Individual at Bedford

Investigation into the circumstances surrounding the death of
a prisoner at HMP Bedford,
in December 2004
Prisons and Probation Ombudsman for England and Wales
December 2005
This is the report of an investigation into the death of the man who died in December
2004, in hospital. The man was a prisoner at HMP Bedford and was found, that
evening, hanging from the window bars of his cell.
I offer my sincere condolences to the man’s family. Despite coping with his drug and
alcohol addiction in recent years, they always remained loyal, loving and supportive.
I have great respect for the dignity they have shown.
I also offer my sympathies to management and staff at the prison. They have to work
under difficult circumstances with large numbers of very vulnerable men who, in the
great majority of cases, are withdrawing from drugs. The number of deaths that have
been prevented thanks to the care and diligence of prison staff can never be truly
quantified. Yet when a death occurs, as in the case of the man, it invariably has a
profound effect on staff and they often feel personally accountable.
Two investigators from my office conducted the investigation.
I am grateful for the assistance they received from the staff and management of HMP
Bedford. I wish to acknowledge too the ready help 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 Bedford Primary Care Trust who conducted the
clinical review.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2005
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Contents
SUMMARY.......................................................................................................4
INVESTIGATION OUTLINE.............................................................................6
BACKGROUND...............................................................................................7
CHRONOLOGY OF EVENTS......................................................................122
FINDINGS AND CONCLUSIONS................................................................222
RECOMMENDATIONS..................................................................................26
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Summary
This is the report of an investigation into the death of a man. The man was aged 23
when he died at 8.53pm on 27 December 2004 in hospital. He was a prisoner at
HMP Bedford and had been found hanging from the window bars of his cell earlier
that evening.
The investigation team reviewed the man’s prison records and interviewed both
prison staff and prisoners. A report prepared by Bedford PCT on clinical matters.
The man had been at Bedford since 18 September 2004, having been charged with
possession of an offensive weapon. This was not the first time the man had been in
prison custody. He was not considered to be at risk of suicide when he died, but had
been so on two occasions previously.
During the reception procedure, the man disclosed his alcohol habit and his history of
depression. He claimed that cannabis was the only drug that he misused and said
that he last attempted suicide in May 2004.
The man said that he was paranoid and heard voices telling him to hurt
someone, so he was located in a single cell accommodation. In the following
weeks, the man was assessed by a Community Psychiatric Nurse (CPN) and
referred to Alcohol Anonymous (AA) meetings.
On 1 November, the man was sentenced to eight-months in prison, with a
release date of 16 January 2005.
On 3 November, the man said that he was depressed and wanted to kill
himself. A F2052SH1 was opened and he was admitted to the Healthcare
Centre (HCC).
Over the following weeks, the man’s mood fluctuated and he frequently
threatened to self-harm and physically did so on three occasions. As his
mood changed, so did the frequency that staff observed him.
The F2052SH was closed on 17 December 2004 as the man appeared to be
stable. However, another F2052SH had to be opened on 21 December 2004
as the man threatened to kill himself.
On 23 December, there was an incident where the man smashed his TV and
was threatening and abusive to staff. This was adjudicated upon the following
morning. The incident arose as the man had been denied a move to another
wing.
On the morning of 24 December, before the adjudication, a F2052SH case
review was held and a decision was made to close the document. The CPN
who attended the review described the man as “purposeful and giving positive
1 Documentation for recording the monitoring, care and support of prisoners identified as
being at increased risk of suicide/self-injury.
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intentions”. The review described the man as apologetic, but said he was
blaming the wing senior officer (SO) for not allowing him to move wings. The
review chair made it clear that the man would not be moving wings. The man
was about three weeks away from release, and assured the review that he
would not self-harm again.
On the evening of 27 December 2004 at 7.45pm, during a routine roll check, the man
was found hanging from the bars of his cell window. Attempts to resuscitate the man
were made and a pulse was found. 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 made every effort to revive the man.
He was subsequently taken to the local hospital but died at 8.53pm.
This report focusses on the man’s time in prison custody and evaluates the systems
in place to establish whether they were (and are) fully effective.
The report makes eight recommendations and identifies one example of good
practice.
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Investigation Outline
The investigation into the man’s death was conducted by two of my
investigators. They visited the prison and were shown the areas where the
man would have been, including the reception and induction areas, the
healthcare unit, the segregation unit and the wings on which the man was
located.
They issued a notice to staff and prisoners inviting anyone with information
relating to the man’s death to make themselves known to the investigation
team. Two prisoners who knew the man came forward, as did one member of
staff.
My investigators also spoke to the Chair of the Independent Monitoring Board
(IMB), the Prison Officers’ Association (POA), one of the prison chaplains, and
various other members of staff, including the governor who is the team leader
for violence reduction and suicide prevention. They also spoke to three
prisoners. Two of these prisoners had seen the control and restraint incident
in which the man was involved (one of whom was going to act as a witness for
the man at his forthcoming adjudication). The third prisoner was located in
the cell next door to the man when he died. He spoke little English and my
investigators spoke to him through their interpreter.
My investigators formally interviewed seven prison staff who were involved in
the events surrounding the man’s death.
The prison gave my investigators full access to all the documentation
surrounding the man’s time in prison. The police also provided copies of the
documents and statements in their possession. My investigators obtained
some further information from the probation and court services.
One of my investigators and one of my Family Liaison Officers visited the
man’s father and stepmother, to discuss their concerns about what had
happened to the man.
Finally, my investigators commissioned the Director of Care from Bedford
Primary Care Trust, to conduct a clinical audit of the man’s care while in
prison.
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Background
Bedford Prison
Bedford prison is a small local prison serving the courts in the county and
nearby, and 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 27 December 2004, it was holding 437
prisoners.
A wing is the largest wing in the prison, and on 27 December it held 123
prisoners. In comparison, C wing, which is mainly used as an induction wing,
held 64 prisoners.
In January 2004, Her Majesty’s Chief Inspector of Prisons conducted an
announced inspection. 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 staff-prisoner relationships. She
found that there were effective systems in place to minimise bullying and
reduce the risk of suicide and self-harm, although she said that the latter could
be better co-ordinated. But she was concerned about the induction process,
and the provision available for people for whom English was not a first
language. She said that black and minority ethnic prisoners should be more
actively involved in the development of the prison’s work on race. She also
considered that replies to complaints were often dismissive and of poor
quality. In addition, she identified a key problem as being the lack of
purposeful activity for prisoners.
The Chief Inspector had some specific concerns about the approach to
prisoners at risk of suicide or self harm. She said that better co-ordination of
elements within the safer prisons strategy would create a preventative rather
than a reactive approach. She also raised the issue of suitable access to
Listeners. (Listeners are prisoners trained by the Samaritans to provide a
listening ear to prisoners in distress.) Finally, she was concerned that there
was a lack of structured, wide-ranging refresher training for staff. She said
that a local target of 20% of staff to receive refresher training each year was
not being met.
In February and March 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. Heath and Safety
arrangements (rated 61% compliant with standards) were considered to be
deficient, and it said there was an expectation from managers that staff and
prisoners could take care of their own safety without guidance from
management. 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. It was noted that there was no
agreed course content for anti-bullying, suicide and self harm awareness
sessions in the induction programme, resulting in some inconsistency of
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delivery. In race relations (rated 81% compliant), there were weaknesses in
the recording and monitoring of racial incidents.
A ‘Measuring the Quality of Life’ survey at the prison in March 2004 identified
some concerns about the high level of drug availability at Bedford, especially
on A wing. But it reinforced the Chief Inspector’s findings about good
relationships and safety within the prison.
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.
There have been four other deaths in Bedford in just over two years. Three
prisoners died towards the end of 2002, and there was one death in
November 2003. 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.
The investigation of the death of a prisoner in 2003 raised some concerns
about communication between healthcare professionals, and put forward
recommendations concerning the treatment of prisoners who speak little
English. As a result of these inspections and investigations, various action
plans have been drawn up, which the Governor told us were being pursued.
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Suicide and Self Harm Procedures
Prison Service suicide and self-harm procedures are set out in Prison Service
Order (PSO) 2700.
The Order says:
“An act of self-harm should always be taken seriously. Even if the
prisoner appears to be using self-harm 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.”
For prisoners who have self-harmed:
“The prisoner should be asked if they are being bullied or intimidated,
and if so the Anti-Bullying Co-ordinator should be notified.”
“After consultation with the prisoner, the nominated next of kin must be
notified, unless:
(cid:190) There is a clinical reason not to, or;
(cid:190) If aged 18 or over, the prisoner does not consent, or;
(cid:190) The prisoner’s support plan indicates otherwise (e.g. in the case
of a prisoner who repetitively self-harms).”
In relation to adjudications, the Order says:
“Special consideration should be given to prisoners on an open
F2052SH [a procedure for dealing with prisoners at risk of self harm]
who are .... subject to an adjudication ... Adjudicators should consider
the implications of the punishment they may impose on a prisoner who
is found guilty of an adjudication, and who is subject to F2052SH
procedures, such as removal from association, loss of canteen and
cellular confinement ...”
In relation to the processing of an F2052SH, the Order says at annex B that
when an F2052SH is opened, the manager of the unit where the prisoner
resides must:
(cid:190) Decide, in consultation with healthcare staff, whether to manage the
prisoner on the residential unit or refer initially to the Healthcare
Centre (HCC), and document reasons.
(cid:190) Ensure that, where available, prisoners on an open F2052SH have
been offered the opportunity to talk to a Listener and/or Samaritan.
(cid:190) Ensure a case review is held within 72 hours, and document a
summary of the review and agreed support plan.
When a F2052SH is raised by non-healthcare staff, a doctor, nurse or heath
care manager must check the prisoner’s Inmate Medical Record (IMR), and
record in it the raising of the F2052SH.
9
A healthcare officer or nurse must interview the prisoner as soon as possible.
The prisoner must also be referred to a doctor as soon as possible, and in any
event within 24 hours of any referral to the HCC. A record of these
assessments must be made in the F2052SH and in the IMR.
A support plan must be drawn up and agreed. Multi-disciplinary case reviews
must be held as necessary, including in the event of a further act of self-harm.
The F2052SH will be closed at a case review when the prisoner appears to be
coping satisfactorily. The case review will agree after-care or follow-up
requirements.
Bedford’s local suicide prevention strategy document
In January 2004, Bedford agreed its local suicide prevention strategy. It sets
out the role of the Safer Custody Committee and arrangements for dealing
with prisoners at risk.
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
HealthCare Manager and must involve the minimum of 3-multi disciplinary
persons with health care and wing staff input.”
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.
Once the form is closed, any ongoing support should be recorded and copied
into the prisoner’s history sheet so that it can be referred to after the closure of
the F2052SH. No later than one week after the form is closed, the prisoner is
to be seen by the Residential Manager who will ensure that the prisoner is
coping satisfactorily and that any ongoing support identified when closing the
F2052SH is being delivered.
The policy dictates the frequency that prisoners should be observed,
dependent on the assessed level of risk: -
(cid:190) Frequent – to be observed randomly every two hours. Authorised by the
Orderly Officer.
(cid:190) Intermittent – to be observed randomly five times every hour. Authorised
by the doctor or a nurse, or the duty Governor, in consultation with the
doctor or a nurse.
(cid:190) Constant – to be observed constantly. Authorised by the doctor or a
nurse, or the duty Governor, in consultation with the doctor or a nurse.
The local policy states that “following all cases of self-harm, 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”.
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Follow-up to deaths in custody
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.
A record should be kept of all those entering where the prisoner died. There
should be an immediate post-incident debrief (a ‘hot debrief’) of staff involved
before they go off duty. A senior member of staff should act as a de-briefer
and a duty care team member identified and, if necessary, called in on duty.
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Chronology of Events
17 September 2004 to 23 December 2004
On 17 September 2004, police charged the man with being in possession of an
offensive weapon. He appeared before the Magistrates’ Court the following day. At
10.40am, the magistrates remanded the man in custody until 20 September. He
arrived at Bedford prison at 1.45pm. The Prisoner Escort Record (PER2) was
completed by the police and warned receiving agencies to be aware that the man
had a history of violence and weapons.
On arrival at the prison, the man told staff that he had been living rough and that he
had no home address. He gave his father’s address (but no telephone number) as
his next of kin. He appeared to be relaxed about being in prison.
The man was given a Healthcare Screening in Reception where he disclosed his
alcohol habit and that he had a history of depression. He claimed that the only illegal
drug he misused was cannabis, which he said he last used on 16 September.
The man was assessed as being of “low risk / medium”, which means he was
deemed suitable to share a cell with other prisoners. However, due to his
request to be on his own and the history of paranoia and anxiety, a single cell
was authorised on C-wing, the induction wing.
The next day, 19 September, the man told staff that he had made a suicide
attempt over a year ago and that his last attempt had been in May 2004. He
also said that he was worried about being with other prisoners. The man told
induction staff that he was paranoid and heard voices telling him to hurt
someone.
The Cell Sharing Risk Assessment was reviewed, and the man was
considered to be a high risk to the safety of another prisoner if they were to
share a cell.
On 20 September, the Magistrates’ Court convicted the man. He was
returned to Bedford to await sentence, as the bench wanted more information
about him before sentencing.
In the following weeks, the man was assessed by a Community Psychiatric
Nurse (CPN), and referred to Alcohol Anonymous (AA) meetings. On 7
October, during a CARATS3 assessment, the man spoke of desire to kill and
said that he wanted to be a mass murderer. He said that he had lived rough
for about two years and that he had been banned from hostels for being
involved in witchcraft. The man said that he had no family contact and saw
being in prison as salvation. He said that alcohol was the only drug that he
misused, and this cost him about £21 per week. The CARATS worker
2 The Prisoner Escort Record (PER) is a document completed before a prisoner is escorted,
and is used to communicate potential problems from one agency to another. There is also a
record made of all key events whilst on escort.
3 CARATS is a drugs service provided by different contractors but available in all prisons.
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referred the man to a CPN for assessment, although, the man made it clear
that he did not want any assistance from a CPN.
On 8 October, the security department decided that due to his inappropriate
comments, and the unsupervised structure of AA meetings, the man was
unsuitable to attend AA meetings.
On 1 November, the man was sentenced to eight months imprisonment. His
release date would have been 16 January 2005.
On 3 November, the man was admitted to the HCC. A F2052SH was opened
as he said that he was depressed and wanted to kill himself. During the
nursing assessment following his admission to the HCC, the man said that he
was unable to cope on ordinary location and threatened to kill himself if he
was not placed in a single cell.
The doctor assessed him and said that he was not acutely suicidal. The
doctor authorised a single cell in the HCC and said that the man should be
observed regularly. Later that night, the man was challenged by staff for
putting his mattress on the floor to sleep. This made it difficult for staff to
observe him.
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 is inserted inside the front cover. This provides a series of tick-box
prompts to assist staff in completing and managing F2052SH documents.
On 4 November, the man was found with a pillowcase on his head. When
challenged, he told staff that he wanted to be left alone. On 5 November, the
F2052SH document was reviewed. During the case review, which included a
CPN, the man told staff that he felt insecure and intimidated. He said that he
felt depressed but did not feel as though he would self-harm. The CPN
reviewed the man’s medication, and later that evening he saw a Listener.
On 8 November, the doctor declared the man fit for location on one of the
main wings. The Cell Sharing Risk Assessment was completed, and the man
was still regarded as a high risk to other prisoners who might share a cell with
him. A single cell was authorised. Later that evening, the man told staff that
he was depressed but now felt okay.
On 9 November, the man refused to associate but said that he was okay. On
10 November, he moved to the largest wing in the prison, A-wing. An
induction exit interview was conducted and staff noted that the man became
paranoid in large groups.
On 11 November, the man declined exercise. He sat in his cell reading and
staff described him as being cheerful. On 12 November, the man was
described as being “full of smiles”. Later he asked to see a Listener, but used
13
the Samaritans phone as alternative. On association, he kept himself to
himself.
On 13 November, the man was feeling very depressed and said he was
suicidal. Staff removed razors from his cell and placed him on an intermittent
watch. At about 8:10pm, he told staff that he was fine. However, at 8:40pm,
the man was found with a ligature around his neck. He was kneeling on the
floor near the heating pipes. His bed had been moved to block the door. Staff
intervened but there was no need to resuscitate. This was not thought to
have been a serious suicide attempt and he was placed in the Listener suite.
Later, the man said he regretted his actions and that he would not do it again.
On 14 November, at 8:25am, the man’s case was reviewed and the
intermittent watch was stopped. He said that he was depressed and felt like
hanging himself. It was agreed that the man would move back to the HCC at
lunchtime.
At 9:55am, the man asked to see a Listener but was offered the Samaritans
phone instead. This was because he was assessed as being a high risk to
other prisoners. At 10:20am, he was given the Samaritans phone to use. The
man said that he no longer wanted to kill people.
At 11:45am, the man attempted to hang himself and was moved to the HCC
immediately and placed back on an intermittent watch. At 12:40pm, he used
the Samaritans phone. At 3:30pm, he saw a Listener, and at 9:15pm, he used
the Samaritans phone for over an hour. There is no evidence that after either
of the self harm attempts on 13 or 14 November, the man was asked if he
would like his next of kin notified.
On 15 November, at 9:15am, 11:00am and 3:26pm, the man was frustrated
and repeatedly asked staff for the hair clippers. At 11:30am, during a
F2052SH case review, the man said that he was depressed and had thoughts
of killing himself so that he would be nearer the church. He explained that he
wanted to be cremated and his ashes left in a church. This was so that he
could be in the church forever. He was assessed by a CPN.
At 3:42pm, the man packed his belongings and refused to return to his cell,
saying that he wanted to go to the Segregation Unit. This was not allowed,
and at 4:40pm the man reluctantly returned to his cell, again complaining that
he was unable to use the hair clippers.
At 5:54pm, the man saw a Listener, and at 6:10pm he told staff that he was
low in mood and wanted to hang himself. At 6:25pm, the Duty Governor
spoke to the man and, due to the concerns of staff about the man’s suicidal
behaviour; he was placed in strip conditions and given a sedative.
On 16 November, at 9:55am, the man had the haircut that he had been asking
for. At 11:05am, following a F2052SH case review, the intermittent watch was
changed to frequent observations. The man said that he was depressed and
was having thoughts of self-harm. That afternoon, he told staff that he was
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scared to go back to ordinary location, and that he felt that people were
watching him through his blanket that covered the window. Later that
evening, the man saw a Listener.
On 17 November, the man was deemed by the HCC to be fit for a single cell,
on normal location. The man saw a CPN and asked to move to a normal
location wing. That afternoon, the man was moved to C wing.
On 18 November, the man was described as “chatty” whilst on association
and said that he was happy to be back on C wing. On 19 November, the man
said that he felt very happy on C wing because it was a small wing and he
struggled to cope with lots of people around him.
Unusually, on 21 November the man declined church. He was chatty, but
said he felt depressed and lonely, and that he found it difficult to socialise.
The doctor said that there was no evidence of mental illness, but described
the man as being vulnerable.
On 23 November, the man associated on the wing and was described as
being in a good mood. He declined to go to the library and exercise, but he
said that he was okay. On a F2052SH case review, which was not multi-
disciplinary, the man said that he still felt a bit depressed and still had slight
suicidal thoughts. Later, the possibility of in cell work was discussed with the
wing manager. The man said that he was happy and comfortable on C wing.
Over the next few days, the man declined exercise but said that he had no
problems although he declined Bible studies as he thought someone would go
into his cell. He did, however, see the chaplain, who described the man as
being in good spirits. The man was seen laughing and joking on the wing. On
29 November, the man said that he felt much better and had no problems. He
asked the staff to prepare a homeless discharge grant for him, as he had no
address to go to when released. This would have been issued to help with
housing.
A F2052SH case review was held on 30 November. The man said that he
was feeling better, but still wanted to be on his own. The CPN agreed to
review the medication prescribed to the man and discuss cognitive behaviour
treatment when the F2052SH had been closed. The wing manager spent
time with the man encouraging him to spend more time out of cell. The man
was described as being in good spirits, and was looking forward to doing
some wing based work. The next day the man saw a Listener in the
Listeners’ suite, for 45 minutes.
On 2 December, the man told staff that he felt ready to come off the
F2052SH. He was helping to clean the wing, declined exercise, and said that
he had no problems. He was chatty on association. At 10:00pm, the man
spoke to a Listener for an hour and 25 minutes.
At 11:40am on 6 December, the man told staff that he was concerned that if
the F2052SH was closed staff would not speak to him as much. He was
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reassured that support would still be available, regardless of the F2052SH. At
3:05pm, the man told staff that he was planning to hang himself that night but
would press the emergency cell bell to alert staff and to give them a chance to
save him. He said that if staff failed to save him, then it would be staff that
would be blamed. At 8:30pm, staff found and removed two nooses and a
razor from the man’s cell. He promised not to hang himself, as he was now a
wing cleaner. The man was placed on an intermittent watch and he later told
staff he had had a bad day, but felt better after chatting.
On 7 December, the man completed his cleaning on the wing, and staff said
that he seemed to be happy. A F2052SH case review was held where he
told staff that he had made the nooses the previous night so that he could
remain on an F2052SH. He felt that being on an F2052SH was a good
method of engaging with staff. The review team told the man that that was
not the purpose of the F2052SH. The man said that night staff would need to
watch him closely, as he was feeling depressed. His observation levels were
set as normal observations in the daytime and intermittent observations at
night.
At 00:10am on 8 December, the man was found hanging from the end of the
bed in his cell. He was still conscious and was seen by a nurse. He was
issued with the Samaritans phone and spoke for about 26 minutes. At
1:55am, when the phone was retrieved, he said that he felt less like hurting
himself.
At 10:49am on 8 December, a F2052SH case review was held to discuss
what staff described as a disruptive night. The man said that he was
depressed and that he had been giving his medication to other prisoners. He
was kept on normal observations in the daytime and intermittent observations
at night. Again it does not appear that the man was asked if he would like his
next of kin contacted following his self harm attempt.
That afternoon, the man was moved to A wing, and this appeared to cause no
problems. The man told day and night staff that he would press his cell bell if
he was having thoughts of suicide or self-harm. Staff said that he seemed
more relaxed.
On 9 December, the man declined exercise and association. To alleviate the
problem of his giving his medication to another prisoner, the man collected his
medication at the end of the association period. At 10:42am, a F2052SH case
review was held and the man said that he attempted hanging when he was
depressed and wanted to talk to staff. He said that he was happier, and night
observation was returned to normal. The CPN saw the man and said that he
appeared to be paranoid and confused.
On 10 December, the man complained that he did not have his radio which he
had ordered from the prison shop. The man was allowed a supervised shave
on association. He made an application to see the Independent Monitoring
Board (IMB) regarding access arrangements to his son. He was advised to
contact his solicitor.
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Over the next few days, the man said that he was okay, but declined
association and repeatedly enquired about his radio. It was explained to him
that the radio he had ordered from the prison shop had been delivered, but to
be electronically tested for safety. This would take some time to complete, as
there was a queue to have the test completed. On 13 December, the man
associated on the wing for a while. He was said to be happier now he
understood what was happening with his radio.
By 17 December, the man appeared to be associating and coping on the
wing. A F2052SH case review was held, and a decision was made to close
the document. The review was multi-disciplinary, with three people present
including a CPN. The review described the man as an “attention seeker and
not a self-harmer”, who had self-harmed due to a fluctuation in his medication.
He was now taking his medication regularly and so was more stable and, on
these grounds, the review team felt it was appropriate to close the document.
A F2052SH was opened on 21 December, when staff found three ligatures in
the man’s cell. The man said that he intended to kill himself. A CPN
assessed him and the man said that he liked being on a F2052SH because he
felt safer and supported by staff. The doctor’s section of the F2052SH was
not completed. A decision was made to manage the man on A wing with
normal observations.
On 22 December, the man claimed to be feeling more stable as he was taking
his medication on a more regular basis. He was assessed by a CPN who said
that the man remained paranoid and insular. That night, the man had a long
conversation with night staff, as the Samaritans telephone was not working.
23 December to 27 December 2004
At 3:45pm on 23 December, the man asked when he would be moved to C
wing, claiming that wing Senior Officer (SO) had agreed to the change of
location. When consulted about the agreed move to C wing, the wing SO said
that she had not agreed to this and that the man was manipulating the system
and would not be moving wings. It was explained to the man that C wing was
for induction, and it was the policy to progress from C wing and not to return
as space would be needed for new prisoners. At interview, the wing SO said
that she had told the man a few days previously that she would do what she
could about a move, but that she was not sure it would be possible.
At 5:25pm, the man told staff that he would commit suicide and that he was
writing a suicide note. The man later denied saying this.
At 6:15pm, the man smashed the television in his cell, claiming that he was
frustrated at being refused a move to C wing after the wing SO had said he
could move. The man claimed that the wing SO had lied to him about his
request for a move of wings. He calmed down and spent some time talking to
staff. One of the wing cleaners began to clear up the broken pieces of TV and
the wing remained on association.
17
At about 6:50pm, the man smashed up his furniture in his cell and placed it on
the landing outside his cell. He was told to return to his cell but refused. He
became aggressive towards the staff and was restrained using Control and
Restraint techniques (C & R) and taken to the Separation and Support Unit
(the SSU or segregation unit).
Following his location in the SSU, the man was found to have sustained no
injuries during the C&R incident. The man told staff that he made comments
about suicide because he was not being moved to C wing. At 7:55pm, the
man was moved back to his cell on A wing. Following his return to the wing,
the man apologised to the Officer to whom he had become aggressive and
they shook hands. At 10:55pm, the man told staff that he felt down and
depressed about the earlier incident.
On 24 December at 8:20am, the man used the Samaritans phone on C wing.
This is recorded in the log section of the F2052SH, but not in the main part of
the document. The man returned to A wing at 8:55am and told staff that he
was fine.
At 9:10am, the man was told that he would be taken before a Governor and
adjudicated on for two offences against prison discipline which had taken
place the previous evening. These were charges as follows: -
1. Rule 51, Paragraph 17 – Destroys or damages any part of a prison or any
other property, other than his own.
2. Rule 51, Paragraph 20 – Uses threatening, abusive or insulting words or
behaviour.
At 10:15am, a F2052SH case review was held and a decision was made to
close the document. This case review was conducted by only two people –
an SO and a CPN – not the minimum three. Neither of the review team was
aware that the man had used the Samaritans phone earlier that day. The
CPN described the man as “purposeful and giving positive intentions”. The
review noted that the man was apologetic, but was blaming the wing SO for
not allowing him to move wings. The review SO made it clear that the man
would not be moving wings. He told my investigating team that the man was
worried that he would be put in the segregation unit following the adjudication.
The review SO told the man that he would make sure this did not happen if
the man gave him an assurance that he would not self-harm again. The man
gave that assurance. The review team placed a great deal of trust in the
man’s promises not to self-harm or attempt suicide. No specific follow-up was
agreed.
At 10:45am, the man was taken to SSU for his adjudications which were
heard by an adjudicating governor. By then, the review SO says he had
already had a prior word with the adjudicating governor. At the hearing, the
man: -
18
1. Pleaded guilty to damaging property and was punished with 14 days of
half pay and 21 days with no TV. He was also given a suspended
punishment of three days cellular confinement and 14 days of no
association or canteen. The conduct report said that the man was like an
attention seeking child, and used threats of self-harm to get his own way.
2. Pleaded not guilty to being threatening and abusive. As two of the officers
involved were not available, the adjudication was adjourned until they
could be present.
The adjudicating governor told my investigators that she had read through the
man’s F2052SH before the adjudication, was aware that he was vulnerable
and did not want to put additional pressure on him. That was why she
suspended some of the punishment.
At 11:35am, the man returned to A wing and said that he was not happy. He
felt that nobody believed him and that the wing SO was picking on him by not
allowing him a move back to A wing.
At 11:40am, the man spoke to a landing officer, and at 11:50am to the
adjudicating governor. He was concerned about being in the same room as
the officers involved in the incident of 23 December when the adjudication
restarted. Both reassured him that staff would not intimidate him.
At 4:40pm, the man spoke again to the landing officer and at 5:00pm to the
adjudicating governor. He was still concerned about being in the same room
as the witnesses. Both staff reassured him that staff would not intimidate him.
He had also asked for a Black or Asian governor to hear his case. Although
not formally notified, the adjudicating governor told the man that the
adjudication was likely to be reconvened on 27 December, provided the
relevant staff were in. If not, she said that it would be held later in the week.
On the afternoon of 24 December, the man was issued with the radio that he
had bought from the prison shop.
The review SO said at interview that he spoke to the man on Christmas Day
or Boxing Day. The man said he was worried about the adjourned
adjudication. The review SO assured him that he would not be sent to the
segregation unit or lose his association.
There are no further references to the man in any document until 27
December when, at 2:00pm during the association period, the man and an
Officer talked for about 15 minutes. The man was positive – especially about
the future – with plans following his release from prison.4 However, the man
was telling staff that he was worried about the remanded adjudication. The
man had also discussed this with another prisoner who had agreed to attend
the adjudication as support for the man. This prisoner said that the man was
concerned that he would not be treated fairly. He said that the man expected
4 The man had an automatic release date of 16 January 2005.
19
the adjudication to be held on 27 December, and he had to reassure him a
number of times that afternoon. It appears that the man was not told that the
adjudication would not happen that day.
At 4:15pm, the association period ended and all the prisoners were locked in
their cells. At 4:45pm, the prisoners were unlocked and served the tea meal.
At 5:35pm, the prisoners were again locked in their cells.
At 7:45pm, an officer began to count the prisoners on A4 landing and found
the man hanging from the window bars of his cell. The ligature was made
from torn bed sheets. The officer who found him entered the cell and at the
same time called out for assistance. He also summoned help from the
communications room, using his UHF radio. The officer who found him cut
the ligature and lay the man on the floor.
Two officers were conducting roll counts on another landing and responded to
the shouts of the officer who found the man. An SO and a Nurse responded
to an emergency message broadcast over the UHF radio. The response SO
believed there was a faint pulse and commenced CPR with one of the roll
check officers who had responded. The nurse arrived, she took over the CPR
from the response SO.
The emergency services received a call at 8:02pm. At 8:07pm an ambulance
arrived at the prison and at 8:15pm, the ambulance crew took control of CPR.
At 8:20pm, the police arrived. At 8:31pm, the ambulance left the prison and
took the man to hospital, arriving at 8:38pm. At 8:53pm, the man sadly
passed away.
Events after the man’s death
My investigating team spoke, through an interpreter, to the prisoner in the cell
next door to the man. He said that no one had spoken to him about the man’s
death, and that he had been offered no support. He said he found it
particularly difficult between Christmas and the New Year.
The local police informed the family of the man’s death. This appears to have
been handled with appropriate sensitivity. However, the police gave the
family the main telephone number of the prison which was frustrating when
the family rang. A direct number or mobile would have been more
appropriate. (I feel bound to add that such apparently small but significant
misunderstandings are all the more likely to occur when the police, not the
Prison Service itself, inform a family of the death of someone in prison
custody.)
Bullying
One prisoner told the investigation team that the man had difficulty standing
up for himself, and was being bullied. He said that bullying was a particular
problem on A wing. A prison Chaplain also said he wondered if the man was
being bullied, although other staff said they saw no evidence of this.
20
However, the prisoner in the cell next door to the man on A wing said there
were no problems on association, and that he had seen no violence against
the man.
Clinical review
The Director of Care at Bedford Primary Care Trust, carried out the review.
He concludes that the man was a vulnerable character, who was able to
manipulate those around him, but that the man’s medical needs were
managed appropriately. He identifies record keeping, procedural and
management systems that require review.
21
Findings and Conclusions
There is no doubt that the man was a vulnerable and troubled young man,
who was not easy to manage in the prison setting. He made three self-harm
attempts using a ligature while in Bedford, and during that time two F2052SHs
were opened and closed.
F2052SH opened on 3 November 2004
The F2052SH was opened correctly and the man was referred to the HCC.
The doctor assessed the man as “not acutely suicidal”. But due to known
mental health problems and the threat of self-harm, the man was wisely
admitted to the HCC in a single cell under “regular” observation.
There were ten case reviews completed and, apart from the review on 23
November, they were multi-disciplinary with particularly good CPN input. The
assessments, observation levels and support plans were balanced and
appropriate. However, observation levels are regularly described as “regular
or normal” in the case reviews, when the local policy outlines three levels of
observation – frequent, intermittent and constant. Entries in the supervision
and support record are consistent with “frequent observations”. Although the
practical outcome was the same, the use of different terms by staff could lead
to confusion and should be avoided.
I am satisfied that, overall, the observation levels were appropriately
considered and were followed. I do, however, have some doubts that the
decision on 14 November to remove the man from intermittent watch following
a self-harm attempt was right. Indeed, shortly after that decision, the man
made another self harm attempt and the watch was resumed.
I am also concerned that the prison did not find out if the man wanted his next
of kin contacted after any of his self harm attempts, as Prison Service Orders
require. I do not know what the man might have wanted had he been asked,
but contact with family could potentially be very important for a distressed or
self-harming prisoner.
Entries in the supervision and support record indicate a good balance
between observations and interactions with the man.
The F2052SH was closed at a multi-disciplinary case review held on 17
December. On the evidence available at that time, this decision was
appropriate.
F2052SH opened on 21 December 2004
The document was opened correctly, and the man was managed on A wing in
a single cell under “normal” observation. Again, this is not consistent with the
terminology in the local policy.
22
National and local policy says that a doctor must assess a prisoner within 24
hours of a F2052SH document being opened. In this case, the doctor did not
assess the man.
Entries in the supervision and support record indicate a good balance
between observations and interaction with the man.
The F2052SH was closed at the 72 hour case review on 24 December. The
review was multi-disciplinary, but only consisted of the review SO and a CPN.
The decision was made in good faith but, in my view, without sufficient
consideration of the control and restraint episode the previous evening, the
telephone call that the man had made to the Samaritans early that morning,
the adjudication that was about to take place, and the fact that it was the
festive period. Additionally, the review team relied upon a promise from the
man that he would not self-harm again, when this was obtained from him in
return for the assurance that the adjudication would not result in him being
placed in the segregation unit. I do not think it was appropriate to rely on a
promise from the man given in such circumstances. My view is that it might
have been wise to keep the F2052SH open. While this may not have
prevented the man from making a further self harm attempt, as he had in the
past, the additional attention of being on a F2052SH might have reduced the
risk. In any event, once the document was closed a support plan should
certainly have been put in place.
Although I accept that the man’s behaviour often appeared manipulative, I am
also concerned that, over time, this may have meant that staff started to take
the man less seriously. Yet the fact that he made three self-harm attempts,
whatever the motivation meant that the man was someone who was a very
high risk indeed.
Regarding manipulation, the Prison Service Order says:
“An act of self-harm should always be taken seriously. Even if the prisoner
appears to be using self-harm 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.”
Bullying
The man said that he felt intimidated and was described as being vulnerable. There
is no direct evidence of bullying. However, the man did admit to having given his
medication to other prisoners, as a result of which he was given his medication when
no other prisoners were in the area. There was no attempt to identify any of the
perpetrators, or to check whether the man was in any additional trouble. My view is
that the prison should have conducted an investigation into any possible bullying,
including who was taking his medication.
23
Adjudication
The incident of 23 December appears to have been an attempt by the man to
obtain a move from A wing to C wing. Although the regime and nature of C
wing may have suited the man better, and this was where he found contact
with staff easier, I accept that the system did not allow for continued
placement upon this wing. I conclude that the placement on A wing was
appropriate. I also consider that staff dealt well with what happened on 23
December, particularly that the man was quickly returned to his own cell and
not kept in the segregation unit.
The punishment for smashing the TV was appropriate, as was the initial
remanding of the adjudication for being threatening and abusive.
I am, however, concerned that the man was clearly expecting that the
adjourned adjudication would be held on 27 December, and made his worries
about the adjudication absolutely explicit. It seems that there are no systems
in place to tell prisoners when to expect an adjudication to resume, apart from
the F1127 (notification of report) which is issued at least two hours before the
hearing. In the light of his extreme anxiety, my view is that the prison should
have told the man as soon as it was clear that the adjudication would not
happen on 27 December.
The man said that he wanted a black or Asian governor to conduct the
adjudication hearing. There is no evidence to suggest that this was because
he feared racial discrimination. The original adjudicator was the only black or
Asian governor at Bedford, and the man perceived her to have treated him
fairly. I am confident that the man simply made this request because he
thought he would get a more sympathetic hearing if he had the same
adjudicator.
Emergency Medical Assistance
The man was found hanging in his cell shortly after 7:45pm. The ligature was made
from a prison bed sheet (the most common means of suspension in prison) and was
easily cut.
The response was immediate, once the alarm was raised. Medical professionals
were administering emergency aid within minutes of the man having been found. It is
to the credit of all concerned that every effort was made to revive the man. The
prompt arrival at the cell of the Ambulance Service is also impressive.
After the man was discovered
Procedures were followed in line with contingency plans. The various offices and
individuals were informed of events as required.
However, I do have some concerns that the prisoner in the cell next to the man, who
spoke little English, does not appear to have been told of the man’s death, or offered
any help or support over the Christmas period.
24
The adjudicating governor, a senior manager, was appointed as Family Liaison
Officer. The adjudicating governor played a hugely important role in keeping the
man’s family informed of events and helping them come to terms with what had
happened. However, the family was frustrated when they called the prison, as they
were given the number of the main switchboard, and not a direct contact number. In
this report and elsewhere, I have indicated where I believe responsibility for informing
a family of a bereavement in prison should lie.
Medical Care
The clinical review concludes that the man’s medical needs were managed
appropriately, but identifies some record keeping shortcomings.
Suicide Awareness
Bedford prison’s local “Suicide Prevention Strategy” is a comprehensive policy
document which is consistent with national policy.
25
Recommendations
1. I recommend that the Governor of Bedford reminds staff that prisoners who self
harm as a means of gaining something should be taken seriously, and helped to
find constructive ways of meeting their needs.
2. I recommend that the Governor reviews arrangements for informing a family of a
death in prison custody, in particular that the person who informs the family
(whether Prison Service or police) has a direct dial number to call to save
bereaved families the frustration of having to negotiate the main switchboard.
3. I recommend that the Governor of Bedford reminds staff to be vigilant to bulling
for prescribed medications, and that all potential incidents of bullying are to be
investigated.
4. I recommend that the Governor of Bedford reminds staff that, when setting
observation levels, they use terminology consistent with the local policy.
5. I recommend that the Governor of Bedford reminds staff of the national policy
concerning the notification of next of kin following incidents of self-harm, and that
such decisions are to be documented in the F2052SH.
6. I recommend that the Governor of Bedford reminds staff that case conferences
carried out 72 hours after the opening of an F2052SH reviews are conducted by
three members of staff, as local procedures require.
7. I recommend that the Governor of Bedford reminds medical staff that a doctor
must review all prisoners on an open F2052SH within 24 hours of the document
being opened.
8. I recommend that the Governor of Bedford reviews procedures for informing
prisoners when a remanded adjudication will be heard.
Good practice
Bedford has a very helpful locally devised sticker added to the front cover of the
F2052SH. This shows target dates for case reviews and when a review has been
completed. This enables staff and managers readily to see if a review is required
and when the last one was completed. It also has a locally devised information page
inserted inside the front cover. This provides a series of tick-box prompts to assist
staff in completing and managing the F2052SH document.
26