Individual at Bedford

Investigation into the circumstances surrounding the
death of a man at HMP Bedford
on 22 February 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
May 2008
This is the report of an investigation into the circumstances of the death of a
man on 22 February 2007 at HMP Bedford. The man was found in his cell
with a ligature around his neck attached to toilet handrails. He was 37 years
old.
I would like to offer my sincere condolences to the man’s family and those
touched by his death. I apologise for the delay in completing this report.
The investigation was undertaken on my behalf by a colleague. Both she and
I would like to thank the then Governor of Bedford, and the appointed Liaison
Officer, for their cooperation during the course of our inquiries. I would also
like to thank the second Governor at HMP Woodhill for facilitating our
investigation.
The man had been in custody at Woodhill between October 2006 and
February 2007. He left Woodhill to attend court on 12 February 2006 but,
following his appearance, was taken to Bedford because it was closer. The
man was only in Bedford for ten days before he died.
Although designated a rule 45 (vulnerable) prisoner, the man was housed in a
dedicated cell in a normal wing as there was no room in the vulnerable
prisoners unit. The location of the cells allocated to vulnerable prisoners
allowed for only poor observation by staff. As a result, the man experienced
intimidation and threats from other prisoners, a wholly unacceptable situation.
I have been pleased to learn of the Governor’s prompt action in response to
my investigation in reallocating the cells closest to the wing office for use by
vulnerable prisoners.
The man did not eat for five days and his collection of meals and intake of
food was poorly monitored. The reasons were not sufficiently probed as staff
were unclear as to the procedures when a prisoner refuses food. By the time
it was discovered, nurses were concerned about the man’s state of health. I
make three recommendations in total, including one about dealing with food
refusal.
This version of my report, published on my website, has been amended to
remove the name of the man who died and those of staff and prisoners
involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman
February 2008
CONTENTS
Summary
The investigation process
HMP Bedford
Key findings
Issues
- Response to bullying allegations
- Rule 45 prisoners on D wing
- Food refusal
- ACCT
- Healthcare
- Crisis management
- Conclusion
Recommendations
Annexes
SUMMARY
The man was remanded to HMP Woodhill on 17 October 2006, having been
charged with sexual offences. It was noted on reception that he had
previously attempted suicide, and for a short period he was supported using
the Assessment, Care in Custody and Teamwork (ACCT) document (used to
support and monitor those thought to be at risk of self harm).
The man was transferred to HMP Bedford following a court appearance on 12
February 2007. He had been expecting to return to Woodhill and was
unhappy about being at Bedford. He applied for rule 45 status (under which
prisoners considered to be vulnerable are located away from other prisoners
for their own safety). In this man’s case, he felt under threat due to the nature
of his alleged offences. However, the wing for rule 45 prisoners was full, so
he and his cellmate were moved to a normal residential wing (D4 landing).
Over the next five days, the man and his cellmate were subject to abuse and
threats from other prisoners which led to them both declining their meals.
Healthcare staff were notified on 17 February and the man was found to be
dehydrated with low blood sugar levels. He was admitted to the healthcare
centre and an ACCT was opened. However, once in the healthcare centre
the man began to eat again. Following an assessment and case review on 18
February, the ACCT was closed. It was felt that the man’s food refusal had
largely been a protest at being in Bedford, and staff were looking into the
possibility of a transfer. Whilst the closure of the ACCT was reasonable, the
man was still concerned about being housed on D wing. The man mentioned
several times about being intimidated on D wing and my investigators found
that this had not been fully considered by staff.
During the night of 21/22 February 2007, the man was checked more
frequently than was formally required, the last check being at 7.30am when he
was in his bed. Just before 8.00am, an officer entered his cell to find the man
on the floor with a ligature around his neck attached to the handrails in the
toilet area. She summoned assistance, the ligature was cut and nurses
attempted to revive the man. The ambulance crew continued attempts, but to
no avail.
Following the man’s death, all contingency plans were followed and staff and
prisoners were well supported.
Two major issues emerged from the investigation. I found the location of the
cells for rule 45 prisoners on D4 landing unacceptable as they afforded poor
observation from the wing office. The Governor has since changed the cells
to be closer to the staff office. Secondly, staff were unclear about how to deal
with prisoners refusing food. In the man’s case, this was not properly
monitored or recorded, nor the reasons for refusal fully explored. Healthcare
staff were not informed until it was identified that the man had not eaten for
five days. Once this was identified and healthcare staff assessed the man, he
was appropriately moved to the healthcare centre and an ACCT was opened.
THE INVESTIGATION PROCESS
1. I appointed my colleague to lead the investigation on my behalf. She
visited HMP Bedford where she met the then Governor. On her initial
visit, she was given a tour of Bedford, including the cell where the man
had died. She met members of the local committee of the Prison
Officers' Association (POA) and the Independent Monitoring Board
(IMB). Notices were issued to prisoners and staff at both Bedford and
Woodhill, inviting anyone who might have information relating to the
man to make themselves known to the inquiry.
2. My colleague and one of my family liaison officers, visited the man’s
parents and partner to discuss the investigation and ascertain any
particular family concerns and questions. The man’s family said that
he had seemed content and settled at Woodhill, and were concerned
he had deteriorated in such a short period of time at Bedford. They
asked if the man had been taking medication and whether this had
been monitored. The man’s parents also sought more detail of the
checks on prisoners and if anything had happened to him the evening
before his death. These issues are explored further in the report.
3. The man’s parents also felt that he had friends at Woodhill, with one in
particular close and supportive friend. They felt the absence of this
friend was a key factor in the man’s depression
4. My investigators interviewed staff and prisoners at both Woodhill and
Bedford, formally and informally. The team examined the man’s prison
record, medical records and a series of prison documents.
5. My colleague asked Bedfordshire Primary Care Trust to undertake a
clinical review of the man’s healthcare in custody. They commissioned
an independent healthcare consultant, to undertake the review. Once
the investigation was complete, she provided feedback to the Governor
regarding her concerns.
HMP BEDFORD
6. HMP Bedford is a local, category B prison, serving the courts of
Bedfordshire and adjoining counties. It was built in 1801 and enlarged
in 1849. A new gate lodge, houseblock and healthcare centre were
added in early 1990s. There is 24 hour medical cover and 12 beds are
available in the healthcare centre.
7. HM Chief Inspector of Prisons, last inspected Bedford in April 2006.
The inspectors found that the prison was performing reasonably well
against the four tests of a healthy prison. The inspectors said the
prison was generally safe, providing a well controlled environment.
However, more work was needed in supporting victims of bullying and
challenging those who bullied.
8. The Chief Inspector reported that a safer custody meeting was held
every month, attended by the violence reduction coordinator and
suicide prevention coordinator, as well as representatives from other
departments such as healthcare, the chaplaincy, CARATS and mental
health in-reach staff. All incidents of self-harm and bullying were
discussed at this meeting, and any trends identified were analysed. In
addition, both the violence reduction and the suicide prevention
coordinators highlighted areas where policy or good practice was not
being adhered to. A violence reduction survey of both staff and
prisoners had been conducted in January/February 2006 and its results
indicated that most prisoners felt safe at Bedford, and that incidents of
bullying were rare.
9. The inspector said Individual relationships between staff and prisoners
were generally good. Prisoners described their treatment by staff as
good, and the inspectors saw and heard staff behave only in a
professional and respectful manner in their routine dealings with
prisoners.
10. Inspectors were concerned that the in-patient regime for prisoners in
the healthcare centre was poor. They made a recommendation that
the programme to install in-cell electricity be extended to include the
healthcare accommodation.
11. F wing holds 30 prisoners and is used solely to house prisoners under
rule 45. These are largely, but not exclusively, those charged with sex
offences. When F wing is full, prisoners subject to rule 45 are held on
D wing for as short a time as possible until a space becomes available
on F wing. Rule 45 prisoners on D wing are taken to F wing for
exercise and association, but take their meals and showers in D wing.
For this, they are unlocked separately from other prisoners. Staff told
my investigators that it varied how often D wing needed to be used as
an overspill, but the cells were not constantly in use for rule 45
prisoners.
KEY FINDINGS
12. On 17 October 2006, the man was remanded into Woodhill prison,
pending trial for alleged sex offences. The man felt depressed. He
told staff he had felt suicidal in the past and had not eaten for nine
days. When he spoke with clinical staff, he said that he was feeling
better. He began to eat and no longer wanted to harm himself.
13. The man’s time in Woodhill was unremarkable. At first he was a little
nervous, and was supported by other prisoners from the “Insiders”
scheme (under which trusted and trained prisoners support others in
prison, particularly in the early stages of custody). Generally, the man
seemed to settle in well and was described by staff as quiet and
pleasant. He made friends easily as people warmed to him, and he
associated with a small group of other prisoners.
14. In December 2006, the man became withdrawn. A prison officer
remembered that other prisoners spoke to him about their concerns
that the man had been discussing self-harm. The prison officer spoke
with the man directly. He said that the man was quite tearful and upset
as social services had prevented him from having access to his
children. The sense of loss was worse leading up to Christmas. The
man had lost his appetite and was only eating a small amount of food.
15. The prison officer opened an ACCT form. The man was not thought to
be actively suicidal, but was finding things difficult and needed extra
support. The man admitted he had previously attempted self-harm by
cutting at HMP Bedford, and by overdose and ligature at HMP
Wayland, but this was some time ago and he no longer felt suicidal.
The prison officer told my investigators that the man then settled quite
well, “he became quite sociable within the prison groups, freely spoke
to other prisoners, spoke to staff, and joked with staff and prisoners.”
The ACCT was closed on 29 December 2006.
16. The man worked as a cleaner in the prison and seemed to be
progressing well. At the end of January 2007, he visited the prison
doctor, complaining of sickness, headaches, depression and poor
appetite. He reported that his headaches were worse during the night
whilst watching television, and that his last eye test had been seven
years previously. The man said he was not eating very much because
of nausea and vomiting and that his sleep pattern was poor. The
doctor documented that there was no evidence of psychosis and the
man denied any thoughts of self-harm or suicide.
17. On 30 January, the doctor prescribed sominex 40 mg at night for
insomnia, chlordiazepoxide 20mg twice daily for anxiety, nefopam
60mg three times a day for pain, and metoclopromide 10mg as
required for nausea.
18. On 12 February, the man was taken to court where he was further
remanded until 21 February. The man was then taken to Bedford
prison although he had been expecting to return to Woodhill. There is
no evidence in the clinical records that the man had been assessed as
medically fit for transfer. Another prisoner was also taken to Bedford
rather than returning to Woodhill.
19. On arrival at Bedford, the man had a reception health screen with the
reception nurse. The man explained he was prescribed nefopam daily
and had been seeing the doctor over the last few months for a head
injury and depression. He said he had previously taken anti-
depressants and had tried to hang himself about four months before.
He made good eye contact during the interview and was calm. The
reception nurse told my investigators that the man was quiet and
although he answered all questions put to him, he did not “open up”.
The first night procedures were of a good standard.
20. The reception officer conducted a first night interview with the man.
Again, he admitted that he had previously attempted suicide but said
he did not feel suicidal at that time. He said he was not concerned
about being in custody. He told the reception officer that he had eight
children and a supportive family.
21. The following day the man saw the prison doctor. The man had
previously suffered a head injury. The prison doctor reported there
were no signs of any injury but reviewed his medication and prescribed
acupan (nefopam) 60mg three times a day for pain, and
fluoxetine20mg once daily for anxiety/depression. The man collected
this medication on 14 and 15 February, but not on 16 February.
22. The man and the prisoner that transferred with him successfully
applied for rule 45 status (i.e. to be separated from the other prisoners,
due to the offences with which they had been charged).
23. As noted, F wing is designated to hold prisoners on rule 45. When the
wing is full, several cells in D wing are used to accommodate such
prisoners until a space becomes available. There was no room
available on F wing, so the man and the other prisoner were located
together on the fourth floor of D wing (D4-01). Even if space had
become available it would not have been possible for the other prisoner
to move to F wing due to potential problems with a different prisoner
already located there. The other prisoner told my investigators that the
man had been quite protective of him and said he would stay with him
as he knew he was vulnerable. The other prisoner said that the man
looked after him, for example he went without a blanket to make sure
he was warm enough.
24. That evening (13 February) the man declined his evening meal, saying
he was not hungry. The landing officer recorded this in the man’s wing
record. The prisoner that transferred with the man told my
investigators that other prisoners were shouting through the door, and
the man told them to go away. On 14 February, the landing officer
recorded that the man declined lunch, again saying he was not hungry.
However, he did have a shower and cleaned his cell. The following
day, the man said he did not want to come out to take a shower or
clean his cell as he had done so the day before. He asked if he could
have a tea pack (this contained tea bags, milk and sugar).
25. The other prisoner told my investigators that, during the evening of 15
February, a group of prisoners had been shouting things through the
door like, “Nonces, we’re going to cut you open, going to kick you.”
The man had shouted back at them, and they then pushed burning
paper into the cell. The night Officer checked prisoners on D wing.
The man and the other prisoner said they were spending a lot of time in
their cell and asked if they could have some tea bags. They also
asked for an application form to see the Independent Monitoring Board
(IMB). (The IMB is made up of independent volunteers who monitor
the treatment of prisoners.) The night officer provided both the tea
bags and the form.
26. On 16 February, the other prisoner completed the IMB application
form. He wrote that he and the man had been in their cells since they
arrived. They were being bullied and had burning paper pushed under
their door. The other prisoner was also upset at being in Bedford, and
felt he had been lied to as he had been told he would be returning to
Woodhill. (By the time the IMB received the application and went to
see the other prisoner, he had already been moved back to Woodhill.)
27. That evening (16 February), the night officer was on duty. One of his
tasks was to check that all prisoners were in their cells. When he
approached cell D4 01 he noticed that someone had written “nonce” on
the door. As it was in non-permanent ink, the night officer was able to
rub it off. He asked the man and the other prisoner if they were okay.
The other prisoner replied that at about 7.45pm someone had pushed
burning paper under their door. The night officer could see there was a
mark on the floor. He then submitted a security information report
(SIR) to alert others to the problem. The night officer told my
investigators that the other prisoner had been quite upset and difficult
to talk to, whereas the man had been rational and explained what had
happened.
28. The SIR was followed up the next day. The other prisoner was unable
to move to F wing, as there were likely to be problems with another
prisoner residing there and he was due to move to Woodhill as soon as
there was space. The man was not mentioned. The Senior Officer
(SO) on duty suggested the mark on the floor was some distance from
the door, and said she thought the mark had been made by a previous
prisoner. It was noted in the wing observation book that staff should be
alert to the situation.
29. On 17 February, the man and the other prisoner again declined to have
a shower, go out to exercise, or use the phone. It was the landing
officer’s first day at work since 14 February. He noticed that the man
and the other prisoner declined their lunch again and notified
healthcare staff. The other prisoner told my investigator they had not
collected their meals because they were too scared to leave the cell.
30. Two nurses visited the man and the other prisoner in their cell. The
first nurse said that, at first, both men were lying on their beds. The
other prisoner was very vocal, and angry about being in Bedford. He
said that the nurses were the first to listen to them and was grateful to
see them. The first nurse asked if they had reported their issues to the
appropriate staff, and listened to them for between 30 and 40 minutes.
The other prisoner said that they were not going to eat unless they
were moved to Woodhill. The nurse explained the potential
consequences of not eating. The man and the other prisoner said that
they were not comfortable leaving their cell for any reason, including
collecting food, and that staff had not helped them with this.
31. The first nurse assessed the man’s physical state. He was much
quieter than the other prisoner but seemed to agree with what the other
prisoner was saying. He said that it was easier for his family to visit
him at Woodhill and he had not even phoned them whilst at Bedford.
The man was dehydrated, had dry skin, poor skin colour and low blood
sugar. The nurse told my investigators that she was concerned about
the man’s physical health.
32. The nurses explained to the man and the other prisoner that they could
not immediately help with the request to move to Woodhill as it was a
Saturday, but it would be followed up on the coming Monday. They
asked the men if they would start eating again if they were moved to
the healthcare centre. The first nurse told my investigators that she
knew this could be viewed as blackmail, but was concerned about the
man and felt that he in particular needed to start eating and drinking
again.
33. Both men were taken to the healthcare centre at about 4.45pm. They
were placed in single cells rather than the dormitory, partly because
staff were not sure how much the two men were encouraging each
other not to eat. The first nurse said as soon as the man arrived in
healthcare he seemed happier. It was meal time when they arrived
and the man went to the servery and returned with a plate of chips.
The nurse returned later to check if the man had had enough to eat
and drink. He replied that he had. The nurse completed the admission
paperwork. She noted he was receiving treatment for a head injury
and depression. She recorded the reason for admission as food
refusal, dehydration, low mood, and low blood sugar (3.9).
34. An ACCT form was opened on both men by a prison officer and senior
officer, the reason given as “due to not eating since 13.2.07”. An
immediate plan was made - moving them to healthcare, regular checks
and interaction. Staff also made them aware of the support they could
access through the Listeners (prisoners trained by Samaritans).
35. The nurse from reception carried out a complete physical and
psychological needs assessment of the man. She noted that he had
good speech and eye contact. The man said he felt low, but not
suicidal. He was alert and aware of the situation, but felt slightly faint
and had not been sleeping well. His skin was dry. Healthcare staff
started a fluid balance chart to monitor the man’s fluid intake. This is
good practice when someone has not been eating.
36. On 17 and 18 February, the man was checked regularly. Staff said he
was polite and friendly but did not easily engage in conversation. The
man ate and drank normally, and said he was feeling better. He came
out of his cell, and chatted to the other prisoner. A prison officer said
the man responded to her encouragement to eat. She said that she
gave him a fresh set of clothes and shower gel. He had a bath and a
shave and immediately looked much fresher. He also came out of his
cell, and went to watch football in the television room with other
prisoners.
37. In the afternoon of 18 February, a full ACCT assessment was
completed by another officer. The man said he had stopped eating as
a protest at being at Bedford. He said he felt unsafe on D wing, but
was more comfortable in healthcare, was coping, and did not feel
suicidal. This officer said that the man did not present as someone
with problems. His manner and demeanour were fine and relaxed. He
maintained eye contact and answered all her questions.
38. Following the assessment, an ACCT review took place with the man, a
senior officer, the second nurse and a second prison officer. They
agreed they would explore the possibilities for transfer. They all
decided to close the ACCT as the man’s food refusal had not been a
protest and had ended. The man had no thoughts of self-harm, and
most of his problems had been dealt with in the previous 24 hours. It
was agreed that he would be visited on 25 February as a follow up to
the closure of the ACCT.
39. A second doctor saw the man the next day. The man explained he had
experienced chronic head pains following an assault in 1986. The
doctor noted that the man was taking Prozac for depression. The man
engaged well and maintained good eye contact. There were no longer
signs of dehydration. The doctor assessed that the man was fit to
move from healthcare to a normal wing. However, there were still no
places available on F wing, and he was assured he could stay in the
healthcare centre until a place became available.
40. The second prison officer made enquiries about the man and the other
prisoner moving to Woodhill. It was agreed that the other prisoner
would be transferred that afternoon, but as the man’s next court
appearance was at Luton he needed to stay in Bedford. The court
appearance after that would be at St Albans, and he would then return
to Woodhill. The second prison officer said that the man was still very
concerned about returning to D wing. She reassured him that he would
not be moved to D wing. She said she could make arrangements for
the man to go to F wing at exercise times and association and to
integrate slowly into the wing. They expected cells on F wing to
become available later that week.
41. Although the man did not have in depth conversations, the officer felt
he was comfortable and he did chat to other prisoners in healthcare.
He was also looking into education courses and had been reading
books.
42. The healthcare assistant was on night duty in the healthcare centre
from Monday 19 February. He described the man as quiet, and as
someone who liked to keep himself to himself. The healthcare
assistant said that he would ask the man if he wanted anything, but he
rarely did and, as a consequence, they did not have much opportunity
for conversation.
43. The first nurse saw the man on 20 February. The man said that some
of the prisoners from D wing had been shouting out of their windows
and he felt threatened by them. The first nurse said that the man often
seemed deep in thought and kept himself to himself. The next day she
noticed that he chose to stay in his cell during association.
44. It is noted that the man had a legal visit via video link on 20 February.
(There is no further detail.) It is also recorded that he was due to
appear before Luton Magistrates’ Court again the following day via
video link. A third nurse was on duty in the healthcare centre when a
member of staff collected the man for his legal visit. The man had not
mentioned the visit beforehand, and did not speak about it on his
return. The third nurse described the man as very quiet, polite and
unassuming.
45. The man’s mother received a letter from him. She said there was
nothing to indicate that he was not coping. The man’s parents had
been trying to arrange a visit at Bedford, but had found the bookings
system difficult in comparison to that of Woodhill.
46. That evening (20 February), the healthcare assistant and the
healthcare officer came on duty at about 8.30pm. The healthcare
officer performed the roll check to check everyone was in their cells.
There is no requirement to check on prisoners throughout the night,
unless there is a medical reason, or they are subject to an ACCT. Staff
also perform “pegging” (certain points on the landing have to be
electronically pegged to show that staff are patrolling the landing and
the prison is secure).
47. The healthcare assistant explained that in practice, he checked
prisoners frequently:
“We have to do pegging at each end of the ward, so we’re doing
that every half an hour. So as I come round, usually I carry a torch
and I check everybody. Sometimes there might be people awake,
sometimes they might ask for hot water, which I get for them, and
just generally make sure everybody’s OK. But because of the
ACCT documents, plus the pegging, I mean we’re going to be
coming round every 20-30 minutes anyway.”
48. The night of 21-22 February was no different:
“I’d asked him [the man] earlier on before everybody started settling
down if he wanted anything, if he wanted any hot water. He replied
no and that was it really. He went to bed and that was it really. I
checked him through the night, he was in his bed. I think once he
got up maybe to use the toilet. He came back and the next time I
came round he was back in bed again and that carried on all the
way through the night.”
49. A separate prisoner, told a governor that he had spoken to the man at
about 10.00pm and had given him some tobacco. This separate
prisoner said that the man appeared optimistic. He said he had a legal
visit and was only expected to be sentenced for one of the charges he
faced. This prisoner said he had trouble sleeping, but did not speak to
the man again or hear him moving around during the night.
50. At around 6.00am on 22 February, the healthcare assistant conducted
another roll check of all prisoners and found nothing unusual. Just
before he finished his shift at 7.30am, he checked all the prisoners
again and saw that the man was in bed.
51. The second prison officer came on duty at this time. Healthcare staff
were conducting a handover of the patients, and she began to check
the prisoners on ACCTs and collect hot water for prisoners who
requested it.
52. Just before 8.00am, she reached the man’s cell (number 6). She could
not see the man and thought he might be on the toilet so called his
name. When she did not hear a response, she looked more closely
and could see the man’s legs on the floor. The officer opened the cell
door and could see that the man had a ligature around his neck,
attached to the handrails in the toilet area of the cell. She shouted for
help and supported his weight. At that time, a governor came onto the
landing. He heard the shouts and went to the cell. He saw that the
man was unconscious so used his radio to call for urgent assistance
and request an ambulance.
53. Nurses ran to the cell, cut the ligature and began cardio pulmonary
resuscitation (CPR). The man was warm to touch and they felt he had
only recently used the ligature.
54. The automatic defibrillator machines are designed for easy use. Once
attached to the patient, the machine instructs the user either to stand
back while it administers a shock or, if it cannot detect any electrical
activity in the heart, to continue CPR. When the nurses attached the
defibrillator, it instructed them to continue CPR. Two nurses continued
CPR until paramedics arrived at 8.08am. Sadly, the resuscitation
efforts were unsuccessful.
55. Following the man’s death, a note was found that he had written to
staff. It said that he was expecting to go to court before canteen
supplies arrived, and asked whether he would be allowed to have his
canteen early or have a smokers pack to take with him.
56. Contingency plans for dealing with a death in custody were activated,
and the various tasks were allocated and carried out by staff. This has
been well documented.
57. Prisoners and staff were told of the man’s death and offered support.
Staff contacted Woodhill so the news could be broken to staff and
prisoners who knew him there, including the other prisoner.
58. The prison’s family liaison officer offered the man’s family an
opportunity to visit HMP Bedford. This was accepted.
ISSUES
Response to bullying allegations and Rule 45 prisoners on D wing
59. My investigators found that staff were aware that intimidation of rule 45
was likely on D wing. On the whole, when issues were identified they
were dealt with appropriately.
60. When the night officer saw the writing on the man’s cell door and was
told of burning paper being pushed under the door, he acted
appropriately by submitting a SIR. Staff felt that the mark left on the
floor from the paper had been present before the incident. The senior
officer spoke to the man and the other prison officer about the
problems they were having. They told her that water had been poured,
and burning paper pushed, under the door, and that various prisoners
had shouted abuse.
61. The senior officer told my investigators that she had tried to find out
who was responsible. The man and the other prisoner did not know
but one of the wing cleaners suggested two names. There was no
evidence that these two prisoners were responsible, but the senior
officer warned them what would happen if she found them intimidating
other prisoners. She also noted the details in the wing observation
book, warning staff to be alert.
62. The other prison officer told my investigators he thought staff knew that
he and the man were being bullied. No staff member remembered
actually witnessing any bullying; they said they were aware of their
responsibilities in addressing bullying.
63. The location of the cell occupied by the man and the other prisoner - on
the fourth floor, in the far corner - afforded poor observation from the
wing office. Staff acknowledged that, due to the low number of staff
and their various duties, as well as the location of the cells, there were
many opportunities for bullying to take place around these cells without
their knowledge.
64. I accept that prison overcrowding leads to many difficulties when
allocating prisoners. However, holding vulnerable prisoners on landing
4 in D wing led to unacceptable abuse at the hands of other prisoners.
65. My investigators found that the man had been subject to bullying and
harassment in D wing. This was examined in depth, and my
investigators spoke to a number of prisoners. All rule 45 prisoners who
were spoken to and who had been held on D wing said they had been
subject to bullying from other prisoners. Many, like the man, had been
frightened to leave their cell, and had foregone showers, association,
and using the phone. Most prisoners said that staff had offered these
services, but they did not feel comfortable leaving the cell.
66. Some prisoners said that staff had explained the regime and
encouraged them to press their cell bell if they had any problems.
However, in practice, they felt forgotten about on the fourth landing.
67. I understand that rule 45 prisoners are held on D wing for as short a
time as possible. However, by definition these prisoners are vulnerable
– all the more so since they are either in prison for the first time or have
recently transferred from elsewhere.
68. I also understand that D4 had the advantage of a stairwell leading to
easy access to F wing, as well as being locked off from the rest of the
wing. However, against this must be counted the fact that most
residents on D4 were normal location prisoners, many of whom would
be unsympathetic to those on rule 45.
69. Use of D4 also meant there was little interaction between staff and
prisoners on rule 45. This was discussed with the Governor at the time
of the investigation. As a consequence, a bid was submitted to have
another wing changed to hold rule 45 prisoners but this had
consequences for the type of population Bedford would hold. The cells
for holding rule 45 prisoners on D wing have now been moved near the
staff office. This seems the most practical short-term solution in
difficult circumstances.
70. When my investigators discussed the issues with other prisoners who
had been held on D wing, they felt more concerned about staff being
unaware of intimidation than about access to any service or facility.
The Governor should review arrangements for monitoring how
frequently D wing cells are used to hold rule 45 prisoners, and any
incidents involving those prisoners.
Food refusal
71. When staff first found the man was not eating his meals, the landing
officer explained to him that all other prisoners were locked up and
those prisoners working on the servery had been warned to be
courteous. Many staff felt that the food refusal was a protest at being
in Bedford. There appears to have been some truth in this. However,
the other prisoner told my investigators that he and the man had
received comments from other prisoners like “enjoy your food” and that
one member of staff had said he could not guarantee their safety.
When the man moved to the healthcare centre he immediately began
eating again. This would indicate that the motivation for refusing food
was not only in protest at being in HMP Bedford.
72. My investigators asked if, as an exception, staff would consider taking
meals to those who were scared. Staff had mixed views about this.
However, a Governor felt that staff should do this as a temporary
measure. It was never fully recognised by staff that the man was both
apprehensive of collecting his meals on D wing, and upset at being in
Bedford. It appears that no staff had in depth conversations with the
man regarding his concerns.
73. Staff and managers did not seem to be clear about the process to deal
with food refusal and varied in their understanding. Whilst some
recorded that the man was not collecting his meals, five days of
refusals had elapsed before he was assessed by healthcare, by which
time the nurses were concerned for his health. Staff could not provide
the investigation team with a coherent explanation of the actions that
should be taken when someone refuses food.
74. The clinical reviewer has expressed concern that healthcare staff were
not informed that a prisoner had been refusing food for five days. I
share that concern.
The Governor should implement a clear and coherent procedure
for prisoners who refuse food. This must include notifying and
involving healthcare staff at an early stage.
ACCT
75. It was appropriate that staff opened an ACCT when they found the man
had been refusing food. He was also low in mood. When someone is
unsure whether to open an ACCT, it is right to err on the side of
caution. Opening the ACCT means a full assessment by a trained
professional will occur within 24 hours, and the decision whether to
keep the document open can be taken. The ACCT was closed by a
multi-disciplinary team including the man. This decision was
reasonable, and ACCT policies and procedures were properly followed.
76. However, I am concerned that staff felt the food refusal had only been
a protest at being in Bedford. The man was certainly unhappy with his
transfer from Woodhill and refusing food had been, in part, a protest.
However, there was also evidence that he was fearful of coming out of
the cell, and taking the food. Other prisoners had commented on the
food, leading the man to be suspicious. Whilst in healthcare, the man
also experienced shouting from prisoners in D wing and on several
occasions sought reassurance that he would not be housed there.
Healthcare
77. The man’s treatment in the healthcare centre was good. Healthcare
staff and the second prison officer made efforts to engage with the man
and to help address the problems he was facing. However, I concur
with the clinical reviewer’s finding that it was very difficult to identify
those staff due to illegible signatures in the paperwork. Other
healthcare staff could not identify some signatures either.
The Governor and Head of Healthcare should consider the clinical
review and its findings.
78. The man’s father was concerned that the handrail in the cell was an
obvious ligature point. For a physically able man the rail is
unnecessary, but of course many of those located in the healthcare
centre will need such a support. However, while I make no formal
recommendation, the Governor will wish to consider whether the rails
should be removed from some cells in the healthcare centre. Many of
the prisoners located there may have a past or current history of self-
harm (I acknowledge there may be many other possible ligature
points).
Crisis management
79. When staff found the man hanging, they acted appropriately,
sensitively and speedily. Considerable efforts were made to save the
man, and the Governor will also wish to consider if any members of
staff should be recognised formally.
80. Once the man had been pronounced dead, all contingency plans were
carried out professionally and thoroughly. The investigation team
found that a good level of support was demonstrated and offered to
staff.
81. The manner in which the sad news of the man’s death was broken to
his family, and the subsequent family liaison, was also handled well.
Conclusion
82. This man had some history of suicidal ideation, had been transferred
from a prison where he had settled, and was subject to some bullying
and abuse from other prisoners. However, he had moved to the
healthcare centre – where the evidence suggests he felt much safer –
some five days before his death, and had given neither staff nor fellow
prisoners any reason he was planning to hang himself. I do not think
his actions on the morning of 22 February 2007 could reasonably have
been anticipated by those responsible for his care.
RECOMMENDATIONS
The Governor should review arrangements for monitoring how
frequently D wing cells are used to hold rule 45 prisoners, and any
incidents involving those prisoners.
The Governor should implement a clear and coherent procedure for
prisoners who refuse food. This must include notifying and
involving healthcare staff at an early stage.
The Governor and Head of Healthcare should consider the clinical
review and its findings.