offered the
same service. He recalled attending a meeting about a week after the
man had died where they were told that the man would have died
anyway because of his medical history with heart trouble. The prisoner
did not believe this was strictly true. In his opinion, the exchanges
between the Unit Governor and the man played a “significant part” and
might have brought on his collapse.
62. The fourth prisoner had moved onto West Hill around the same time as
the man. He described the man as “a bit of a character” and said he
was rather set in his ways and would speak his mind. The prisoner
also said that the man would try to help people if he could and that,
because of his age, other prisoners listened to him. The man attended
the prisoner representative meetings on a regular basis. At the
meeting in question, the prisoner said that he could not remember
exactly what the man was talking about except that it he thought it was
something to do with the cooking. He recalled that the man asked to
go and visit the kitchens to look at how they were managing things. He
said the kitchen staff were happy with this as long as the Unit Governor
agreed. The prisoner said that the man was beginning to get wound
up. He could not remember the Unit Governor saying that the man
could not go to the kitchens, but he did remember the man being told
that he should use the food complaints book and that issues should be
brought up as they arose so that matters could be dealt with at the
time. The prisoner offered the view that the man was getting himself
too wound up by it all. He thought that the man had got his point
across and that he should have let things move on. But he said that
the man did not want to let the matter drop. According to the prisoner,
the Unit Governor let the man “rant on” for a bit, and then suddenly the
man fell onto him as he had been sitting next to him during the
meeting. The prisoner said that he thought initially that the man was
“playing around” but then he saw that he was shaking. He got up and
laid the man across the chairs. He thought the prison officer who
attended then left the room to call for medical staff. The prisoner said
the man’s breathing was initially like snoring, and that the Senior
Officer and Unit Governor tried to revive the man whilst medical staff
were on their way. The prisoner said he was told later that day by an
officer that the man had died. He attended the memorial service that
afternoon and remembered a few members of staff asking him if he
was okay.
63. The prisoner recollections of the man are that he was a likeable man
who was direct and not reluctant to speak up with his opinions. During
the meeting on the day he died, the man became worked up during his
discussions with the Unit Governor about the quality of the potatoes
and whether he would be able to visit the kitchens. Most of the
prisoners were of the view that the man “wound himself up”. The
recollection of all but one prisoner is that the Unit Governor stayed
calm throughout their discussions about the food. The man suddenly
and unexpectedly collapsed onto the prisoner sitting next to him.
There were no indications that he had been feeling unwell at any time
leading up to his collapse.
ISSUES CONSIDERED
Medical care
64. The clinical review was carried out by a panel of five clinical staff from
Hampshire Primary Care Trust. I am most grateful to them for their
work. Their review identified a number of points that I summarise in
the paragraphs below.
65. The man suffered from chronic long term conditions (coronary heart
disease and arthritis). He had previously undergone a coronary artery
bypass graft and was on medication for his angina. The medication he
was receiving was standard medication for somebody who had
suffered a myocardial infarction 15 years ago. The panel would expect
there to be a beta-blocker included in the medication, however there is
no information in the medical records whether or not a beta-blocker
was contraindicated. The PCT’s Medicines Management team also
commented on the lack of other anti-anginal medication such as a
nitrate. Nicorandil is generally not a first-line agent for the treatment of
chest pain so the panel would expect other medications to be
prescribed for angina. However, there were no recorded instances of
chest pain or complaints of coronary pain during the man’s time in
Winchester.
66. The medical records for the man indicate little in the way of chronic
disease management that the panel would expect to be provided to a
patient receiving primary care services. The records show one Blood
Pressure recording which is not dated. There is no other recording of
routine measurements or health promotion for a person with angina.
67. A hospital appointment for a hip block for the man was cancelled by the
prison with no reason recorded in his records. A further hospital
appointment for an x-ray at a county hospital was cancelled and
changed to a hospital more local to the prison.
68. The man’s medical records were factual, consistent and accurate but
not comprehensive. They were written in a timely manner but do not
necessarily provide current information about the care and condition of
the patient. The records are not perfectly legible, nor accurately dated
and timed. The records were respectful, consecutive, with a lack of
jargon or abbreviations. They identified problems but not the action
taken to rectify. There was clear evidence of the care planned but not
communicated and the basis for decisions was not clear. Actions to
the nursing care plans were also poorly documented in the records.
69. The panel considered the response to the man’s collapse to have been
appropriate and timely and the outcome could not have been avoided.
They panel made the following recommendations:
The process for assessment on admission (reception-screening)
needs to be audited to ensure compliance in relation to the
completeness of the assessment tool and the accurate
identification of patients requiring a medical assessment.
Patients with chronic disease and/or complex care management
needs should be identified on admission and seen by a doctor at
the earliest possible time. Management plans should include
regular review, and not merely consist of reactive responses to
isolated clinical events.
The Prison Healthcare Service should review its capacity to
manage patients with long term medical conditions, particularly in
light of the projected increase in the average age of prisoners.
This review should include an audit of the prevalence of chronic
disease in the prison and encompass the resources, expertise
and training that is required to manage patients with
complications, or complex nursing needs.
The primary care services provider should consider whether their
GPs and nurses with training and experience in chronic disease
management should work with the Prison Healthcare staff to
promote a more proactive approach.
A computerised clinical system should be put in place to assist
with record keeping, audit and chronic disease management.
70. In addition to the views of the clinical review panel, I also wish to
comment on the locally developed form entitled, ‘Secondary Health
Assessment’. This form was completed at some point regarding the
man. Unfortunately, the design of the form means that key information
such as the date of completion and the name and details of the person
completing the form are not captured. This form needs redesigning if it
is to be of value in capturing the medical details of a particular patient
at a given time.
The ‘Secondary Health Assessment’ form should be redesigned
by the PCT and Winchester so that it captures key information
such as the location of the prisoner, date of completion, name,
signature and job title of person completing the form.
Staff and prisoner statements
71. My investigator first spoke to the liaison officer at Winchester prison on
29 January 2007. During their discussion, my investigator asked the
liaison officer to send all of the relevant paperwork to my office so that
the investigation could begin. She specifically requested documents
such as the man’s core record, his medical record, prison contingency
plans for a death in custody and the staff statements. My investigator
subsequently received some papers in mid-February. There were no
staff statements in the paperwork that had been sent. My investigator
chased this up with the liaison officer during her visit to Winchester on
20 March. The liaison officer said that no staff statements had been
made other than the completion of the “Orderly Officer’s Incident
Report”.
72. My investigator then said that she had some information about the
man’s death in the medical record – entries made by the nurse and GP
who attended, but that all staff present should have made a written
statement as soon as possible after the man’s death whilst the details
were still clear in their minds. My investigator said that it might have
been appropriate to ask some of the prisoners who were at the meeting
to write down their recollection of events too. She said that she would
be speaking to some of those prisoners during her visit that day, so
there was no need to ask for statements from those people. However,
all of the staff who had not written an account of what happened should
be asked to do so now. The liaison officer agreed to arrange this and
to forward the statements onto my investigator. Unfortunately, none
was forthcoming.
73. Prison Service Order 1400 concerns Contingency Planning. In relation
to a death in custody, it states that the first on the scene should write a
statement to the governor about the incident and their actions. It goes
on to say that the duty governor must, “Take note of the names of all
staff and inmates who responded immediately to and/or witnessed the
incident. Inform those involved to remain in the vicinity pending the
taking of statements.”
74. It is useful for staff to write down their recollection of what has
happened, not just to assist in my investigation into the death, but also
because some or all of the staff present may be called to attend the
Coroner’s inquest. That may be several months or even years after the
death. Without a written statement to refresh their memory, staff may
find it difficult to give a full and accurate account and to explain what
actions they took to the Coroner.
The Governor should ensure systems are put in place so that all
relevant staff who are witnesses to, or involved in the
resuscitation or aftermath of a death of a prisoner, write a full and
comprehensive statement of their own recollection of events as
soon as possible after the death. The Governor should also
consider whether it is appropriate to ask some prisoners to write
a statement.
Home Detention Curfew
75. The man was refused release on Home Detention Curfew (HDC) on 10
January 2007. Had he been successful his release would have been
due on the day after he died.
76. Prison Service Order (PSO) 6700 on Home Detention Curfew states
that all prisoners who are serving sentences of over three months but
less than four years are eligible to be considered for HDC (unless they
fall into an excluded category, for example, sexual offences). The PSO
states that, “prisoners must normally be released on Home Detention
Curfew unless there are substantive reasons for retaining a prisoner in
custody until his or her conditional or automatic release date”. The risk
assessment to determine whether a prisoner is released or not “…must
take into account the prisoner’s previous convictions, the risk predictor
assessment based on those convictions and the report of the home
probation service…” Other documents, such as the pre-sentence
report should also be taken into account where they are available.
77. An enhanced assessment is completed for certain prisoners. The
assessment must be completed by a board comprising at least a
governor grade and a member of the seconded probation team. The
board must consider the various forms that have been completed and
other relevant factors such as “home circumstances and the stability of
close relationships”, “relevant behaviour in prison, for example
disciplinary offences” and “previous criminal history”.
78. The PSO states that, “It is not possible to guarantee an offender’s law
abiding behaviour upon release. The assessment of risk for HDC must
therefore balance any risk to the public presented by the bringing
forward of the release date against the potential benefits of
incorporating a period of Home Detention Curfew within the prisoner’s
sentence”. The PSO goes on to say that, “Assessment of risk must be
on the basis of objective evidence of the prisoner’s past record and
current behaviour, and must be conducted in a way that is consistent
with Prison Service values, rigorously and fairly and free from
discrimination.”
79. Section 5.13 of the instruction states, “… prisoners must normally be
released on HDC unless there are substantive reasons for retaining the
prisoner in custody until his or her conditional release date. The
reasons must fall under one of the five headings below:
(cid:127) an unacceptable risk to the victim or to members of the public
(cid:127) a pattern of offending that indicates a likelihood of re-offending
during the HDC period
(cid:127) a likelihood of failure to comply with the conditions of the curfew
(cid:127) lack of suitable accommodation for HDC
(cid:127) shortness of the potential curfew.”
80. The man was refused release on HDC and given the reason that he
was “a potential threat to public safety” (this falls under the first bullet
point from the above list).
81. The PSO goes on to further describe what “risk to the public” means
and states, “prisoners who present a clear and immediate threat to the
public must not be released on HDC. Prisoners must be refused HDC
on these grounds where they have displayed in their current, or
previous behaviour, a clear tendency to violent or sexual offending and
there is evidence to suggest that they continue to present an
immediate substantive risk to members of the public.”
82. I have already outlined in detail the contents of the reports from West
Hill unit staff, the prison based probation team, Hampshire police and
the probation team regarding the man’s release on HDC. None of the
reports was in favour of releasing the man on HDC. The most
influential report was from the man’s local Probation Office. They did
not recommend release for two reasons based on the Crown
Prosecution Service (CPS) summary papers.
83. First, the man had been accused of soliciting an individual to murder in
that he was alleged to have said to a named individual, “I need
someone shut up permanently … if you dispose of this one person, the
whole prosecution case will collapse.” The man allegedly then offered
to pay the named individual between £30,000 and £35,000. The man
had been charged with threats to kill under the Offences Against the
Person Act 1861. The hearing for that case had not yet been
scheduled.
84. Second, the police had searched a van belonging to someone other
than the man. In the back of this van they found a sawn off shotgun
and some other weapons. The owner of the van linked the shotgun to
the man and said that he had seen him with it. This had led to a
charge against the man of possession of a firearm but this was
subsequently dropped by the police and CPS.
85. The ‘Risk Predictor for Sentence Planning’ is used to give guidance
about the probability that an offender with the given history of offending
will be reconvicted within two years. It is meant to aid the judgement of
the person using the information. The man had no previous
convictions and only the impending prosecution outlined above. He
came out as ‘no history for a risk of reconviction for a violent offence’ a
‘low risk of reconviction for other offending’ and a ‘low risk of re-
imprisonment’.
86. It is entirely understandable that the Head of Residence, faced with
only recommendations against granting HDC to the man, decided to
turn him down. Had the man complained against the decision to the
Ombudsman’s office, I have no doubt that we would have found
against him. No one could argue that the Head of Residence’s
decision was unreasonable in the circumstances. That said, there
were other factors that might have acted in the man’s favour. These
factors included his age, the fact that he had no previous convictions
for either violent or non violent offences, that he was not particularly
mobile, that this was his first time in custody, that he had no
adjudications against him during his time in prison, that his risk
predictor for any type of reconviction or re-imprisonment was low, and
that he had a very close and stable relationship with his wife.
87. Moreover, the man was still a category D prisoner (on a medical hold)
at the time of the HDC assessment board. This fact was not recorded
on the HDC paperwork and does not appear to have been considered.
It is very rare, although not wholly unknown, for a prisoner considered
suitable for open conditions to be refused HDC. However, given that
the man was quickly recategorised to C after pointing out his D status
on his HDC appeal papers, it seems likely that the prison may have
overlooked his categorisation during his HDC assessment.
88. My investigator approached the Home Detention Curfew policy unit
within the National Offender Management Service (NOMS) for advice
about the appropriateness of the decision made by the Head of
Residence. The policy unit looked at all of the paperwork and said they
were, “satisfied that the governor made a sound decision based on the
information available to him … the proper procedures were followed
and the decision to refuse release was entirely appropriate”.
89. I make no formal recommendation but would invite the operational
managers who make HDC decisions at Winchester to refresh
themselves with the detail of PSO 6700.
The family’s concerns
90. The family friend made the following comments during a telephone
conversation with my senior family liaison officer on 22 February 2007:
(cid:127) He felt that Winchester had been generally good at dealing with the
family since the man’s death. He said the family was offered help with
the funeral expenses and that the prison had held a memorial service
for the man which he had attended.
(cid:127) He said that different arrangements could have been made for
breaking the news to the man’s wife. It would have been more
appropriate if the person who had gone to visit her with the prison staff
had been a family member - ideally a woman so that she could have
stayed to comfort the man’s wife, who was in a state of shock.
(cid:127) He would like to have the sequence of events leading up to the man’s
death explained to him, particularly facts such as whether the man was
standing or sitting when he collapsed.
(cid:127) He said he was aware that the man had been due for early release the
following week, but that this had been stopped because of the
reference to firearms on his file. He said that the firearms charge had
been dropped and he felt that the paperwork should not have had
firearms mentioned on it.
The way in which the news was broken to the man’s wife
91. It is normal practice for a prison to break the news of a death by
sending out two members of staff, often a senior manager and the
chaplain or a trained family liaison officer. Because a nurse happened
to know the family attended her own church, she suggested that the
prison approach the lay preacher of that church so that he could offer
some support when the man’s wife was to be told of the death of her
husband. This approach was adopted by the prison and I commend
them for trying to be as sensitive as they could be, given the situation.
92. Whilst I acknowledge that the man’s wife would have preferred the
prison to have contacted a female relative who could have stayed with
her after she was told that her husband had died, I find it hard to
criticise the prison for their handling of the situation. The prison acted
with the best of intentions and was not to know that she would have
preferred the news be broken in a different way.
The sequence of events during the prisoner representative meeting
93. I have given a detailed description of the meeting and the man’s
collapse on pages 14 to 16 of my report.
The man’s early release and the firearms charges
94. The man’s release on Home Detention Curfew and all of the issues
surrounding that decision have been explored in the section immediately
above this one.
Family response to the draft report
95. I received comments on my draft report from a family representative.
She raised a number of issues, which I address below:
Speed of the response to the man’s collapse
96. The family representative said that she was concerned that there was a
delay to the resuscitation effort when the man collapsed.
97.As I have described on pages 14-16 of this report, the man collapsed
just before 10.15am on 24 January 2007. After failing to get a
response from the man, a prison officer ran to a nearby office to
telephone the healthcare centre to request assistance. Another officer
made a “code 1” radio call for assistance shortly afterwards, at around
10.15am. A nurse went to the scene immediately on receiving these
messages.
98.The clinical review panel considered the response to the man’s
collapse to be “appropriate and timely”. I agree.
Medical record
99.The family representative said that she was concerned at the lack of
comprehensive medical records and assessment. She described the
man’s medical record as being “a bit hit and miss”.
100.As I have noted in paragraph 68, the clinical review team did not
consider the man’s medical records to be comprehensive. As such,
they made a recommendation regarding the introduction of a
computerised clinical recording system (see recommendation 5,
below). This recommendation was accepted by HMP Winchester.
The man’s reluctance to seek treatment
101. The family representative said that the man “would never have
wanted to seem ill”. She said that he would not have pushed himself to
get regular treatment as he would not want staff to think that he was
whinging.
102.It is common for prisoners to be reluctant to seek medical attention
when they are unwell. This is a choice that each individual must make.
However, the man suffered from chronic long term conditions, including
coronary heart disease. As noted by the clinical review panel in
paragraph 66, the man’s medical records “indicate little in the way of
chronic disease management that the panel would expect to be
provided”. In the case of a prisoner such as this man, who has
reported such conditions at his reception health screen, I would expect
healthcare staff to be proactive in providing management plans and
reviews.
103.The clinical review panel made four recommendations on this subject,
each of which has been accepted by Winchester (see
recommendations 1-4, below).
Pain relief for the man’s ulcer
104. The family representative expressed concern that the man was given
paracetamol for his ulcer, and felt that he should have had Co-
proxamol or Co-codomol instead.
105.On the day of his arrival at Winchester, the man was told that he might
not be able to take Co-proxamol as a painkiller for his ulcer as the
medication was being discontinued. The man apparently replied that
Co-proxamol was the only painkiller that you could take for an ulcer.
He was told that this was not the case and, on 11 September, was
seen by a doctor and prescribed paracetamol as a replacement.
106.The Clinical Governance Manager at the Hampshire Primary Care
Trust and a member of the clinical review panel, said that it would have
been appropriate to use paracetamol rather than Co-proxamol. I
agree.
The man may have been under stress at the time of his death
107. The family representative said that the man may have been stressed
because his application for release on the Home Detention Curfew
scheme (HDC) had been turned down. As I have discussed in
paragraphs 75-89 I consider the decision to refuse release on HDC to
be reasonable.
108. The family representative also thought that the man may have been
stressed because the person who he was alleged to have solicited to
commit murder was apparently on the same wing. There are no
entries in the man’s prison records to indicate that there were any other
prisoners on the wing with whom he did not get on or had a difficult
relationship. There are also no entries to indicate that he wished to
transfer to a different wing or put in an application for such a transfer.
Indeed, on 16 November, the man said that he was happy to stay at
Winchester until his medical appointments and follow ups had been
completed, rather than transfer to an open prison.
RECOMMENDATIONS
Recommendations 1 to 5 are from the clinical review carried out by
Hampshire Primary Care Trust.
1. The process for assessment on admission (reception-screening)
needs to be audited to ensure compliance in relation to the
completeness of the assessment tool and the accurate identification
of patients requiring a medical assessment.
The Prison Service accepted this recommendation and said,
“Computerised notes are in place which can be audited. Healthcare
managers have already been instructed to carry out daily checks on
reception screens”.
2. Patients with chronic disease and/or complex care
management needs should be identified on admission and seen by a
doctor at the earliest possible time. Management plans should
include regular review, and not merely consist of reactive responses
to isolated clinical events.
The Prison Service accepted this recommendation and said, “Practice
nurse to oversee all chronic disease referrals & follow ups”.
3. The Prison Healthcare Service should review its capacity to
manage patients with long term medical conditions, particularly in
light of the projected increase in the average age of prisoners. This
review should include an audit of the prevalence of chronic disease
in the prison and encompass the resources, expertise and training
that is required to manage patients with complications, or complex
nursing needs.
The Prison Service accepted this recommendation and said, “Audit to be
carried out by newly appointed practice nurse in conjunction with
healthcare manager (previously a practice nurse). New IT system will
enable closer monitoring and audit”.
4. The primary care services provider should consider
whether their GPs and nurses with training and experience in chronic
disease management should work with the Prison Healthcare staff to
promote a more proactive approach.
The Prison Service accepted this recommendation and said, “Recruitment
drive underway; now one practice nurse and two with practice nurse
experience have been appointed”.
5. A computerised clinical system should be put in place to
assist with record keeping, audit and chronic disease management.
The Prison Service accepted this recommendation and said, “IT system
Vision went ‘live’ in June”.
6. The ‘Secondary Health Assessment’ form should be redesigned
by the PCT and Winchester so that it captures key information such
as the location of the prisoner, date of completion, name, signature
and job title of person completing the form.
The Prison Service accepted this recommendation and said, “New format
on Vision in place; system automatically records details (e.g. .date /time /
nurse name)”.
7. The Governor should ensure systems are put in place so that all
relevant staff who were witnesses to, or involved in the resuscitation
or aftermath of a death of a prisoner, write a full and comprehensive
statement of their own recollection of events as soon as possible
after the death. The Governor should also consider whether it is
appropriate to ask some prisoners to write a statement.
The Prison Service accepted this recommendation and said, “This is
included in all contingency action sheets. The slippage in this case was
down to human error. Guidance has been given and a notice to staff will be
issued to reinforce this practice”.