Individual at Bedford

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE
DEATH OF A MAN AT BEDFORD HOSPITAL IN
SEPTEMBER 2005 WHILST IN THE CUSTODY OF HMP BEDFORD
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2006
This is the report of an investigation into the death of a man who died in September 2005, in
South Wing, Bedford Hospital. The deceased, a prisoner at HMP Bedford, was found that
morning, hanging from the ceiling light assembly in his cell. The post mortem examination
carried out later that day confirmed that the cause of death was hanging. This report
focuses on his time in prison custody and evaluates the systems in place to prevent suicide,
self harm and promote wellbeing.
The man had been the subject of suicide and self harm monitoring throughout his
time in Bedford. Although he made no physical attempts to harm himself, he made
numerous threats to do so. He also talked to staff and other prisoners about his
extreme anger with the outcome of his trial and the emotional distress he was
suffering over his relationship with his girlfriend. He was assessed by a visiting
psychiatrist who found no evidence of mental illness and described him as
‘manipulative’. At no time did staff consider the level of watch should be escalated
above the basic requirement for suicide and self harm monitoring. The man was the
single occupant of a double cell at the time of his death. He had frequently
expressed a strong desire not to share a cell and was disturbed by the imminent
prospect of having to do so. During the investigation, prison staff, friends and family
gave every indication of being shocked and taken by surprise, by his suicidal act.
I offer my sincere condolences to the man’s family for the tragic loss of such a young
life in such traumatic circumstances. Despite his persistent offending in recent
years, they had always remained loyal, loving and supportive.
Two of my colleagues who are registered nurses, led the investigation from my
office. I am grateful for the assistance they received from the staff and management
of HMP Bedford. I wish to acknowledge too the co­operation of the Bedfordshire
Police who carried out their own enquiry into the man’s death and shared all
available information. My thanks also go to the appointed doctor from Bedford
Primary Care Trust who conducted the clinical review.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2006
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CONTENTS
Summary
The Investigation
HMP Bedford
Chronology of Events 22 July – 1 September
Events of the morning of 1 September 2005
Events following the man’s death
Findings and Conclusions ­ including the clinical review
Recommendations
Good Practice
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SUMMARY
This is the report of an investigation into the death of a man who was 24 when he
died at South Wing, Bedford Hospital on 1 September 2005. He was a prisoner at
HMP Bedford and had been found hanging from the ceiling light assembly in his cell
early that morning.
The investigation team reviewed his prison records and interviewed prison staff and
prisoners. A clinical review was prepared by Bedford Primary Care Trust (PCT).
The man had been at Bedford since July 2005 when he was convicted of aggravated
vehicle taking and sentenced to 22 months imprisonment. A custody officer at Luton
Crown Court completed a suicide and self harm warning form because he had said
he would kill himself with an overdose at the first opportunity. It was not the first time
the man had been in prison custody. During the reception procedure, he disclosed
that he had taken an overdose while in Bedford on a previous sentence in 2003. He
also said he had cut his wrists two weeks prior to coming into custody this time. He
told staff he felt unstable and mixed up and might harm himself. Consequently, on
the evidence available, including the warning form, he was considered to be at risk of
suicide and self harm. Suicide and self harm monitoring was initiated in reception,
using the Prison Service F2052SH document.
Initially the cause for concern was his anger and distress over the sentence which
was longer than any he had served previously. Later, his distress was compounded
by frustration and upset over the deterioration in his relationship with his girlfriend.
The man described himself as deeply in love but he was in fear of losing her
because of the length of his sentence. After many loving phone calls in the early
part of his sentence his fear was exacerbated by his being unable to speak to her
because her mobile phone went continually to answer­phone mode.
Over the following weeks, his mood fluctuated and he frequently threatened to self­
harm, although he made no physical attempts to do so. He talked to staff and other
prisoners about his extreme anger with the outcome of his trial and the emotional
distress he was suffering over his relationship with his girlfriend. He was assessed
by a visiting psychiatrist on 18 August who found no evidence of mental illness and
described him as manipulative. At no time did staff consider the level of watch
should be escalated above the minimumrequirement for suicide and self harm
monitoring. This was despite him having shown an officer a note for his girlfriend
‘which read like a suicide note’ on 21 August at 7.25pm. The next day at 8pm he
described to a member of staff in the health care centre how he could store his
medication to obtain an overdose which he would take before hanging himself from
the strip light in his cell.
On 25 August there was an incident in the healthcare centre when he was alleged to
have thrown a book at a prison officer. He made a counter allegation that the officer
had assaulted him. His allegation was the subject of an investigation at the time of
his death.
On the morning of 1 September 2005 at 7.45am, during a routine roll check, the man
was found hanging from the strip light assembly in his cell. Strenuous attempts were
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made to resuscitate him. Actions taken by staff following the discovery of the man
hanging in his cell are described in detail within the report. All staff concerned
reacted quickly and together with ambulance service personnel every effort was
made to revive him. He was subsequently taken to the South Wing, Bedford
Hospital, but at 9.30am the nurse who had accompanied him in the ambulance rang
the prison to inform the Governor that the man had been certified dead.
This report focuses on the man’s time in prison custody and evaluates the systems
in place to prevent suicide, self harm and promote wellbeing. The clinical review of
his health care by Bedfordshire Primary Care Trust has contributed to the findings
and conclusions of the investigation.
My investigation makes 10 recommendations. Examples of good practice identified
by the Primary Care Trust clinical reviewer have also been acknowledged.
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THE INVESTIGATION
1. The investigation into the man’s death was undertaken by two investigators
both of whom are registered nurses who work for my office. They visited
the prison and were shown the areas where the man would have been held
including the cell where he died.
2. They issued notices to staff and prisoners inviting anyone with information
relating to his death to make themselves known to the investigation team.
Three prisoners who knew the man came forward to speak to them. My
investigators formally interviewed four prison staff who were involved with
the man’s management and/or the events surrounding his death.
3. My investigators also spoke to members of the Independent Monitoring
Board (IMB), the Prison Officers’ Association (POA), two of the prison
chaplains, and various other members of staff.
4. My investigators were given early access to the documentation that had
been gathered covering his time in prison. On further occasions prison staff
sought out and produced a number of documents my investigators noted
were missing from the initial bundle. They also met at an early stage with
members of the Bedfordshire police who were investigating the man’s
sudden death. The police later provided copies of the documents and
statements in their possession. I am most grateful to them for their co­
operation, which assisted my investigation.
5. One of the investigators and one of my family liaison officers visited the
man’s mother and sisters to discuss their concerns about what had
happened to him.
6. My investigators commissioned the Director of Care from Bedford Primary
Care Trust, to conduct a clinical audit of the man’s health care while in
prison.
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HMP BEDFORD
7. Bedford prison is a relatively small, local prison, serving courts in the county
and further afield. It provides for a rapidly changing population of adult male
prisoners. It is a Victorian prison, with some new buildings added in the
early 1990s. Its accommodation is ideally for 325 prisoners, and its
maximum operational capacity is 494. On 1 September 2005, it was
holding 460 prisoners. C wing, which is mainly used as an induction wing,
was holding 74 prisoners.
8. The most recent inspection by Her Majesty’s Chief Inspector of Prisons was
in January 2004 therefore its relevance to this investigation must be taken in
that context. She found Bedford to be a fundamentally safe and well­
controlled prison. She said that it provided a largely respectful environment
with good, mutually respectful staff­prisoner relationships. The Chief
Inspector had some specific concerns about the approach to prisoners at
risk of suicide or self harm. She said that better co­ordination of elements
within the safer prisons strategy would create a preventative rather than a
reactive approach.
9. In 2004, the Prison Service conducted its own internal audit of Bedford
prison. It found the prison to be operating at a high level and improving,
although there were some areas of concern. Suicide and self harm
procedures were good (rated 92% compliant) but some inconsistencies of
process and monitoring were noted and reviews were not always acted
upon.
10. In November 2004, Bedford prison was rated level 4 in the Prison Service’s
Performance Rating System. Level 4 is awarded to exceptionally high
performing establishments, consistently meeting or exceeding targets, with
no significant operating problems, achieving significantly more than similar
establishments with similar resources. The rating is based on cost
performance and output data, compliance with Prison Service standards,
findings from external inspections, and the views of the Prison Service Area
Managers and Management Board.
11. There have been five previous deaths in Bedford in the past three years.
Three prisoners died towards the end of 2002. There was one death in
November 2003 and one on 27 December 2004. The Chief Inspector said,
following her January 2004 inspection, that the small number of
recommendations arising from the investigations into the 2002 deaths had
all been implemented.
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CHRONOLOGY OF EVENTS 22 JULY – 1 SEPTEMBER
12. On 22 July, the man was received into custody at Bedford prison following
sentencing to 22 months imprisonment. A suicide/self­harm warning form
raised at court and sent with him to prison stated that he had said he
intended to kill himself at the first opportunity by overdose.
13. During the prison reception assessment the man stated that he has had his
life taken away from him following receipt of the ‘hardest sentence of his
life’. He also said that he had had enough of his life. A Suicide and Self
Harm monitoring form (F2052SH) was opened and staff noted that he
should be in a shared cell, with a Listener1 if possible. The level of
supervision was set by the nurse who assessed him after discussion with
the doctor. She set it at ‘normal’. From the evidence available it can be
deduced that this was implemented in line with the ‘minimum’ requirement
set out in the local suicide prevention policy.
14. The cell sharing risk assessment stated that he did not feel comfortable
about sharing but would accept a listener. He was assessed as a ‘low risk’
to other prisoners, for cell sharing. The man was located in the First Night
Centre (FNC) on landing one on C wing at 8.56pm but at 9.16pm he was
moved to a cell on landing two without any explanation being recorded.
15. The man’s first F2052SH review was held on 23 July. He stated that he felt
like killing himself as he had received a long sentence (the longest he had
ever received) and also he was worried that his girlfriend would leave him.
He stated that he wanted to get transferred to another prison and complete
some courses. He also asked to see the community psychiatric team
(CPN). The next F2052SH review was arranged for ten days time (1
August). The man asked to be moved to his friend’s cell.
16. On 25 July 2005 he was moved to a cell on landing four in C wing. The
records do not make it very clear whether he was sharing a cell or not.
However on 27 July a note was made in the F2052SH that he did not want
‘anyone in his cell with him anymore’. By 30 July 2005 he was described as
appearing happier and much more cheerful than he had done previously.
He told staff that he wished to come off the F2052SH at the next review. He
moved from C wing to A wing on 31 July to share with a prisoner with whom
he had previously shared.
17. On 1 August a F2052SH review was held at 4pm. The man was still
concerned about the length of his sentence. It was decided that the
F2052SH should remain open and be reviewed in 10 days. On 2 August,
he was taken by the police to St Alban’s police station. Forensic evidence
had come to light that linked him to an accident in a stolen car. He was not
charged with any offence, following the police investigation.
1 A Listener is a prisoner who has undertaken a training course by the Samaritans in order to support
fellow prisoners contemplating self harm or suicide.
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18. On 5 August he told staff that he had received a ‘bad letter’. A note was
made in the observation book and staff were asked to be aware. A
F2052SH review was held on 11 August at 10.30am. He was frustrated due
to security mislaying his cash disbursement form. This had apparently put a
lot of strain on his relationship with his partner. The man stated that if he
and his partner split up he would take his own life as he felt there was no
point in living anymore. The next review was arranged for ten days ahead.
At 4pm he threatened to self harm if his visit on Saturday did not go well.
19. On 13 August he told staff that he was concerned about his girlfriend and
that she would not talk to him. He reiterated that if she finished with him he
would kill himself as he had nothing outside to live for. The man told staff
on 14 August that his girlfriend had said she would visit the following week
so he was feeling better.
20. On 16 August he was seen by a doctor at 2.50pm (according to F2052SH
records). That night, at 2am, he told a member of staff that he did not feel
well ­ No other note was made as to exactly how the man was feeling and
no action was documented. On 17 August, at 9pm, he told a member of
staff that he was concerned about his girlfriend, but when spoken to, he said
he was ‘content to leave his problem till the morning’.
21. On 18 August 2005 at 9.15am and at 12.05pm, on A wing, the man
threatened to climb up onto the rafters and tie himself up there if the CPN
did not come and see him by the end of association and pay him attention.
At 2.30pm a wing officer noted that the man was ‘in a very agitated state’.
The officer reassured him that the CPN was coming to see him. At 3.40pm
another officer noted that he was still agitated and requesting to be taken to
B1 (the segregation unit2 ). The further records of the events that day
conflict chronologically. From careful scrutiny of all the available documents
my investigators concluded that events were as set out in the next
paragraph.
22. The ‘Use of Force’ records and the evidence given at a subsequent
adjudication indicated that at 4.07pmthe man refused to return to his cell.
He was protesting because he considered the interview with the CPN and
the psychiatrist had been unsatisfactory. The man held onto the bars of a
gate and refused to let go. He was restrained using control and restraint
techniques (C&R) and taken to the SSU. An entry in the F2052SH at
4.15pm noted his relocation. The Local Inmate Database System (LIDS)
printout showed that he moved from A4­28 to B1­05 at 4.21pm.
23. The CPN made an entry in the F2052SH, timed at 4.15pm, in which she
recorded that the man was expressing suicidal intentions and saying he was
on day two of a hunger strike. She described him as not clinically
depressed and refusing medication. In the medical record the CPN
described the interview in more detail saying that the man was angry in
mood and manner, believed that he was worthless and his life not
2 At Bedford the segregation unit on B wing is known as the Separation and Support Unit (SSU)
9
worthwhile. There was no evidence of any thought disorder and/or clinical
depression or any requirement for treatment. She noted that she had seen
himtogether with specialist psychiatric registrar (SPR) who also wrote a
report for the record. The doctor’s findings concurred with the CPN’s.
However, the psychiatrist also suggested that the man’s suicidal ideation
was ‘in order to manipulate a single cell’ and described him as petulant,
unpleasant and sarcastic as well as manipulative.
24. The man complained of sore wrists following the C&R and was
subsequently seen by the doctor at 5.10pm, when, according to the Report
of Injury to Inmate form, no further complaint was made. A Use of Force
form (F2326) form was completed. A Segregation Safety Algorithm was
signed by the doctor but not completed fully. The decision in part B was
that the man was suitable for segregation.
25. On 19 August an adjudication was held regarding the incident the previous
day. The man responded to the charge by explaining that he had been
seen by the CPN (whom he referred to as a psychiatrist). When the officer
asked her if the man was OK, she replied ‘yes’. The man was upset
because he felt he was not alright. He alleged that he had not eaten for
three days and that he was on hunger strike. He also mentioned that he
had nothing to live for if he lost his girlfriend and also that he been ‘stitched
up by the judge’. He was punished with a seven day loss of privileges
suspended for three months. He was told at the adjudication that if he was
not happy with his consultation with the ‘psychiatrist’ he could see another
one. He was informed that he would be referred anyway (the person to
whomhe was subsequently referred was also a CPN and not a
psychiatrist). The adjudicating governor sent a memo to the CPN’s stating
that the man was saying he was on hunger strike and he had some issues
that he wanted to discuss and seek help with but with which he felt he was
not getting any help.
26. The clinical record entries for 18 and 19 August are out of chronological
order. An entry by the primary care doctor on 19 August indicated that
having seen the man in SSU, he spoke with a CPN. He noted that the man
was to see a psychiatrist on Monday and prescribed medication to ‘ease
him’ until then. According to the record, he was seen by another CPN, on
19 August, although the first CPN made the entry.
27. Later on that day a routine assessment for the issue of lighting materials in
the SSU concluded that the man was at risk of self harm, had a ‘poor frame
of mind at present’ and should not be issued with lighting materials. An
F2052SH review was held at 3.30pm. The man told the review panel that
he wanted to end it all. He has stopped getting letters from his girlfriend.
He said he was on hunger strike. The CPN team had arranged for himto
see a doctor the following Sunday, 21 August. He left the room whilst the
arrangements were being explained to him, returning some 10 minutes
later. He made a promise to eat and to see the doctor on Sunday. A
segregation form was completed which stated that the man felt with his
state of mind he may assault another prisoner if placed on normal location.
10
It was decided that he would remain in SSU until his next review on 22
August and he was to be seen by the psychiatrist on 21 August.
28. On 20 August the man had been expecting three visitors. When they did
not turn up for the visit, he was shown into the visits holding room where he
smashed a window. He was placed on report pending adjudication. On 21
August he was recorded as ‘making silly comments about self harming’. An
officer wrote that the man was ‘playing mind games’ and staff should be
aware. The man was due to be seen by the psychiatrist on this day but due
to an administrative oversight concerning another prisoner with the same
name, he was not seen.
29. An adjudication relating to the smashed window was held on 22 August at
11.15am. The man said that he was guilty in himself but in his mind he was
not. The man told the adjudicator that he felt the sooner he was dead the
better. He said he was seeing a psychiatrist that day. He had apparently
tried to call a number the previous day but was told he could not ring it. My
investigators have been unable to ascertain what this referred to. The man
also said that if he was sent back to the wing he would attack the other
prisoners so that they would kill him. He said he would climb onto the main
beam and tie a noose around his neck. In his reply to the charge, he
claimed that he started hearing the voice of the person who had raped him
when he was younger. He saw the person’s face in the window and so he
punched it, in the hope that it would slice his wrists open. He also wrote in
his response that they should read his reply to his previous adjudication.
He stated that he had nothing left to live for inside or out. He wrote at the
bottom, ‘Now I’ll just have to die’. The man was punished with one day of
cellular confinement. He had not been assessed by a doctor in respect of
his fitness for cellular confinement.
30. An F2052SH review was held at 3.40pm. The man said he remained
depressed over his situation. He showed staff letters which he had written
to his girlfriend telling her how he felt. The CPN recommended that he be
moved to healthcare. A review was arranged for seven days. The man was
admitted to the health care centre (HCC) and in the admission form it was
stated that he was continually stating he wanted to die. He became quite
aggressive, he pulled his bunk bed apart, said the room smelt and he
stuffed tissue paper in his nose.
31. On 23 August the man remained very angry and was making threats of self
harm if he was not moved out of HCC to a single cell. He was still very
distressed about his relationship, which he believed to be over. He was
reported not to be showing any psychotic symptoms but the F2052SH was
continued as he appeared not to be coping. He stated that he wanted to go
back to SSU. He was reassured and advised to give his medication time to
work. At 4pm on 24 August he was found breaking the doors off the locker
in his cell in healthcare. He was placed on report pending adjudication.
32. On 25 August he was seen again by the CPNs. At approximately 10amthe
man allegedly attempted to assault an officer in the HCC when he was
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asked to clean his cell. He was controlled and restrained and a Use of
Force form was completed where no injuries were noted. In the Use of
Force form the F213 was documented as being completed by a staff nurse.
However the F213 was not signed by the nurse. A doctor signed that there
were no injuries to the man. That entry was dated 27 August. According to
the LIDS printout, the man moved from H1­001 to A4­027 at 10.37am, at
11.03am he moved to B4­013 and at 5.01pm to B1­006. At some stage
during this day a security information report (SIR) was submitted reporting
that the man had made a weapon from a broken knife. It further reported
that the man said he was going to ‘get’ an officer as he had been assaulted
by him. The weapon was removed from him and stored to use in any
adjudication which followed. The SIR was not signed or dated and timed
but numerically it preceded the form submitted by a wing nurse (see below).
33. On 25 August, the wing nurse submitted an SIR at 1.30pm reporting that
during the previous day the man had told her about a threat to an unpopular
officer on A wing. The security department concluded that this was a
repetition of an earlier rumour which had not been substantiated.
34. An adjudication was held on 26 August at 10.55am on the charge of
breaking the doors off his locker on 24 August. The man pleaded guilty and
his written statement was read out. He stated during the adjudication that
he smashed the locker because nobody was listening to him and that he
wanted to be on his own. He was told by the acting Governor who was
adjudicating, that he would not be given a single cell on the wing until he
stopped saying that he was going to harm himself. The man was punished
with five days cellular confinement. The man had been assessed fit for
cellular confinement by the doctor before the hearing.
35. A second adjudication followed at 11.05am on a charge that the man
allegedly threw a book at a wing officer on 25 August. The man counter­
alleged that he had been assaulted by the officer. The man wrote in his
response that he was scared of this officer and that he had asked security
for a photograph to be taken of the bruising he suffered when the officer
punched him. The man claimed that photographs had not been taken
before the swelling went down. The adjudication was adjourned pending an
investigation into the man’s allegations. The acting governor commissioned
a Principal Officer (PO) to undertake the investigation and a copy of her
report was made available to my investigators. It concluded that the man
had not been assaulted and that he had been behaving in a threatening
manner towards the officer.
36. On 26 August, the man was fitted for segregation by the doctor at 11am.
The duty governor, made a note that his violent behaviour deemed him
unsuitable for HCC. An assessment for the issue of lighting materials was
completed and lighting materials were issued. Although he was on open
2052SH it was noted that there were no self harm concerns at that time.
37. At 2pm the man told a member of staff that when he was moved to the main
prison he intended to climb up onto a beam with a noose around his neck
12
until the prison brought the press in for him. An SIR was submitted to the
security manager by an officer about this threat. In the SIR process, on 27
August, security staff noted that the man had mental health issues and
might be capable of carrying out his threat. When the acting Governor,
signed off the SIR he wrote that when the man was moved out of SSU his
location needed careful consideration. However no further action, for
example, communicating this recommendation to wing staff was ordered.
38. An F2052SH review was held at 3pm and it was decided that the man
should remain on F2052SH for a further ten days. The man had issues
about the alleged assault and the investigation. He presented as a very
angry man who stated that he was depressed. He was reassured by the
residential senior officer that he was safe in SSU. The CPN was made
responsible for looking into his medication. A review was arranged for ten
days time (5 September). The man was assessed as fit for segregation at
4.45pm, although he was still on an open F2052SH.
39. The doctor saw himon 27 August and declared him fit for normal location.
At 2.54pmthe man was moved from cell B1­06 in the SSU to C1­03 in the
FNC in order that another prisoner could be located in SSU. He was very
happy about this. He was still serving his period of cellular confinement. It
had not been rescinded before he was removed from the SSU.
40. On 30 August an untimed entry in the wing history sheet showed that when
he was unlocked to receive his medication, he refused it and slammed his
door shut. The duty senior officer noted in the F2052SH that the man
remained adamant that he did not wish to share a cell.
41. On 31 August the man was unhappy to learn from the FNC manager that he
was soon to be moved because his period of cellular confinement was
complete. At interview the FNC manager told my investigators that she had
had a lengthy conversation with himabout his girlfriend. She subsequently
telephoned his girlfriend for him but could only leave a message. At 9pm
that day he was given a prison letter form by an officer. The officer noted
that the man had rung his bell a couple of times and described him as
‘wanting to talk’ but that he did not want to share his cell.
13
EVENTS OF THE MORNING OF 1 SEPTEMBER 2005
42. At 6am on 1 September the man was observed as part of the routine
F2052SH checks. He was described as lying on his left hand side and
appearing to be asleep. During the morning count he was seen lying on his
bed at 6.15am. A second wing officer noted in the record that he was
awake. At approximately 7.45am the man was found by a third wing officer
hanging from the light fitting in his cell in the FNC. He had made a ligature
out of a sheet. The third wing officer summoned help. The cell door was
then unlocked and the wing senior officer cut the ligature and removed it
while the 3 rd wing officer took his weight. Staff laid the man on the floor and
officers commenced two­person cardio­pulmonary resuscitation (CPR).
Urgent assistance was requested by radio. Initially, health care staff
thought they were being called to B wing and this caused confusion, but no
undue delay.
43. At interview, the operational support grade (OSG) working in the
Communications Roomtold my investigators that an officer who was
working with her (now on maternity leave) thought the first telephone call
was from B1, but in a second call she was told it was C1. The OSG
explained that depending on which telephone the call comes in to, they may
know where the call originates from, but may not. Two phones in the
Communications Roomhave caller display on them, but the one does not.
44. An emergency call was made by the communication room to Bedfordshire
Ambulance Control. There was some confusion during this call too. The
communication staff had not been fully briefed as to the exact nature of the
incident. During interview, the OSG described the pressure she felt at the
time. She told my investigators that when an incident occurs there should
be a third party in the communications room but on this occasion there was
no third party, so she and the officer were trying to deal with the calls as
well as making a log of events.
45. An ambulance arrived at approximately 7.55am. There were two
technicians in attendance and no paramedics. A second ambulance was
requested at approximately 8.05am and although the OSG made the call
she was unsure as to why it was required. She thought someone had died.
A fairly long conversation between her and ambulance control followed in
which ambulance control explained that they did not convey dead patients.
It was eventually established that the first ambulance crew were still working
on the man and required assistance from another crew. A second
ambulance with a crew of two technicians arrived at approximately 8.15am.
The request should have been for a paramedic ambulance crew as this
would have enabled appropriately qualified staff to make a decision about
ceasing resuscitation efforts. The man was taken to South Wing, Bedford
hospital. A prison nurse accompanied him in the ambulance. She rang the
prison at about 9.30am to inform the Governor that the man had been
pronounced dead.
14
EVENTS FOLLOWING THE MAN’S DEATH
46. At about 9am the duty governor convened a post incident debrief (the so­
called ‘hot debrief’) in the Governor’s boardroom. He made a retrospective
note of that meeting at my investigator’s request. He recalled the
attendance of the night staff and the day staff who had found the man and
attempted to save his life. The list of attendees did not include the
communications room staff. The OSG confirmed at interview that they had
not been called to attend. There were no healthcare staff on the duty
governor’s list. The healthcare manager held a separate debrief for her
team later that morning.
47. The family were informed of the man’s death by the Bedfordshire police
through an arrangement made by the prison’s police liaison officer. There
was some delay in breaking the news to his mother because he had given
his girlfriend’s name and address as next of kin. He gave her surname as
his, which added to the misinformation. The police went to the given
address but she could not be found. The police checked their records of
himand found a different address. They checked on the electoral roll and
found a person with his mother’s surname registered at that address. A
police sergeant who went to break the news rang the prison from the house
and his mother spoke to the prison’s acting family liaison officer. The
prison’s family liaison officer was a governor grade on loan from the Prison
Service Area office. She endeavoured to answer the mother’s initial
questions and give her necessary information. Subsequently she and the
prison’s lead chaplain spoke to the man’s mother on separate occasions
and made arrangements about tributes from prisoners and staff attendance
at the cremation in Luton.
48. The acting Governor offered the man’s mother financial help in funding the
funeral. When my family liaison officer visited the man’s mother on 10
October she was still awaiting settlement of the invoice from the funeral
director. Prison staff also facilitated contact between the man’s prisoner
friends and his mother, whom they also knew. The prison staff balanced
the needs of the young men with the need to protect his mother from
upsetting intrusion.
The family’s concerns
49. His mother said she had been happy when she found out that her son was
in prison. It meant he was off the streets and she believed he would be safe
there. The main concerns she raised with my FLO and investigator were:
a. She was first told that the last check done on himbefore he died was
6am and that he was then found dead at 7.45am. In a phone call with
the chaplain three day’s later she was told that the last check was at
6.30am. Which was the correct time?
15
b. The mother said she was told that the prison was short staffed as, in
her eyes, an inadequate excuse for her son’s death. Are they really
short staffed?
c. Did her son press his buzzer and if so was it ignored? She told us that
knowing himshe was almost certain he did not intend to kill himself. It
was in her view a cry for help as he “knew the system”. She said the
fact that he had attached a sheet to the light fitting suggested he did
not expect it to take his weight. She said that the prison had confirmed
to her that the man might well have expected to be found before he
died.
d. Was there a stool in the man’s cell?
e. Why did he not want to return to his normal wing? Was it connected
with the officer whom the mother believed “beat him up”? She would
have expected him to want to return to the wing as his friends were
there.
f. When they saw himin the chapel of rest he had a graze on the side of
his nose, one on his temple and a small graze or cut on his neck. His
sister and mother felt these marks might be from the officer who “beat
himup”.
g. His mother told us that her son had written several letters to people
about being attacked by a “screw” in the HCC and said he had suffered
from severe headaches as a result of the attack. She volunteered two
letters in which he referred to the incident, one written to his sister on
27 August and one written to a neighbour.
h. The mother said the man was a very heavy sleeper and for him to be
awake and dressed at six am would have been very out of character.
Why were staff not alerted by this?
i. His sister raised the issue of why he had been placed in a single cell.
Why did his cell sharing risk assessment state that he could have
presented a risk to others?
16
FINDINGS AND CONCLUSIONS
The family’s concerns
50. The investigation has found the following answers to the issues raised by
the man’s mother and sisters:
a. The mother was first told that the last check done on the man before he
died was 6am and that he was then found dead at 7.45am. In a phone
call with the chaplain three day’s later she was told that the last check
was at 6.30am. Which is the correct time?
Although unable to explain why the chaplain mentioned 6.30am, the
investigation confirmed that the man was checked at 6.00 amand 6.15
and discovered hanging in his cell at 7.45am by a wing officer.
b. The mother said she was told that the prison was short staffed as, in
her eyes, an inadequate excuse for her son’s death. Are they really
short staffed?
The investigation found that the prison was experiencing some
shortage of staff but whenever shortages occur priorities are
established and less necessary work is dropped. The clinical reviewer
elicited evidence from a number of his interviewees which indicated
that three individual prisoners were causing a significant drain on
resources. The acting Governor told my investigators that suicide and
self harm monitoring was always a priority.
c. Did the man press his buzzer and if so was it ignored? His mother told
my family liaison officer that knowing himshe was almost certain he did
not intend to kill himself. It was in her view a cry for help as he “knew
the system”. She said the fact that he had attached a sheet to the light
fitting suggested he did not expect it to take his weight. She said that
the prison had confirmed to her that he might well have expected to be
found before he died.
The prison does not have the type of call bell system which provides
electronic records of use and response, so this question cannot be
answered beyond doubt. However, the records show that the interval
between the last night staff check and the first day staff check on 1
September were not significantly different from any other morning.
There was no evidence that the man could have been sure of being
found before dying.
d. Was there a stool in the man’s cell?
The seating in his cell was described by witnesses as a chair rather
than a stool.
17
e. Why did he not want to return to his normal wing? Was it connected
with the officer whom his mother believed “beat him up”? She would
have expected him to want to return to the wing as his friends were
there.
The man did not want to return because it meant sharing a cell. The
officer whomhe had alleged assaulted him worked in the healthcare
centre, not in the wing to which he was due to return.
f. When they saw himin the chapel of rest he had a graze on the side of
his nose, one on his temple and a small graze or cut on his neck. His
sister and his mother felt these marks might be from the officer who
“beat himup”; and
g. His mother told us that the man had written several letters to people
about being attacked by a “screw” in the HCC and said he had suffered
from severe headaches as a result of the attack. She spoke of two
letters in which the man referred to the incident, one written to his sister
on 27 August and one written to a neighbour.
The man alleged he had sustained a blow to the head and face due to
an assault by the wing officer. The man was not granted his wish to
have his injury photographed. The only evidence that he saw a doctor
following the incident is an injury form (F213) signed two days later.
Fellow prisoners told my investigators about marks or bruising on the
man’s face. Letters home report him suffering headaches. However he
does not appear to have complained to staff of pain or discomfort. The
local investigation ordered by the acting Governor and carried out by a
principal officer found that there had been no assault. It found that it
was possible that the man and the wing officer had clashed heads
during the application of restraint measures after the man threw a book
at the wing officer. Without contemporaneous photographic evidence,
it was not possible to resolve the conflicting evidence as to whether
there was an injury or whether it was the result of a clash of heads,
being hit directly or from hitting the floor.
h. The man’s mother said her son was a very heavy sleeper and for him
to be awake and dressed at six am would have been very out of
character. Why were staff not alerted by this?
The detailed suicide and self harm monitoring record showed that on
the majority of mornings in prison, the man was asleep when the night
staff carried out the last check of their shift. However, there had been
a number of previous mornings when he was awake, perhaps reading,
writing or smoking.
i. His sister raised the issue of why he had been placed in a single cell.
Why did his cell sharing risk assessment state that he could have
presented a risk to others?
18
The cell sharing risk assessment identified him as having a history of
assault and unpredictability. However he was assessed as a low risk
for sharing and was therefore eligible to share. He was identified on
reception as describing himself as having concerns about sharing. To
a great extent his sole occupancy of a cell was his own choice. There
was ample evidence that he resisted sharing a cell on a number of
occasions. During the investigation evidence emerged that suggested
his reluctance to share accommodation might at least in part be
attributed to his self­confessed history of suffering sexual assault.
Bedford’s local suicide prevention strategy document
51. Bedford’s local suicide prevention strategy was dated January 2004. It did
not have an expiry date but was noted to be subject to continual
assessment. The edition given to the investigators was signed and dated
by the then Governor on 5 January 2005. It sets out the role of the Safer
Custody Committee and arrangements for dealing with prisoners at risk.
52. Once an F2052SH is opened, a case conference must take place within 72
hours. The local policy requires the review to be chaired by “a Residential
or Health Care Manager and must involve the minimum of three multi­
disciplinary persons with health care and wing staff input.” (Section C 3 iii.)
Once raised, an F2052SH can only be closed following a case review, as a
result of team discussion, and normally only if there is a unanimous
decision.
53. The policy dictates the frequency that prisoners should be observed,
dependent on the assessed level of risk: ­
· Minimum (or normal) – The schedule is laid out comprehensively in the
policy document and repeated in each individual F2052SH record. It
requires:
1 x visit/entry at roll check 07.30 – 08.00
1 x visit/entry during morning No more than 2 hours after unlock
1 x visit/entry during afternoon 13.30 – 17.30
1 x visit/entry during evening 17.30 – 21.00
7 x visits during the night By night staff on taking over the roll
22.00 – 23.30
23.00 – 01.00
01.00 – 02.30
02.30 – 04.00
04.00 – 05.30
05.30 – 07.30
· Frequent – to be observed randomly every two hours. Authorised by the
orderly officer for those needing a higher level of supervision than normal.
19
· Intermittent – to be observed at irregular intervals at least five times every
hour. Authorised by the doctor or a nurse (in consultation with the duty
governor) or the duty governor (in consultation with the doctor or a nurse).
· Constant – to be observed constantly. Authorised by the doctor or a
nurse (in consultation with the duty governor) or the duty governor (in
consultation with the doctor or a nurse). Case review to be held as soon
as is practicable and certainly within four hours (or immediately before
unlock the following morning if constant watch is commenced during the
night). Prisoner should be referred urgently for a mental health
assessment.
54. The local policy states that “following all cases of self­harm, the next of kin
must be informed, unless the prisoner refuses consent, there is a clinical
reason not to do so, or the prisoners support plan indicates otherwise”.
55. At Bedford, all F2052SH documents have a locally devised sticker added to
the front cover showing target dates for case reviews and when a review
has been completed. This enables staff and managers to see easily if a
review is required and when the last one was completed. A locally devised
information page providing a series of tick­box prompts to assist staff in
completing and managing F2052SH documents is inserted inside the front
cover, together with a sheet setting out the minimum observation schedule.
The management of the man’s suicide and self harm risk
56. There is no doubt that the deceased was a vulnerable and troubled young
man, who was not easy to manage in the prison setting. He was on suicide
and self harm monitoring (F2052SH) throughout his period of imprisonment.
Although he made no actual physical self­harm attempts, he talked about
killing himself on many occasions, sometimes citing overdose as a method,
sometimes starvation by hunger strike and sometimes by hanging. He
wrote statements for his adjudications which mentioned having nothing to
live for and showed staff a letter to his girlfriend which an officer described
as reading ‘like a suicide note’.
57. On one occasion when he was distressed about his girlfriend, a member of
staff rang her and conveyed a positive message to him. Prison Service
Orders require next of kin be contacted after a self harm attempt unless the
prisoner has refused permission for this. Since he did not make any actual
self harm acts or attempts (except once suggesting he had swallowed a
razor blade) his family were not contacted. They therefore did not know
how distressed he was except from what he said in telephone calls to his
sister. He had only one visit when his girlfriend and two other friends came
to see him. (His girlfriend was under 18 and therefore unable to visit without
an accompanying adult).
20
58. The man’s behaviour was described by the psychiatrist as manipulative.
Regarding manipulation, the Prison Service Order says:
“An act of self­harm should always be taken seriously. Even if the prisoner
appears to be using self­harm as a means of gaining something, it is still a
desperate act and the prisoner should be helped to find constructive ways
to meet the underlying need.”
59. It is of concern that not only the man, but, on some occasions staff,
appeared to be unable to distinguish between a community psychiatric
nurse and a psychiatrist. The roles, although complementary, are different,
not least because a psychiatrist has the knowledge and authority to
diagnose and prescribe. In the opinion of the clinical reviewer, not seeing a
psychiatrist for a planned appointment (due to an administrative error) had
almost certainly detrimentally affected his state of mind. This, coupled with
his anger over what he saw as a disappointing encounter with the CPN
indicated that he was very concerned about his mental state and wanted
professional help.
60. On 21 August, in the SSU, an officer made entries in his history sheet and
F2052SH referring to him playing ‘mind games’. This reference was
repeated even after the officer had read the note which looked ‘like a
suicide note’. The officer quite appropriately contacted the orderly officer
(OO) to report the note. The officer recorded that the OO instructed him/her
to keep an ‘extra eye’ on The man but the officer’s entry continued in
brackets NOT INTERMITTENT WATCH. The only reference throughout the
F2052SH document to the level of watch to be applied to the man was the
nurse’s entry on 22 July. The registered nurse who completed the nursing
assessment ordered ‘normal’ observations and recorded it on page 5
together with a note that she had ‘discussed (it) with MO’ (meaning the
doctor). No mention was made about the intermediate option of increasing
the man’s watch to ‘frequent’ (randomly every two hours).
61. With the exception of some of the language used about him‘playing mind
games’ and ‘making silly comments about self harming’, the entries in the
F2052SH are of a high standard, demonstrating quality interaction with him
and showing evidence of staff taking care of his wellbeing. Prison Service
policy requires regular case reviews and in the man’s case these occurred
on six occasions. The records of the case reviews show that the majority
had a satisfactory multi­disciplinary attendance although there was minimal
continuity of members of the review panel. The summaries of each review
were comprehensive although most of the support plans were fairly
generalised and did not identify individual accountability.
21
62. The Prison Service Order says:
“Special consideration should be given to prisoners on an open F2052SH
who are .... subject to an adjudication ... Adjudicators should consider the
implications of the punishment they may impose on a prisoner who is found
guilty at an adjudication and who is subject to F2052SH procedures, such
as removal from association, loss of canteen and cellular confinement ...”
63. The man was adjudicated upon on 19 August and, in apparent compliance
with the order quoted above, an unscheduled case review was held later
that day. The adjudicating governor chaired the case review. There was
other evidence that this governor was aware of the link between the event
of the adjudication and the man’s ongoing self harm management. On 22
August, however, the man was given a day’s cellular confinement as an
adjudication punishment without having been examined by a doctor and
passed fit for such punishment (as was required at that time). At a case
review held later that day, the reviewers arranged for his immediate
admission to the healthcare centre.
64. On 26 August the man was again brought before a governor for
adjudication, this time there were two separate charges. One related to
damaging his cell furniture and the other to throwing a book at an officer.
Both incidents occurred in the healthcare centre. When the man made his
counter allegation that he had been assaulted by a wing officer, the
adjudicator and acting governing Governor adjourned the hearing pending
an investigation of his allegation. On the other charge, the acting governor
found himguilty and punished him with five days cellular confinement.
Later that day a case review was held. The man aired his anger about the
alleged assault and also asked for his medication to be reviewed. This was
ordered by the chair of the review who allocated the responsibility to a
community psychiatric nurse who was party to the review. A further review
was booked for 5 September.
Communication between departments
65. Multi­disciplinary attendance at F2052SH reviews at Bedford was of a good
standard. However, there was no action ordered by the acting governor on
28 August to implement his decision that the man’s next location must be
given careful consideration following his threats to climb on the beams as
reported in the SIR on 26 August. The man was moved from the SSU to a
cell in the FNC on 27 August. Records showed that the move was
prompted by the need to find a cell in the SSU for another prisoner. There
is no evidence that the move was given special consideration. There is no
evidence that any link was made between the man’s written statements
describing a past history of sexual assault in a young offenders institution
and his reluctance to share a cell.
22
Follow­up to deaths in custody
66. PSO 2710 gives instructions on action to be taken following a death in
custody, including the support arrangements for staff and prisoners. The
PSO says that priority must be given to communicating the facts about the
death to prisoners and staff. It says it may be useful to issue a written
statement to prisoners to defuse rumour and myth but that this will depend
on local judgement. Any prisoner who may have been particularly affected
by the death should be offered support. The management at Bedford acted
more than appropriately with regard to prisoners. They not only issued a
timely notice to prisoners about his death but took extra measures to
identify his friends and offer individual support from the chaplain and other
staff. In addition, after his mother and her daughter visited the prison on 28
October the Governor circulated to prisoners a typewritten version of a most
thoughtful thank you letter the man’s mother had written to the prisoners
and given to him during her visit.
67. On the issue about supporting staff, there was an immediate ‘hot debrief’ of
some of the staff involved, but no contemporaneous note was made.
Healthcare staff and control room staff were overlooked. The clinical
reviewer established that the lack of support to at least one member of
healthcare staff, a pharmacy technician with no previous experience of a
traumatic death, led to distress and a period of illness. The OSG from the
control room told my investigators that no–one had checked on her
wellbeing on the day. She just went on working. She was later offered
counselling and the FNC manager had offered to take the OSG with her to
counselling but she felt it was too late. Two weeks after the man’s death
the deputy governor had told her they were having a critical incident debrief
and invited her but she had declined saying she had needed the hot debrief.
She had seen a member of the Post Incident Care Team but only after he
had learned informally that she was upset.
Clinical review
68. The Director of Care at Bedford Primary Care Trust carried out a clinical
review and he concluded that, overall, policies and procedures appeared to
have been adhered to and the man received care equitable to other
prisoners, and no worse than he might have expected in the wider
community. His more detailed findings and conclusions have been drawn
together in the paragraphs below.
a. The man was well known at Bedford Prison and was reported by those
interviewed to be different on this admission. Previously he had
presented as a cheeky, likable rogue. During this sentence he was
angry, venting his frustration on furniture, windows, and staff. At times
he appeared confused and frightened, making repeated threats to kill
himself in a variety of ways but never actually carrying out any of the
threats.
23
b. The man was haunted by his past and chose either to seek help from
prison listeners, CPN’s and others or to turn it down, refusing to share
any problems with officers and others, turning to ‘childish tantrums’
and failing to mix well with other prisoners at times.
c. Additional counselling may have helped himcope with the loss of his
girlfriend and other historic issues.
d. The man was not deemed to require in­patient health care assistance
towards the end of his life but had been in the in­patient unit for a
period during this sentence. He had regular access to CPNs and
medical staff throughout his sentence.
e. The psychiatrist not seeing himas planned, due to an administrative
mix up, could have contributed to the final outcome, but the health care
team reassured the clinical reviewer that the care plan, clinical
diagnosis and management plan would not have been different had the
consultant seen him. He was seen by an SHO (senior house officer)
and regularly by the CPNs
f. The ‘assault incident’ played a role in the man’s belief in himself and
the system. He was not allowed a photograph as evidence and there
is no evidence that he was seen by a doctor other than the F213,
signed two days later.
g. The man was alone in a double cell the night he died; the records
clearly indicate his wish not to share a cell and his delight at the
location. Fellow prisoners state the he wanted to share and should not
have been alone, as his behaviour was going down hill. He had been
advised of the impending transfer from this cell the night before he
died. This may have been a factor in his state of mind, but calls on the
cell bell seem to have been answered and available support offered
h. Qualified nurses responded to the first call for assistance, but the
second call required assistance by a nurse and a pharmacy technician.
This technician, who was involved was very disturbed by the events,
but refused the option of attending the ‘Hot debrief’ taking extended
sick leave immediately following interview by the author.
i. The radio call for assistance to B1 landing rather than C1 caused
confusion, but not an undue delay. CPR had been started by the
prison officers and was rotated to health care staff as they arrived. The
confusion was unfortunate, but not a contributory factor in the man’s
death.
j. The two calls for an Ambulance were confused and vague. The first in
respect of what had happened exactly, the second in the specific
requirements. A paramedic crew would not have been able to act
differently, as nursing staff had administered medication. However
they may have been able to make a decision regarding continued CPR
24
in the light that the man was not responding to treatment, as indicated
by his general observations and the resuscitation machine reading.
These issues were not contributory to his death.
k. Members of staff were genuinely disturbed and deeply upset by the
man’s death. From written and verbal accounts given, clinical and
prison staff seemed in need of formal post­incident support.
l. There was little doubt in the clinical reviewer’s mind that the prison was
under a significant amount of pressure at the time leading up to the
man’s death. Several staff reported three particularly difficult prisoners
that were taking up considerable resources.
m. Where an incident occurs on a Saturday (e.g. the man smashing a
window in the visiting area) prisoners are not seen by the prison doctor
until the following Monday morning if the injuries are considered minor
or appear non­existent. In his case the incident took place on a
Saturday. The medical paperwork was completed on the Monday but
the doctor dated his report on the Wednesday. The doctor has since
left the establishment and so this could not be clarified but the clinical
reviewer concluded that attention should be given to an audit of such
delays and follow up actions agreed
n. Algorithms used in the SSU (Segregation and Support Unit) were not
always completed.
o. Abbreviations and undistinguishable signatures should be addressed in
all records, by ensuring summary sheets and signature lists are in
every file.
69. The clinical reviewer made the following recommendations which I endorse:
A. A review of the need for counselling, psychological support and a
consideration of the need for CBT (Cognitive behaviour therapy) should
be undertaken.
B. All allegations of assault should allow the prisoner access to a
photographer and a doctor.
C. The administrative oversight that resulted in the man not seeing the
consultant psychiatrist should be addressed in order to prevent similar
occurrences in the future.
D. Communications, specifically around the request for ambulances
should be reviewed and a proforma or similar developed.
E. All notes should contain signature lists and an abbreviation summary.
Continuous chronological records, whilst difficult to operate on a daily
basis, would make the investigation process and other review systems
simpler.
25
RECOMMENDATIONS
1. I recommend the Governor of Bedford reminds staff that prisoners who
self harm (or make serious threats to do so) as a means of gaining
something should be taken seriously, and helped to find constructive
ways of meeting their needs. Staff should also be reminded that the use
of judgemental or derogatory language is unprofessional and should be
discouraged in verbal and written communication.
A Notice to Staff has been issued regarding the use of language in communications,
both written and verbal. The ACCT training also reinforces to staff that self­harm
must be taken seriously.
2. I recommend that the Governor of Bedford seeks to ensure that staff are
fully conversant with the range of observation levels for F2052SH /
ACCT forms, particularly the difference between normal and frequent
observations.
The local ACCT training is addressing this point.
3. I recommend that the Governor of Bedford seeks to ensure that
communication between security and other departments in the prison is
timely and accurate.
Safer Custody is now a standing agenda item on the Security Committee.
Residential Principle Officer’s cross check Security Information Reports relating to
injuries and bullying.
4. I recommend that the Governor of Bedford reminds staff of the content of
Prison Service Order 1700 (Segregation) and the revised Discipline
Manual, particularly in regard to the completion of Segregation Safety
Algorithms and the requirement for a medically qualified person to
authorise cellular confinement.
A notice to staff has been drafted reminding staff of the requirements of PSO 1700.
5. I recommend that the Governor of Bedford reviews the local
arrangements for supporting all staff after a death in custody to ensure
that proper records are kept and that no staff are omitted from the
support available.
The contingency plans are to be updated.
6. A review of the need for counselling, psychological support and a
consideration of the need for CBT (Cognitive Behaviour Therapy) should be
undertaken.
CPNs can now refer offenders into a ‘Beat the Blues’ programme. Psychological
support services and relaxation therapy are now available.
26
7. All allegations of assault should allow the prisoner access to a
photographer and a doctor.
This procedure has been introduced at Bedford.
8. The administrative oversight that resulted in the man not seeing the
consultant psychiatrist should be addressed in order to prevent similar
occurrences in the future.
Revised procedures are now in place to prevent any similar occurrence.
9. Communications, specifically around the request for ambulances
should be reviewed and a proforma or similar developed.
Prison Service procedures as set out in PSO 1400 and the National Security
Framework provide the necessary structure and format for this to be implemented in
Bedford’s local policies and procedures. The national audit system undertaken by
the Prison Service Standards Audit Unit will monitor its implementation.
10. All notes should contain signature lists and an abbreviation summary.
Continuous chronological records, whilst difficult to operate on a daily
basis, would make the investigation process and other review systems
simpler.
This is being addressed through training. In addition, those undertaking the role of
log keepers will take notes, avoid abbreviations and sign appropriately.
27
GOOD PRACTICE
I acknowledge the good practice identified by the clinical reviewer in his report and
repeat them below:
· There was evidence of good care and concern for the man, by specific
prison officers and healthcare staff. The man had been able to develop
good relationships with named individuals who were clearly offering him
support and assistance.
· The actions surrounding the call for assistance are noted as good
practice, especially the rotating of the CPR at the scene of his death,
between prison staff, healthcare staff and the ambulance staff, who
clearly worked as one team.
· The high level of upset and concern expressed by many NHS and Prison
staff is indicative of a caring and professional staff team, who supported
each other well in the time immediately after the man’s death.
· There is a general wish to learn from the events described. At interview
several staff have sought to learn from the events surrounding the
man’s death, such that care is improved for future prisoners.
28