Individual at Altcourse

INVESTIGATION INTO THE DEATH OF A MALE PRISONER
AT HMP ALTCOURSE ON 4 FEBRUARY 2005
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN
FOR ENGLAND AND WALES
JUNE 2005
This is the report of an investigation into the death of a male prisoner at HMP
Altcourse. The man apparently took his own life on Friday 4 February 2005, the day
he was due in court and with his trial to begin the following Monday. He was
charged with the murder of his long term partner and, by the time he took his life,
had been held on remand at HMP Altcourse for seven months. I hope that this
report will be helpful to the man’s family, and also to the prison as they look after
other prisoners in his situation.
The loss of a loved one is always distressing, but particularly so for a family which
had already experienced such grief and upset. I would like to add my condolences
to those already expressed by my Family Liaison Officer, on behalf of the
Ombudsman’s office.
This investigation has been undertaken by one of my investigators on my behalf. I
would like to thank the Director of Altcourse and staff for their participation in the
investigation. Merseyside Police provided invaluable information and assistance that
is much appreciated. North Liverpool PCT undertook a review of the man’s clinical
care, and I appreciate their assistance as well.
This published version of the report does not include the original annexes.
Stephen Shaw CBE June 2005
Prisons and Probation Ombudsman
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CONTENTS
Page
Summary 4
Conduct of the investigation 5
Background 6
HMP Altcourse 7
Key Findings 9
Recommendations and Good Practice 18
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SUMMARY
1 The subject of this report was born on 1 December 1942 and was 62 years
old when he died on 4 February 2005. He had been charged with the murder
of his long term partner and held on remand at Altcourse since11 August
2004. Between his partner’s death and being charged, the man received
hospital treatment for loss of consciousness, injuries to his hand and a
suspected heart attack. On reception at the prison, he was appropriately
placed on their Suicide and Self Harm monitoring arrangements for eight
days, in which time no incidents occurred and after which the close
observations ceased.
2 Throughout his stay at Altcourse, the prisoner continued to experience chronic
ill health and received extensive treatment from the healthcare centre and
from outside hospital. He was generally located on one of the prison wings,
but had occasional brief periods in healthcare.
3 The man was described by staff as fully compliant with the prison’s rules and
did not present any problems to the regime. He was older than many on the
wing and did not voice any concerns with his personal officer or other staff.
Remand prisoners at Altcourse are monitored in the same way as convicted
prisoners, but in his case there were omissions to the so-called Weekly
Behavioural checks conducted by his personal officer and in the monthly
manager’s monitoring. These omissions may not have been significant to his
decision to take his life, but should be corrected.
4 The prisoner who died was described as a quiet person, such that it was said
by one staff member that you would not know that he was there, and he did
not let staff know that his trial was due to start. The prison had no system
which would inform staff of events of this significance, even though they might
be considered an obvious source of anxiety for any prisoner. In this man’s
case, it was particularly significant as, at his trial, he would be confronted with
evidence of events of which he had always denied any recollection.
5. The man was found on the morning of 4 February with a bag over his head
and a ligature around his neck. Having discovered him, wing and healthcare
staff acted promptly in response and medical attention was provided speedily.
6. The investigation report makes recommendations for improvements to Suicide
and Self Harm arrangements, to the healthcare centre and the personal
officer role.
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CONDUCT OF THE INVESTIGATION
7. The investigation into the man’s death began on 7 February 2005 with a
meeting with the Director of Altcourse and representatives of the Independent
Monitoring Board and the GMB, the trade union recognised at the prison.
Notices were displayed to announce the investigation and invite prisoners and
staff to contact the investigator. In the event, there were no responses.
8. Three prisoners, including the man’s cell mate, were interviewed informally on
7 February. Formal interviews were conducted with 13 staff, including those
who knew the prisoner when he was alive, those who dealt with the incident
on 4 February and those responsible for the running of various aspects of
prison life. In addition, the man’s solicitor, who spent the day of 3 February
with him, was also interviewed.
9. The man’s family were contacted by the Family Liaison Officer and
commented on the healthcare he received at Altcourse.
10. Prison records, including medical records, were made available together with
relevant policies and procedures.
11. A clinical review was undertaken at the direction of North Liverpool PCT.
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BACKGROUND
12. The prisoner was born in 1942, and was aged 62 when he died. He had been
married and had two adult children, his daughter being named as next of kin.
His son was held in custody at the time of the man’s death. Before his arrest
the man who died had lived for eight years with his partner, who was the
victim of the offence with which he was charged.
13. His previous convictions were as a young man and he was last in custody
some 40 years earlier.
14. For many years, the man who is the subject of this investigation was reported
as having poor health and he had been prescribed pain relieving medication
for arthritis.
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HMP ALTCOURSE
15. HMP Altcourse is a male Category B local prison with an operational capacity
of 1,010. At the time of the man’s death, the prison had reduced its numbers
from 903 to 600 because one wing was closed for refurbishment. It opened in
1997 and is a privately managed prison, run by Global Solutions Ltd (GSL).
The prison has six main house blocks, each divided into two units.
Approximately a third of the prisoners are on remand and the remainder
convicted and sentenced or awaiting sentence. The full facilities and regime
of the prison are available to all. At the time of his death, the prisoner was
being held in the Melling Brown unit. The average age of the prisoners on
that wing was 29.
16. The most recent inspection of the prison by Her Majesty’s Chief Inspector of
Prisons was being carried out in the week that this investigation began and no
information from the inspection team is yet available. The director of the
prison reported that no concerns were identified about the procedures for
dealing with suicide and self harm. The previous inspection took place in
1999. It made a number of recommendations regarding suicide and self harm
arrangements, some of which have been acted on, and also included a
number of examples of good practice.
17. The most recent audit of Altcourse by HM Prison Service’s Standards Audit
Unit was between November and December 2004. It assessed four discrete
areas: Decency and Health, Organisational Efficiency and Effectiveness,
Regimes, and Safety and found that it was a high performing prison. The
report states that systems for suicide and self harm reduction appeared to be
firmly in place, with good identification systems and initial screening. There
were three minor aspects of the relevant standards which were not complied
with, relating to incomplete records and support plans which were
standardised rather than individualised.
18. The prison’s week day routine is as follows:
5:00 am roll check
6:15 am prisoners attending court are unlocked
7:15 am other prisoners are unlocked
8:00 am work, visits, programmes, education etc
12:00 am prisoners are locked in their cells and a roll check is
carried out
12:25 am lunch
1:00 pm work, visits, programmes, education etc
5:10 pm prisoners are locked in their cells and a roll check is
carried out
5:25 pm evening meal
6:15 pm evening association
8:50 pm prisoners are locked in their cells
after 9:00pm roll check
19. The roll checks at 5:00 am and before 9:00 pm are the responsibility of the
night staff, and the others are carried out by early and late staff who are
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required to check that each prisoner is present. Some day staff begin their
duties at 6:00 am as they are responsible for getting prisoners ready for court.
The rest of the day staff begin at 7:15 am and both groups work until 1:15 pm.
Late staff begin work at 1:00 pm until 9:15 pm and night staff work from 9:00
pm to 7:15 am.
20. The prison has two levels of response to prisoners who may be at risk of
suicide or self harm. The first is a local arrangement, the Suicide and Self
Harm (SASH) Form A, which is designed for occasions when a prisoner is in a
situation which may potentially be stressful, such as receiving bad news from
home, but is not actually indicating any intent to harm themselves. The Form
A is time limited to 48 hours, after which it must be closed or the prisoner
placed on the SASH book. The SASH book is the second local arrangement,
identical to the F2052SH used throughout the Prison Service. This is used
when there is direct evidence of self harm.
21. A third procedure for observation of prisoners is the First Night Watch for all
prisoners when they arrive until 10:00 am on the day after their reception. All
three systems include staff observations of the prisoner every 15 minutes
throughout the period of the watch. Prisoners on a SASH book are reviewed
each Thursday by a standing meeting of multi disciplinary professionals from
across the prison, including specialists such as the chaplain and probation as
well as representatives from each wing. Approximately 12 staff come to the
meeting, not all of whom will know each prisoner to be discussed. The
meetings are held in the prison boardroom and prisoners do not attend.
These arrangements differ from those in many prisons where review meetings
are held when most appropriate for the prisoner, and are attended by the
prisoner and staff who know him or her.
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KEY FINDINGS
22. The man’s partner was murdered during the night of 26 – 27 July 2004.
Cheshire Police were called to the house in the morning of 27 July as she did
not attend a meeting with a relative. The prisoner who is the subject of this
report was found unconscious in an upstairs bedroom and bottles of
medication were scattered about. There was a ligature in the house, but
Cheshire Police state that it had not been used. The man had an injury to one
hand and was taken under police guard to Whiston Hospital for treatment. He
remained unconscious for some days, but the blood samples taken by the
hospital were unfortunately mislaid, and so the diagnosis was not identified.
Whilst he was an in patient at the hospital, the man was suspected of having
a heart attack.
23. He remained under police guard at the hospital until 9 August when he was fit
for release and was taken into police custody. The following day he was
charged with the murder of his partner, and he appeared at Warrington
Magistrates’ Court on 11 August from where he was remanded into the
custody of Altcourse prison. The prisoner escort record (PER form) noted that
the man was at risk because of his medical condition, and his medication was
carried by the escort. He was also assessed as at risk of suicide and self
harm, and had tried to self harm in relation to the incident he was arrested for.
He made several subsequent court appearances and was seen by Cheshire
Police on these occasions, but they did not interview him after this date. The
solicitor representing him confirmed that he maintained throughout his arrest
and period on remand that he had no recollection of the events of 26 – 27
July.
24. The man who died arrived at Altcourse at midday and went through the
standard reception procedures. Reception staff recognised that the escorts
had identified him as being at risk and the Security Record (F2058) states that
because of this he was admitted to the healthcare centre, where he was
referred to a Registered Mental Nurse (RMN). In the induction interview, he
disclosed that he had been prescribed temazepam for many years and had
retired from work due to ill health. He said that he suffered from arthritis and
abscesses and had recently had a heart attack. He went on to say that he
had no immediate concerns. He was referred to a counsellor for support.
25. The first reception health screen records that the prisoner said he had not
seen a doctor recently prior to his admission at the prison and he was
prescribed medication for a heart condition. He had injuries to his left hand.
The man told the nurse that he had tried to harm himself in prison previously
by hanging, but he did not currently feel like harming himself. He asked to
see a doctor but the reason for the request was not recorded. The nurse
recorded that the prisoner appeared to be depressed and upset. Because he
was identified as having harmed himself before his arrival at the prison, and
was charged with a serious offence, the First Night Watch was supplemented
by the SASH book which was opened at 15:05 during his interview with the
RMN.
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26. The forms used to record staff observations are pre-printed with the times
every 15 minutes. In interview, the prison’s Suicide Prevention Coordinator
said that staff do not use the times on the form predictably as this would mean
that prisoners would be able to anticipate when they would be observed.
However, they do not record the actual time that the observation takes place,
although it could be of vital importance to some situations. Observations may
take place at any point in a 15 minute period and this should be identified as
otherwise a period of just short of 30 minutes may elapse between
observations.
The director is recommended to ensure that the actual time of each
observation is recorded in the record of all watches.
27. The man remained in the healthcare centre until 13 August when he was seen
by a doctor and assessed as fit for normal location, which should be in a
downstairs cell with a bottom bunk. This is the type of accommodation which
was allocated. Because Altcourse holds remand and sentenced prisoners in
the same wings, there is a procedure whereby prisoners are asked whether
they consent to sharing a cell with a prisoner of different status. The man who
is the subject of this report was asked this on 11 August and agreed to
sharing with sentenced prisoners. He was placed on Furlong Green unit,
which is the induction wing, until 23 August when he moved to Melling Brown,
which was where he died. At the time the man was there, Melling Brown held
enhanced sentenced and remand prisoners. Prisoners in the enhanced
category are those who comply with the prison’s requirements and so have
earned additional privileges. In interview, the director of the prison said that
holding sentenced and remand prisoners together contributed to a more
settled regime which would be beneficial to all. He confirmed that the man
was likely to be older than most of the other prisoners on the unit.
28. The SASH book remained open when the prisoner moved on to the wings and
15 minute observations were continued. The watch records do not record the
time that the observations actually occurred and the entries are brief. There
are more detailed entries in the Daily Supervision and Support record, which
is part of the SASH book. These indicate that the man communicated with
staff and prisoners alike and there were no SASH issues. The first review
was held on Thursday 12 August, a day after it was opened, and the record
states that it was too early to remove him from it. The support plan merely
stated that staff support should be given and no details were included as to
how that should happen or how it should be made most relevant to the
prisoner. It did state that, when managed in normal location, the 15 minute
watch should continue and the man should be in a double cell and receive
RMN support.
29. The man attended court on 16 August and the observations were continued
by the escorting company.
30. The SASH book on the man was reviewed again on Thursday 19 August and
the record states that he has been settled and not self harmed since arrival at
the prison and it was deemed safe to remove from watch. The review
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meetings followed the standard prison procedures and so were held on a
regular day, with the standing members and without the prisoner attending in
person. These arrangements differ from those in the public Prison Service
and may not provide the best decision making for each individual prisoner and
should be reviewed.
The director is recommended to review the standing arrangements for
SASH review meetings to ensure that they promote individualised
decisions and that prisoners can participate.
31. The man was not subject to either the SASH Form A or SASH book during the
rest of his time at Altcourse. There is no indication of any actions by him
which should have led to either of the arrangements being reinstated.
32. It is standard procedure at Altcourse for all prisoners, whether remand or
sentenced, to be allocated a personal officer. The procedure is designed as a
means for prisoners to have a named individual officer to deal with any
requests and for the officer to focus on any poor conduct. The aim is that the
prisoner builds up trust with a member of staff which should assist custody
planning. The personal officer should also complete a Weekly Behavioural,
which is a face to face discussion to consider any conduct matters. The
Weekly Behaviourals are monitored by a monthly Management Review. The
records of the weekly and monthly checks are held in the prisoner’s F2058 but
in this case many are missing. In the months between his arrival at Altcourse
and his death, there are only four records of Weekly Behaviourals and two
Management Reviews. I conclude that the system for monitoring prisoners
did not operate properly as far as the subject of this report was concerned.
The director should remind all staff that the routine for personal officers
to carry out weekly checks and for managers to monitor them each
month is to be implemented according to the prison’s policy.
33. The arrangements for allocation of personal officers changed during the
man’s time at the prison, but for most of the time he had the same personal
officer. In interview, his personal officer said that he did not think he had
received sufficient training for the role, that he was not in the practice of
introducing himself to prisoners and that the prisoner concerned had not
approached him with any issues.
The director should review the training offered to personal officers to
enable them to carry out the role properly.
34. Another standard Altcourse procedure is for all prisoners, whether remand or
sentenced, to have a Custody Plan Review. These should be held each
quarter and should be attended by the prisoner, the personal officer if they are
on duty, the wing manager and the probation officer. The purpose of the
meeting is to look at any issues raised in the weekly and monthly checks and
make plans, for example, to attend offending behaviour courses. In the case
of the man who died, reviews took place as required and were held on 9
11
November 2004 and 10 January 2005, but different staff chaired each
meeting and his personal officer attended neither.
35. In interview, one of the managers of the Melling Brown unit, who also chaired
the Custody Plan Review of 9 November, described the prisoner as a quiet,
unassuming older man who attended education and never presented a
problem to wing staff. As an example, he said that the man was always ready
at the gate and never had to be reminded to get ready for appointments.
36. The Custody Plan Review of 9 November commented perceptively that the
prisoner may become distressed when the evidence is presented to him in
court because he maintains he has no recollection of the offence.
Regrettably, it was not apparent that these comments informed subsequent
arrangements for the man, and in interview neither the personal officer nor the
manager of the Melling Brown unit said that they were aware that his trial was
about to begin. The man who later died had not told them, and there was no
other means which would have given them the information - even though an
imminent trial might well be a factor which increases the risk to prisoners. All
staff receive annual Suicide and Self Harm Awareness training which covers
risk factors such as trigger points. But this is of limited benefit if information
about individual prisoners is not available.
The director should review ways of informing wing staff and personal
officers of events that might increase the risk to prisoners.
37. The second Custody Plan Review on 10 January was brief. It recorded that
the man had no issues with his family. There is a section of the form entitled
Expected Outcome, which enquires about a possible sentence plan for
prisoners who are expecting a custodial sentence. In this case, that section of
the Review is marked N/A.
38. It is also standard procedure at Altcourse that prisoners facing the possibility
of a life sentence are interviewed by either a probation officer or Lifer
Manager soon after they are received at the prison. Subsequent interviews
are only arranged for specific purposes or at the request of the prisoner. The
man’s interview took place on 17 August with a probation officer at the prison,
who recorded on the F2058 that the lifer process was explained to him but he
refused an information booklet. An internal audit by the Lifer Manager
subsequently discovered that their record of the interview had been mislaid
and so the interview was repeated at a later date.
39. Throughout the man’s time at Altcourse he made extensive visits to the
healthcare centre. His requests were recorded in out dated terminology, such
as “attended special sick” and reported for “sick parade”. Terms such as
these contrast with the usual interaction between staff and prisoners at
Altcourse, which is positive, respectful and individualised. The Director may
wish to review the use of terms such as these, and consider how they can be
replaced with ones which are more appropriate.
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40. The Registered General Nurse (RGN) was interviewed for this investigation
as she attended the man on his death. She also knew him when he was alive
and described him as a quiet and amenable individual, who always had
genuine clinical complaints and whom she recognised because of his age and
because he had been at the prison for a long while. On approximately 30
occasions he attended for dressings to the injury to his left hand. As well, he
made at least 12 requests to see the doctor because of various complaints,
including pains to the arm and hip and, on two occasions, complaints of chest
pain. On four of these occasions, he was admitted overnight to the healthcare
centre and on 21 October he attended Fazakerley Hospital as an out patient.
The clinical record does not state the purpose of this appointment but it does
contain a letter from the Department of Pain Relief which proposes specific
medication.
41. The man’s healthcare is assessed more thoroughly in the clinical review
carried out by North Liverpool PCT. But this investigation attempted to
explore whether there were any arrangements for a holistic review of the
needs of a patient who presented at healthcare so frequently. In interview,
the healthcare manager said that the doctor would have the patient’s full
clinical record to hand at each appointment and could arrange such a review.
However, the healthcare manager thought it likely that the frequency of
appointments was due to him suffering a long term chronic condition. The
Registered General Nurse also said that she did not think the frequency of
appointments was unusual for a man of the prisoner’s age and condition.
42. The man remained on Melling Brown, in a ground floor cell and sleeping in the
bottom bunk. The wing observation books for his period on the wing contain
no entries about him, other than one entry about the need to locate a record
after a court appearance.
43. On 17 November, the prisoner successfully applied for level 4 status, which is
the highest level in the prison. It means that the prisoner is fully compliant
with the demands of the regime and that they are entitled to enhanced
privileges such as extra visits and cash.
44. On 10 January 2005 the man had a physiotherapy appointment, and
reminded the physiotherapist that six months had elapsed since he injured his
hand. At the time of the injury, he had been advised to wait until six months
after his heart attack, and then seek advice about reconstructive surgery. The
physiotherapist informed the prison’s doctor of the man’s request, and the
next day a letter was sent to the orthopaedic surgeon at Fazakerley Hospital.
The man had a further physiotherapy appointment on 31 January.
45. In Paragraph 37 of this report, I say that the internal audit carried out by the
Lifer Manager identified that the record of the man’s interview as a Potential
Life Sentence Prisoner had been mislaid and so, rather than have a gap in the
records, she decided to repeat it. The interview was carried out on 2
February and is recorded on form LSPO. The Lifer Manager said that she
introduced herself and her role. She described the prisoner as well informed
about the legal processes, saying that there were medical reasons which his
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legal team were looking at which he hoped would get him off the charges.
The record of the interview states that the man said that his head was
cabbaged when he was admitted to the prison, but that by this time he was
thinking and feeling straighter. The Lifer Manager said that he used the word
‘cabbaged’, which she had heard previously from prisoners charged with
serious offences to describe coming to terms with what they have done. She
asked whether he felt like harming himself, and the prisoner said that he
would have done so in the early days at the prison but would not do so now.
She informed him of the various sources of support within the prison, but said
that the man replied he was fine.
46. The following day (3 February), the man had an all day meeting with his
solicitor, his counsel and clerk. In interview, the solicitor said that he had
known the subject of this report since he was charged with the murder of his
partner. The solicitor was aware at their first meeting that the man was under
constant surveillance by the police and suspected that this was because he
was considered to be a suicide risk. The solicitor himself said that he
considered this possibility at the beginning of their acquaintance and
subsequently. The solicitor stated that there was no occasion when he
considered that he needed to alert the prison of specific risks, and the man
never suggested that he was likely to harm himself. However, he also said
that he assumed that Altcourse would be monitoring the situation because
they were aware of the nature of the charges and that the trial was
approaching.
47. The man’s solicitor said that he was aware of the man’s physical condition
and that he raised it with the prison. He described the man’s physical and
mental health in the early stages of their relationship as being at a low ebb,
but that he seemed to get stronger as time went by. He complained of poor
sleep and lack of medication, but not to the extent that the solicitor was asked
to write to the prison. He described him as having a degree of physical
disability but that his gait improved and his arm injury was healing.
48. The solicitor said that he had a number of meetings whilst the man was
remanded in custody. Throughout them the man said that he had no
recollection of the night of 26 – 27 July. The solicitor said that this made it
difficult to advise how he should plead and so a trial was inevitable. In order
to investigate the man’s claim of lack of memory he arranged for a report by a
consultant neurologist to be prepared as well as the routine psychiatric report
prepared for all offences of this nature. Neither of these reports have been
made available to this investigation.
49. During the meeting on 3 February, the solicitor said that they went through the
likely events of the trial, the possible length of sentence and the benefits of
pleading guilty. The prisoner had previously refused to have legal papers in
his possession, but at the court hearing of 13 January he had requested a
copy of a forensic report which set out the evidence and made it clear to him
that no one else could have been involved in the crime.
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50. The meeting between the man and his solicitor ended at about 4:30 pm and
the latter said that he would see him in court the next day, with a further
meeting arranged for Saturday 5 February. The man then returned to the
wing where he had his evening meal and evening association, and where he
was locked up for the night by one of the wing officers. The night roll checks
were carried out by another prison officer. The records of this period are
routine and do not contain anything untoward in respect of the man who died.
In interview, the officer who carried out the night roll checks described the
5:00 am check on 4 February, saying that all the prisoners appeared to be in
their beds and at 5:50 am he passed the head count information to the control
room. He said that he could see a shape on the bottom bunk which he took to
be the prisoner sleeping there.
51. According to this officer, at 6:00am he began to wake the prisoners for court.
They included the man who is the subject of this report and so he knocked at
cell 6. He saw the prisoner on the top bunk lift his head and he assumed that
this was the man. One of the day staff had been asked to go to another part
of the prison but called first to Melling Blue to look for a colleague. He was on
the wing at 6:10 am and volunteered to take the court prisoners off the wing,
the officer who conducted the night roll checks having told him that he had got
a response from all the cells and all the prisoners were awake. He used his
keys and at about 6.30 am unlocked cells 2 and 5 before reaching cell 6 on
the ground floor about five minutes later. The day officer said that he did not
notice anything when he first opened the cell, but then saw the prisoner in a
kneeling position on the floor, partly obscured by clothing hanging from the
top bunk, and with a white bag on his head. He noticed that his knuckles
were white, but his first thought was that the prisoner was going to jump up at
him.
52. The day officer was not carrying a radio so he called to the prison officer who
carried out the night roll check to join him and he called code 1 at 6:42 am,
which is the Altcourse code for a serious incident and summons all staff
including healthcare. He took the bag off the man’s head and saw a ligature
round his neck, attached to the rail of the top bunk. The officer responsible for
the night roll check was carrying a ligature knife and had been trained to use
it. He used the knife to remove the ligature, whilst the day officer lifted the
prisoner by the elbows to take his weight. They laid the man on the cell floor
and the cell mate was sent out of the cell into the dining area. The prison
officer who conducted the night roll check said that he, like all staff, was first
aid trained, and so was able to check the vital signs of pulse and breathing.
He said that he was able to recognise that the vital signs were missing
because the prisoner’s face was discoloured and his tongue was swollen. As
a consequence no attempt at resuscitation was made. The cell was locked
with the man who died inside.
53. At 6:45 am the control room telephoned for an ambulance.
54. The cell was reopened when the Night Duty Operations Manager arrived. He
said that on arrival he took charge of the incident and attempted first aid. The
on-site Registered General Nurse said that she heard the code 1 at about
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6:40 am and went to the wing, followed by a Healthcare Assistant, who
carried the grab bag with resuscitation equipment. The Night Duty Operations
Manager and the Healthcare Assistant lifted the prisoner on to the floor
outside of the cell so that there was more space for them to work on him. The
Registered General Nurse began CPR and placed the defibrillator pads on the
man. She checked with the Night Duty Operations Manager that he had
already telephoned the control room to call for an ambulance, and carried on
attempting to resuscitate the man who later died.
55. The ambulance arrived with the paramedics at the prison at 6:50 am, and they
were escorted to Melling Brown where they took over from healthcare staff.
They applied their own pads before one of the paramedics said that he did not
think they were achieving anything. The on-site Registered General Nurse
said that the paramedics and healthcare staff agreed that CPR should cease
and the man was pronounced dead at 7:10 am.
56. The man was placed back into the cell and placed on the bottom bunk. The
on-site Registered General Nurse said that she attended to the prisoner who
died to preserve his dignity, straightening his limbs and trying to shut his eyes,
before the cell was double locked for security by the Night Duty Operations
Manager. By this time, the Healthcare Assistant had gone to the wing office
to attend to paperwork and other staff on the scene were dealing with the
other prisoners who were locked in their cells. The dead man’s cell mate was
placed in a different cell with a friend. He was placed on a Form A watch at
9:47 am and was given support by the chaplain and others. He was spoken
to informally as part of this investigation and has subsequently been released
from prison. In his statement to the police, the man’s cell mate said that he
and the man went to bed as usual but that the latter gave him the television
remote control instead of keeping it himself as was their routine. He said that
he did not hear anything during the night and first became aware of his cell
mate’s death when he was woken by staff the next morning.
57. The Duty Governor of the day was notified of the incident at 6:45 am as she
drove to work. She made sure that the prison’s contingency plans were being
followed and, on arrival at the prison at 7:15 am, took charge in the command
suite which had already been set up. She ensured that the police, prison
director, GSL head office and other relevant people were informed as
required.
58. The contingency plans designate the duty chaplain as the family liaison
officer. She was paged at 7:10 am when she was on her way to work and
went straight to the command suite to get the necessary information.
Because she was concerned that the man’s family might be leaving home to
accompany him in court, she took the decision to notify them of his death over
the telephone rather than in person and this was done at 8:10 am. She was
aware that the man’s son was in custody and checked with the family how
they wished him to be informed. Later that day, both she and the Duty
Governor visited the man’s daughter to offer condolences and provide
information.
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59. The wing manager came on shift at 7:15 am, by which time he said the
incident on the wing had largely been dealt with. He placed an officer on duty
outside the cell and the other prisoners remained locked up instead of being
unlocked for breakfast, unless they were escorted for appointments. In
interview, he said that the other prisoners were respectful of this arrangement
and the atmosphere on the wing was quiet.
60. The police arrived at the prison at 7:32 am and were escorted to the wing by
the Night Duty Operations Manager. They took responsibility for informing the
coroner of the death as the prison had been unable to get through on the
telephone.
61. As some staff had been relieved of their duties and had left the prison, the
Duty Governor decided she would divert from the contingency plan and would
not hold a hot debrief meeting for all those involved in the incident. Whilst this
is understandable, it meant that some staff were unaware of the role played
by others and did not have the opportunity to receive feedback on their
actions.
The director should remind senior colleagues that a hot de-brief should
take place after any death in custody in order that staff can participate
and lessons can be learnt.
62. Later in the morning, the Duty Governor briefed the wing manager, and he
identified the man’s body before it was released to the undertaker at 11:30
am. The wing manager said that he undertook this task because he felt it
right to take responsibility. The command suite was closed at 11:59 am.
63. All staff interviewed for the investigation spoke highly of the support offered to
them individually by colleagues and senior managers as well as receiving
letters from GSL to offer external counselling support.
64. Immediately after the incident, GSL commissioned an internal review of the
events in order that any lessons could be learnt. In addition, the Lifer
Manager has decided to make three changes to the way her office. Future
interviews with potential lifers will be carried out jointly by herself and the
probation officer so that both staff will know the prisoner, and afterwards all
such prisoners will be put on a Form A watch in recognition of the potential for
distress from the subject of the interview. Additionally, she is exploring how
information about court dates can be shared and consideration given to
whether a prisoner should be placed on a watch.
65. The changes in procedures introduced at Altcourse are to be welcomed.
However, given the circumstances described in this report, I do not believe
that the man’s death could have been predicted by staff. Prisoners who have
committed violent acts within the family are an at-risk group. However, for
many months after first reception at Altcourse, the man who died had
presented a quiet and placid demeanour despite his many medical needs.
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RECOMMENDATIONS
Local Recommendations
SASH procedures
1 The Director should ensure that the actual time of each observation is
recorded in the record of all watches.
2 The Director should review the standing arrangements for SASH review
meetings to ensure that they promote individualised decisions and that
prisoners can participate.
3 The Director should explore ways of informing wing staff and personal officers
of events which might increase the risk to prisoners.
4 The Director should arrange for a hot de-brief to take place after any death in
custody in order that staff can participate and lessons can be learnt.
Personal Officers
5 The Director should ensure that the routine for personal officers to carry out
weekly checks and for managers to monitor them each month are
implemented according to the prison’s policy. He should also provide training
to enable all personal officers to carry out the role properly.
Healthcare
6 The clinical review makes four recommendations to the prison and Veritas
Limited, provider of healthcare, to improve the provision of healthcare for
prisoners.
GOOD PRACTICE
1 The prison is to be commended for making the personal officer arrangements
available to all prisoners, including those held on remand.
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