Individual at Bristol

Investigation into the circumstances surrounding
the death of a prisoner from HMP Bristol,
who died at Bristol Southmead Hospital
in June 2005
Prisons and Probation Ombudsman for
England and Wales
December 2005
The man, who had been remanded to HMP Bristol in May 2005, was found hanging
in his cell just less than two weeks later. This is the report of an investigation into the
circumstances surrounding his death.
The loss of any family member is distressing, but especially so whilst they are in
custody. I offer my sincere condolences to his partner, children, family and friends.
A member of my office carried out the investigation. I wish to thank the Governor of
Bristol for making my investigator welcome, and for arranging the necessary facilities
to enable him to carry out his work. I also wish to thank the Principal Officer for his
invaluable assistance and support throughout the investigation process.
In the course of the investigation, I asked the Bristol Primary Care Trust to undertake
a clinical review of the care and treatment received by the man from HMP Bristol. I
am most grateful for their report.
My report makes recommendations for the prison and as well as identifying good
practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2005
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Contents
Summary 4
Investigation Process 5
HMP Bristol 6
Findings 7
Recommendations 17
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Summary
1. In May 2005, Bristol Magistrates’ Court remanded the man into custody, following
his conviction for theft and failing to surrender to custody. The court remanded
him for enquiries to be made, and to determine the most suitable method of
dealing with the case.
2. Following his reception into prison, a cell sharing risk assessment was carried
out. The officer completing the assessment assessed the man as low risk. The
officer noted on the form that he said that he had previously been in custody, and
monitored under the F2052SH procedure, some three years previously.
3. Because the prison’s First Night Centre (FNC) was full, he was allocated to G
wing where he shared a cell with another prisoner. However, he was not
interviewed under the First Night procedures, as prison staff were not required to
carry out these procedures anywhere else in the prison.
4. He had engaged with the Counselling, Assessment, Referral And Throughcare
(CARATS) team, and been prescribed a detoxification programme using
Subutex. Security information received following his death suggests that he had
been under pressure from prisoners to pass his medication to them.
5. On a date in June, he met the CARATS worker, who was sufficiently concerned
about him that he asked the Wing Manager to arrange for someone to see him as
soon as possible. The Wing Manager said that she would arrange for him to be
spoken to and, if necessary, open an Assessment, Care in Custody and
Teamwork document (ACCT). The CARATS worker also passed on his concerns
to a Registered Mental Nurse, who is based at the prison, and informed him of
what the man had said.
6. Less than 90 minutes later at 3.25pm, an officer went to speak to the man, and
discovered him hanging from the cell light fitting. The officer summoned
assistance and used an anti-ligature knife to cut him down from the light fitting
and remove the ligature. The officers checked for signs of life, thought that they
detected a weak pulse and breathing, and so began to administer cardio
pulmonary resuscitation (CPR) which continued until healthcare staff arrived.
Unfortunately, they experienced difficulties with the emergency oxygen
equipment which was not working correctly. The defibrillator did not instruct
nursing staff to administer an electric shock, but to continue with CPR.
7. The paramedic staff assessed him and also detected a weak pulse. They asked
the nursing staff to continue with CPR, while they made preparations to transfer
him to hospital. On arrival at the hospital, he was placed on a life support
machine. On 5 June, the machine was switched off and he later died.
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Investigation Process
8. On 9 June my investigator met the Governor, Deputy Governor, Family Liaison
Officer (FLO) and Safer Custody Manager at HMP Bristol and was briefed about
the circumstances leading to the man’s death. The Governor made available a
number of files and records relating to the man which my investigator has been
able to examine. He also met with a member of the local Prison Officers’
Association (POA), and a member of the prison Independent Monitoring Board
(IMB) to brief them about the investigation process.
9. My investigator visited the cell where the man was discovered, and viewed the
light fitting used to secure the ligature. He visited the FNC to clarify the
procedure for prisoners who cannot be accommodated there on their first night at
the prison.
10. A number of staff were identified whom the investigator wished to interview.
Arrangements were made for him to return to the establishment on 28 June to
continue the investigation.
11. The investigator met the Governor prior to leaving the prison on 9 June to brief
her of his initial findings. These included the failure to ensure that all prisoners
are interviewed in accordance with the First Night procedures, regardless of
where they are located in the prison. The Governor welcomed the feedback and
gave instructions to the Safer Custody Manager to ensure that all prisoners were
interviewed. The Governor explained that, since taking responsibility for the
prison, she had made arrangements for the FNC to be re-located. This should
ensure that all prisoners are seen under the First Night procedures, and I
welcome the Governor’s actions.
12. On 28 June, my investigator returned to the prison and, during the course of the
week, interviewed a number of staff who were key to the investigation. He fed
back his findings to the Governor or Deputy Governor on a daily basis. On 1
July, he met with the Governor and Deputy Governor to give an overview of his
findings and potential recommendations. The Governor decided that a separate
investigation was required to clarify the time delay between an officer being
instructed to speak to the man and actually carrying out the instruction. The
Governor commissioned her own investigation and concluded that no further
action was required. Her investigation report does not form part of my own
report.
13. My investigator was well received. Staff and prisoners were aware of his
attendance at the prison and readily cooperated with the investigation.
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HMP Bristol
14. HMP Bristol is an inner city Victorian prison located in the Horfield area of the
city. It first opened in 1883. The prison serves the courts in Avon, Somerset and
Wiltshire. It has Certified Normal Accommodation of 476 and an operational
capacity (maximum crowded capacity) of 606.
15. On 23 August 2004, the Prison Service Standards and Audit Unit audited the
prison. The audit report gives overall scores for:
• Standards Audit, 85%
• General Standards (Critical Baselines), 75%
• Security, 79%
16. On 10 January 2005, Her Majesty’s Chief Inspector of Prisons (HMCIP) carried
out a full announced inspection of the prison. The report’s introduction describes
Bristol as showing all the signs of its recent unsettled past and inconsistent
management. The report described the prison as one which had lost its focus
and direction. The report also identifies good practice, including good staff
relationships with prisoners.
17. A new Governor has recently taken over and has identified a number of key
areas of the prison that require change. A number of these have been
commented upon within this report.
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Findings
18. On 20 May 2005, Bristol Magistrates’ Court remanded him into custody following
his conviction for theft and failure to surrender to bail to enable enquiries to be
made, and to determine the most suitable method of dealing with the case. He
was due to return to court on 8 June for sentencing.
19. Reception Officers and Healthcare staff interview all new prisoners. Part of their
task is the completion of the Cell Sharing Risk Assessment (CSRA), including the
identification of potentially vulnerable prisoners. The officer who completed the
assessment noted that the man said that he had been monitored under the
F2052SH procedure (suicide and self-harm monitoring) approximately three
years previously, whilst in custody on another sentence.
20. The F2052SH system is used by the Prison Service to monitor those prisoners
who have been identified as being at risk of self-harm and is available to any
member of staff to open the document. Once opened, a multi-disciplinary team
assesses the prisoner’s needs and prepares an action plan in partnership with
the prisoner. When the prisoner is no longer considered at risk, the form is
closed.
21. The Reception Officer and Healthcare assessment recorded that the man was
considered as low risk and suitable for multi-cell location. However, neither of the
two staff concerned signed the appropriate sections of the document but inserted
a cross in place of a signature. Additionally, the “New Receptions” document,
which identifies all prison receptions for any given day, asks the officer to
complete the form and indicate if the prisoner has previously been inducted or
not. An examination of the form for 20 May shows that the document was not
completed as required.
The Governor should remind staff of the need to complete documentation
accurately, including dating and signing the records.
22. The prison has a FNC, located on A wing, where the detoxification unit is co-
located. The FNC should ensure that all new prisoners are interviewed by a FNC
officer who assesses their risk of self-harm. The FNC should also ensure that
these prisoners are observed at least every two hours, during their first 24 hours
in custody. Should the officer be concerned about any other prisoner who has
previously been at the prison, they can arrange for them to be observed in the
same way as a new prisoner. This level of observation is a local procedure and
is good practice.
The level of observation during the first 24 hours for those new to custody,
or identified as vulnerable, and located in the FNC, is an example of good
practice.
23. The First Night Interview document instructs staff that all new prisoners must
complete the first night interview assessment on their arrival on to the FNC.
There are no exceptions to this rule. The Policy Statement says the unit has
been set up to:
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• reassure prisoners received into custody
• provide a safe caring environment
• help them deal with concerns and needs
• promote their ability to cope in custody through the induction process.
24. My investigator found that, due to shortage of space, the man was placed on G
wing when he arrived at the prison. G wing is used as an overspill unit for
prisoners who cannot be located into the FNC. If G wing becomes full, prisoners
are then allocated into one of the remaining wings. Unfortunately, prisoners who
are not allocated to the FNC do not receive the usual interview, as there are no
alternative arrangements for this to happen.
25. On 20 May, 18 men arrived at the prison, two of whom were new to custody but
who were not allocated to the FNC and did not receive the same level of care as
those allocated to the FNC. This is a serious flaw in what is otherwise a good
system and requires correcting. My investigator raised the matter with the
Governor who immediately instructed that all new prisoners should be
interviewed under the First Night procedure regardless of where they are located.
I welcome this. The Governor informed my investigator that she had already
identified difficulties with the FNC, and had drawn up plans to re-locate it in larger
premises from October 2005. The Governor’s decision is also welcomed. It
should eliminate the problem of some prisoners not being interviewed
appropriately.
26. My investigator discussed the movement of prisoners through the FNC, and
examined why places would not be available. It was evident that there was a
backlog of prisoners waiting to be transferred from the detoxification part of the
wing to the main prison. Men who should have been in the detoxification part of
A wing occupied a number of FNC cells. Managers of wings in other parts of the
prison would only allocate cells after assessing the prisoner’s suitability. Some
managers were also reluctant to re-allocate the cells of men who had gone to
court in case they returned later. In a prison where cells are at a premium, and
there is little alternative than allocation of new prisoners outside the FNC, it is not
justifiable to keep a cell empty in this way. The investigator found that no one
person was responsible on a daily basis for ensuring that all cells were fully
occupied.
The Governor should consider making an appropriate manager responsible
for the daily allocation of prisoners from the FNC and Detoxification Unit,
and ensure that other wings are fully occupied.
27. On 23 May, the man was interviewed by a drug worker regarding his drug
addiction. He agreed to supply a urine specimen which produced a positive test
for cocaine and opiates. He was placed onto the Subutex Care Plan and given a
start dose of six milligrams.
28. On 24 May, he signed and agreed to the conditions of Non In-possession
Medication. The Detoxification Needs Assessment record shows that the
assessor noted:
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history depression, treated with dothiepin. States that Subutex makes him
have depressed thoughts following administration. Does not appear to be in
any form of withdrawals.
29. He also entered into a Detoxification Care Plan which had three goals:
• To stop abusing illegal and or prescribed drugs. To stop abusing alcohol.
• To develop a normal and regular sleep pattern.
• To understand risks relating to using drugs and/or alcohol.
30. On 31 May, the Detoxification Care Plan Progress Chart record notes that in
relation to the three goals:
• Reports feeling rough and states that he is still withdrawing from heroin,
though he is not showing any signs of opiate withdrawal.
• Reports poor sleep. Therefore Zopiclone.
• Harm minimisation advice given.
31. The prison has a detoxification unit and also offers the CARATS service which
supports prisoners who have a history of drug or alcohol abuse. It can be
accessed by the support service or by the prisoner referring themselves.
32. At 2.00pm on 2 June, the CARATS worker at the prison went to carry out an
initial assessment on the man. He had been referred to the team because he
was on a ten day detoxification programme. The meeting took place in an office
in G wing. The worker described him as not engaging from the beginning of the
interview. He said that he looked stressed, drew heavily on his cigarette, and
was unable to focus. The worker asked him how he was, to which the man
replied that he was fed up with the mind game. The worker asked what he
meant, and he replied that he had used drugs for 12 years, but had only got ten
days on the detoxification programme. He said that the detoxification had come
to an end and that he felt unwell.
33. The worker suspected that he was unable to engage in the conversation due to
withdrawal from drugs, and asked him if he would prefer to speak to him at the
beginning of the following week. He said that this would depend on whether he
was there. The worker asked him what he meant by this, and he said that it was
the mind game. The worker attempted to talk further to him, but said that he
would not speak to him. He noticed that his eyes were red, but was unable to tell
if he was frustrated or sad.
34. At approximately 2.05pm, the worker terminated the interview and the man left
the room to return to his cell. Because the worker was concerned about him, he
immediately informed the Wing Manager of his concerns. He asked that the man
be seen as soon as possible, and believed that the Wing Manager understood
the urgency of his request. However, when interviewed for this investigation, the
worker was clear that his concern was not of a risk of suicide. He believed that
the man demonstrated a strong attitude, and was determined to change his drug
use.
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35. He also passed on his concerns to a detoxification nurse who informed him that it
was common for those at the end of detoxification to go down in mood, and then
improve again a few days later.
36. He spoke to his own manager, who advised him to return to the wing later to
check that the man had been seen as requested. Unfortunately, by the time he
returned, he had already been taken to hospital after being found hanging in his
cell.
37. My investigator found that the worker went to great lengths to ensure that prison
staff and support staff were aware of his concerns for the man.
The CARATS worker should be commended for the level of care that he
gave to the man.
38. At approximately 2.10pm, The Wing Manager returned to the third landing and
met an officer. She asked the officer to speak to the man, assess his mood and,
if necessary, open an ACCT form. She was satisfied that the officer understood
her request and that he would deal with it. She returned to her own duties.
39. ACCT forms are being introduced across the Prison Service to replace the
F2052SH system, and have been in place at Bristol since 1 May 2005. My
investigator has established that both the Wing Manager and officer have
participated in the ACCT training.
40. At approximately 2.15pm, an officer was supervising haircuts on G wing. In
interview, he recalled that the man was having his hair cut. He said that he and
the man had a normal conversation and at no stage was he concerned for his
safety. Once he had had his hair cut, at approximately 2.40pm, the officer locked
him into his cell.
41. My investigator interviewed the prison contracted hairdresser and he recalled that
he began to cut the men’s hair at approximately 2.10pm. He said that the man
was the first one to have his hair cut. (The officer’s account does not concur with
this, as he said that the man had his hair cut at approximately 2.30pm and was
preceded by other prisoners.) The hairdresser said that the man was given a
crew cut which took about five to ten minutes to complete. He recalled that he
said that he wanted his hair to be tidy for his court hearing. He had known him
from previous periods in custody, and said that at no stage did he give him any
cause for concern.
42. At approximately 3.15pm, the Wing Manager asked an officer if he had spoken to
him. He said that he had not done so as he had been busy. She asked him to
speak to him straight away, and then returned to her office.
43. At approximately 3.25pm, the officer opened the observation flap of cell G1:17.
He wanted to check where he was before he opened the door. He saw him
suspended by a ligature from the cell light fitting and shouted for assistance as he
opened the cell door. Another officer, who had been in an adjacent cell,
responded. So did two other officers, who were on another landing.
10
44. One of the officers was carrying an anti-ligature knife (known as a ‘Fish Knife’)
which he got out and used to cut the ligature from around the man’s neck. Fish
knifes are shaped like a fish, and contain a concealed blade in the mouth section
which is designed to allow the user to get underneath the ligature. The action of
pushing the knife forward cuts the ligature away from the body.
45. He and the other officers laid him on to his back on the floor of the cell and began
to check for signs of life. A further officer joined them in the cell and, whilst
checking the man, he thought that he detected a weak pulse. One of the officers
also thought that he detected air coming from the man’s mouth. At that point,
Healthcare staff arrived and took over caring for him.
46. The Wing Manager heard an officer shouting for assistance, realised that a Code
Blue message had been called and went to the cell. (Code Blue is the local
procedure which alerts medical staff that assistance is required for a prisoner
who is having difficulty breathing. It ensures that medical staff take the correct
equipment for the medical emergency.) The Wing Manager arrived on the
ground floor landing, which is known at the prison as the One’s landing. She saw
him lying on his back on the floor of his cell with officers attending to him. She
could see an officer removing a ligature from around the man’s neck. She said
that the officers were not performing CPR, and were removing the ligature and
checking for signs of life
47. At approximately 3.28pm the prison’s Mental Health Service Manager and a
nurse were interviewing a prisoner in G wing. They heard the Code Blue radio
message and responded quickly. Each wing has Grab Bags containing oxygen
and a defibrillator for use in an emergency. They took the bags with them to the
cell and, as they arrived, they met another nurse.
48. One of the officers informed the Healthcare staff that he thought that the man
was still breathing. The Mental Health Service Manager said that one of the
nurses was unable to obtain a pulse, and the other was unable to detect any sign
of breathing. Whilst the nurses looked for signs of life, she opened the grab bags
to set up the resuscitation equipment. However, the tube to the oxygen cylinder
was disconnected and, when she attempted to connect it, she found that the tube
was too large for the cylinder. She created a seal by squeezing the tube against
the oxygen outlet pipe with her fingers. This proved to be successful as the
Ambu Bag filled with oxygen. A further nurse joined the Healthcare staff and also
assisted with CPR.
49. At 3.30pm, the Mental Health Service Manager requested an ambulance, and
asked for a doctor to attend. One was on duty in the prison and responded to the
request and instructed the Healthcare staff to continue with CPR. The
defibrillator, which had been attached to the man’s chest, did not instruct the staff
to administer an electric shock and so CPR continued until the arrival of the
paramedics.
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50. At 3.37pm, the paramedics arrived and told Healthcare staff to continue with
CPR. One of the paramedics detected a weak pulse, and set up an intravenous
line.
51. At 3.50pm, he was moved from the wing to the ambulance. At 3.59pm, he left
the prison to be taken to the Accident and Emergency Department of Southmead
Hospital. He was accompanied by two officers and the Mental Health Service
Manager.
52. Any prisoner required to remain in hospital, who has not been released from
custody on temporary licence, is escorted and monitored by prison officers under
the ‘Bedwatch’ procedures. This usually means that two officers remain at the
bedside and record any significant changes or events. Subject to a risk
assessment process, the Governor decides whether the prisoner should be
handcuffed and the number of officers required to stay with the prisoner. In the
man’s case, he was not handcuffed at any stage during the time he was in
hospital and he was accompanied by a single officer.
53. An examination of the Bedwatch Records shows that appropriate records were
made and prison managers were kept informed. However, there is only one
entry for a member of the prison management team visiting the hospital during
the time the man was in hospital.
The Governor should remind managers of the need to visit a prisoner on
bedwatch at least once every 24 hours and to record their observations and
comments in the Bedwatch Report.
54. The prison has a system where prisoners can make a written application to either
the Healthcare Department or CARATS team. Their applications are placed in a
sealed post box which is opened on a daily basis. The Clinical Review
comments that on 3 June, the day after the man was taken to hospital, an
application from him was found in the post box dated the previous day. He had
written that he needed to see someone from either the detoxification or mental
health teams, as he wanted to sort himself out and not cause himself stress or
harm. By the time he made his application, the box had already been emptied on
2 June, and so it was not opened again until the next day. The time that it was
emptied is unclear, but after emptying the applications were processed and his
was logged. This explains why his application was not found until 3 June.
55. On 6 June, the Detective Sergeant in charge of the police investigation
telephoned the prison to request that any video recording evidence be secured.
He spoke to a senior manager who assured him that the videotape was secure.
However the tape handed to the police was not the correct one, and it showed a
different incident on a different day. My investigator has been informed that the
videotape for G wing on 2 June has not been secured, and has probably been
taped over. This means that potentially important information is not available to
either the police or my own investigator.
The Governor should ensure that systems are in place to secure potential
scene of crime information and a clear chain of custody is maintained.
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56. On 7 June, two prison officers were asked to remove the man’s property from his
cell, and prepare it for re-occupation. During the clearance, they found a note
written by him on the top of a cabinet which had been overlooked by the police
when they examined the cell. The note was not addressed to a specific
individual. It explained the reasons for his actions, which he said were due to
sleepless nights, constant head games and healthcare matters.
57. My investigator discussed the failure of the emergency equipment with the Mental
Health Service Manager to find out the system for ensuring that it was kept in
good working order. She said that the responsibility for the bags was not hers,
but that of another department. She was aware that the bags are sealed, the
equipment is checked every day, and a record of the check is kept. She had also
carried out her own enquiry regarding the equipment failure and was able to
produce a record of the check. The check sheet shows that, on 1 June, an
unidentified member of staff noted that the oxygen tank was full and ticked a box
to say that the bag was intact. There was no record that the equipment had been
tested and was working satisfactorily. The record also shows that on 29 May the
oxygen tank was empty. The investigator asked the Mental Health Service
Manager to explain the equivalent arrangements in an external hospital, and she
said that equipment would be tested daily to ensure that it was in good working
order.
58. Whilst the equipment failure may not have had an effect on the outcome of the
man’s actions, it is possible that vital time might be lost in another incident. My
investigator brought the matter to the attention of the Governor who arranged to
meet the Mental Health Service Manager to ensure that, with immediate effect,
systems were put into place to deal with the failure. I welcome the action by the
Governor and the Mental Health Service Manager.
59. In her statement dated 2 June, the Wing Manager describes her conversation
with the CARATS worker and said that he expressed concerns over the man
being low in mood. She informed the worker that she would instruct an officer to
have a chat with him and if necessary open an ACCT booklet. She said that she
instructed an officer in those terms. The Wing Manager also explained that, at
3.15pm, she asked him if he had seen the man. He had replied that he had not
yet had the chance, because he was answering cell bells, but would go and see
him shortly. The final entry in the Wing Manager’s statement is that, about ten
minutes later, she heard the officer shout for staff assistance as he had
discovered him with what appeared to be a ligature around his neck.
60. When he was interviewed for this investigation, the officer confirmed that he was
the Patrol Officer on G wing during the afternoon of 2 June. The Patrol Officer is
required to answer cell call bells activated by prisoners locked in their cells who
require assistance (cell bells are intended for emergency use only although, in
practice, they are used for non-emergency purposes too). Initially, the officer
said that at approximately 3.00pm he had been supervising a telephone call on
landing four and noticed the man walking towards the hairdresser on landing one.
Following the telephone call, he said he returned to landing three at
approximately 3.15pm, and that it was then that the Wing Manager asked him to
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have a chat with the man. He said that this was the first time that the request
was made.
61. My investigator informed the officer that his account did not concur with that of
the Wing Manager. He then changed his account and said that the request from
the Wing Manager had been made earlier at approximately 3.00pm. He
confirmed that he had been asked to speak to the man prior to facilitating the
telephone call, and that the conversation at 3.15pm was when the Wing Manager
checked whether he had spoken to him as requested. He said that he was asked
to have a chat with him, and that he was not asked to do anything else such as
assess his mood and consider opening an ACCT.
62. Following the interview with the officer, my investigator then interviewed the
hairdresser and the officer who supervised the haircuts. The evidence from them
is that the man had his hair cut between 2.15pm and 2.30pm, and that he was
locked back into his cell at approximately 2.40pm.
63. My investigator examined the computer printout for the telephone calls made by
the prisoner escorted by an officer. The printout confirmed that he made one call
on 2 June, at 2.15pm, and that it lasted for four minutes 21 seconds. The call
was not made at 3.00pm, as stated by the officer.
64. My investigator re-interviewed the officer, and he confirmed that he was asked to
speak to the man prior to facilitating the telephone call for the other prisoner.
When shown the computer printout, confirming the time of the telephone call at
2.15pm, he agreed that the request to speak to him was made before he
facilitated the call. He was asked whether he had forgotten to carry out the
instructions, and he said that he had not forgotten but had been busy.
65. My investigator also examined the cell call computer printout which showed a
large number of calls, none of which were made by the man. The examination
showed that between 1.38pm and 3.50pm, a number of cell bells were activated
which were not responded to for several minutes, and on one occasion the bell
was activated for 40 minutes before an officer checked the prisoner. Nine of the
cell call bells took over ten minutes for an officer to action. This is not
acceptable.
66. The cell call record identifies that four of the cell calls were made after 2.00pm
from prisoners located on landing one. This means that if the officer answered
cell calls in the afternoon, he was on the same landing as the man, knew that he
had been asked to speak to him, but had not carried out the instructions. The
officer said that he could not remember whether he dealt with landing one or not.
67. He was shown the cell call printout and he commented that he could recognise
the prisoner from each cell. He identified a number of prisoners, all on landing
two (Landing 6 on the printout), who he described as persistent cell call users.
He said that he always knew what these men wanted, without visiting the cell. It
is not acceptable that, of the 14 cell calls activated on landing two between
1.58pm and 3.32pm, it took more than ten minutes to respond to seven of them,
three took more than 20 minutes, and another more than 30 minutes.
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Additionally, one call, activated on landing two at 1.46pm, was not responded to
until 2.26pm, some 40 minutes after the original activation. These are worrying
and unacceptable time delays.
The Governor should remind all staff of their responsibility to answer cell
call bells promptly.
68. My investigator raised these matters with the Governor who commissioned her
own investigation to determine whether the officer failed to follow the instructions
from the Wing Manager, and also to examine why cell call alarms were not
answered promptly. On 15 August, the Governor wrote to my investigator to
inform him that she had not identified that disciplinary action was required, but
had made recommendations which were followed up in an Action Plan. I
welcome the Governor’s swift response.
69. When he arrived at the prison, the man was allocated to G wing where he shared
a cell. My investigator met his cellmate who said that at no time did he say
anything about killing or harming himself. He did recall that, approximately seven
to ten days prior to being discovered hanging in the cell, he asked night staff if he
could see a Listener but no one arrived to speak to him.
70. Listeners are prisoners who have been selected and trained by the Samaritans
and are able to offer 24 hour support to prisoners who feel vulnerable, suicidal or
at risk of self-harm. Although meetings are confidential, when a prisoner has
asked to see a Listener the request should be recorded in the Wing Observation
Book and Night Occurrence Log. Neither of these records contains a request
from him to speak to a Listener. My investigator has been unable to identify the
officer whom the cellmate said the man had spoken to.
71. In January 2005, HMCIP carried out a full announced inspection of HMP Bristol.
Her report commented that the safer custody strategy was out of date, and
prisoners had difficulty accessing Listeners especially at night. The Safer
Custody Manager is responsible for Listeners and, since taking over
responsibility, has been told by a number of them that some staff do not pass on
requests to see them. He is examining the service and will be implementing his
own action plan to ensure the Listener Scheme operates correctly, and staff are
aware of their responsibilities.
The Governor should ensure that the Listener Scheme operates correctly,
maximising prisoner access to this service. This should include staff
making appropriate recordings of requests in Wing Observation Books and
the Night Occurrence Book, and a system for Listeners to access those
prisoners requesting their support in a timely manner.
72. His cellmate also said that some prisoners were bullying the man for his
medication, and he had told him to speak to officers as they are approachable.
He told him that he would sort it out himself. The prison’s Security Department
only became aware of allegations of bullying after he died, and they have
identified a number of prisoners who might have been responsible.
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73. In the afternoon of 2 June, the man’s cellmate attended the prison’s education
department. As he was leaving the cell, the man said to him that he would not be
there when he returned. This was the last conversation that he had with him. He
thought that he meant that he was moving to another cell.
74. I offer the family of the deceased person the opportunity to raise any concerns
about the care and treatment the prisoner received whilst in custody. They are
contacted by one of my FLOs who works closely with the investigator. On 24
June, the FLO contacted the man's partner. She said that, on 30 May, he had
written to her and referred to getting off drugs, getting their children back and
making future plans. She said that she was contacted after he was found
hanging, and informed that he had been taken to hospital without information
about the circumstances. The incident log simply shows that contact was made
with his next of kin at 4.35pm.
75. His partner also said that the prison had returned his property, neatly folded and
in a bag and that the Governor had contributed towards the cost of the funeral.
She and his brother were offered a chance to view his cell, but they declined.
She and his family have no concerns about the care he received and have only
one question which is to know what happened. I hope that this report will help
them to understand the events leading up to his death.
76. On 14 June, he was cremated at Bristol Crematorium. The Governor and the
Prison Chaplain attended the service. The following week, a memorial service
was held in the prison, which was attended by his partner and brother. I
commend the actions of the Governor and Chaplain in the aftermath of the man’s
death.
The actions of the Governor and Chaplain in the aftermath of the man’s
death have reflected very well on themselves, their prison and their Service.
77. Following the discovery of the man hanging in his cell, I am satisfied that his care
and treatment were appropriate, and he was treated with dignity throughout.
However, I agree with the Governor that further investigation was required into
why a delay of over one hour occurred following the concern raised by the Mental
Health Service Manager.
78. This is not the first occasion on which I have had to report a prisoner using the in
cell light fitting as a ligature point. The Governor should consider the feasibility of
sealing the edge of the light fitting with a suitable compound to prevent a ligature
being passed through. The Prison Service may also wish to consider if like
advice can be given to other Governors.
The Prison Service should consider the sealing of the edges of in cell light
fittings to reduce the number of ligature points.
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Recommendations for the Prison Service
Policy
1. The Prison Service should consider the sealing of the edges of in cell light fittings
to reduce the number of ligature points.
Operational
1. The Governor should remind staff of the need to complete documentation
accurately, including dating and signing the records.
2. The Governor should consider making an appropriate manager responsible for
the daily allocation of prisoners from the FNC and Detoxification Unit, and ensure
that other wings are fully occupied.
3. The Governor should remind managers of the need to visit a prisoner on
bedwatch at least once every 24 hours, and to record their observations and
comments in the Bedwatch Report.
4. The Governor should ensure that systems are in place to secure potential scene
of crime information, and a clear chain of custody is maintained.
5. The Governor should remind all staff of their responsibility to answer cell call bells
promptly.
6. The Governor should ensure that the Listener scheme operates correctly,
maximising prisoner access to this service. This should include staff making
appropriate recordings of requests in Wing Observation Books and the Night
Occurrence Book and a system for Listeners to access those prisoners
requesting their support in a timely manner.
Good Practice
1. The level of observation during the first 24 hours for those new to custody, or
identified as vulnerable and located in the FNC, is good practice.
2. The CARATS worker should be commended for the level of care that he gave to
the man.
3. The actions of the Governor and Chaplain in the aftermath of the man’s death
have reflected very well on themselves, their prison and their Service.
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