Individual at Brixton

Investigation into the circumstances surrounding the death of
the man at HMP Brixton on 28 September 2004
Report by the Prisons and Probation Ombudsman for England
and Wales
September 2005
This is the report of an investigation into the death of a man at HMP Brixton
on 28 September 2004. The man was on remand, awaiting sentence, and
had been in Brixton for eight days when he died. The purpose of my
investigation was to establish the circumstances and events surrounding the
man’s death, including the quality of care provided by the Prison Service.
In April 2004, my office was passed the responsibility of investigating all
deaths in custody. Under transitional arrangements, a Governor within the
Prison Service’s London Area Manager’s Office was appointed to conduct the
investigation on my behalf and one of my colleagues was my representative
on the investigation. I am grateful for all the assistance that the investigation
team received from the Deputy Governor of HMP Brixton, and from his staff,
including the establishment’s Liaison Officers.
A key objective of the investigation was to make sure that the man’s family
had the opportunity to raise any concerns they had about his death. The
investigation team was able to meet with the man’s mother and his estranged
wife. I am most grateful to them for having these meetings at what must have
been a very difficult and distressing time for them. The investigation team
also had telephone contact with the man’s girlfriend and met with the man’s
father after disclosure of the report.
I offer sincere condolences to the man’s family and friends in their sad loss.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN SEPTEMBER 2005
2
CONTENTS Page
SUMMARY 4 - 5
CONDUCT OF THE INVESTIGATION 6
BACKGROUND INFORMATION:
The man 7
HMP Brixton 8 - 9
EVENTS LEADING TO THE MAN’S DEATH:
The man’s custody at Pentonville and reception at Brixton
10 - 11
Incident with the man’s cellmate: early morning on 28 September 2004
11 - 12
Staff action later on the morning of 28 September 2004 13 - 14
following the incident with the cellmate
Prisoners’ concerns for the man and staff response in the 14 - 15
afternoon of 28 September 2004
Telephone calls made by the man to his partner- 16
27 and 28 September 2004
Telephone calls from the man’s partner and action taken 17 - 19
by Brixton in response
Events of the evening of 28 September 20 – 25
The note left by the man 25
CLINICAL REVIEW 26
CONSIDERATIONS AND CONCLUSIONS 27- 33
RECOMMENDATIONS 34 - 35
Annexes 36 – 37
3
SUMMARY
On 17 August 2004, this young man of 23 years was remanded into custody
at HMP Pentonville, accused of offences against his estranged wife. The
Prisoner Escort Record (PER) which accompanied him from Thames
Magistrates Court noted that he suffered from depression but did not provide
further details. There was no mention of any self harm or suicidal intentions.
The subsequent reception health screen noted that he had been taking anti-
depressants, but that he had stopped taking them a few months before. The
man said that he had taken an overdose in prison in 2000. Prison Service
records showed that he might have been in custody in Feltham Young
Offender Institution (YOI) in 2000 but this could not be confirmed. The doctor
prescribed a one off dose of medication to help him sleep and described him
as ‘somewhat low’. There was no real cause for concern documented and he
was located on a normal residential unit.
On 21 September 2004, the man was remanded into custody in Brixton, to
await Probation Service reports before being sentenced. He said that he did
not have any thoughts of suicide or self harm and was placed on normal
location. He was located in a cell with another prisoner. On 28 September at
1.17am, his cellmate attempted to hang himself in the cell by attaching a
ligature to the cell window. The man supported his body until the staff on duty
came to his assistance. His cellmate was given medical attention and placed
on a F2052SH (suicide/self harm warning form) and the Senior Officer in
charge of the Wing spoke to the man. Both men said they were content to
return to the same cell.
The cellmate went to Court during the morning of 28 September and the man
was left in the cell alone. No further support was given to the man. Another
prisoner arranged to relocate to the man’s cell but he did not go through with
the move as the man told him that he was going to kill himself. He told other
prisoners about this and they told a Senior Officer on duty, Senior Officer A.
She spoke to the man but he denied that he had any suicidal thoughts. She
thought that the prisoners were confused with the event during the morning
when the cellmate had attempted to kill himself. At around the same time,
Brixton received a telephone call from the man’s partner. She spoke to the
Duty Governor, and expressed concerns about the man’s wellbeing following
a number of telephone conversations she had had with him that day. The
Duty Governor asked another Senior Officer on the Wing, Senior Officer B, to
make enquiries and report back to him. Senior Officer B had a lengthy
conversation with the man who convinced him he was fine. Senior Officer B
spoke to Senior Officer A and she mentioned the earlier concerns from
prisoners. Senior Officer B spoke to the man again and he again convinced
him he was alright.
During the afternoon of 28 September, a Suicide Prevention Team meeting
was held and discussed the case of the man’s cellmate. The attendees
decided that the cellmate should be relocated to Healthcare when he returned
4
from Court. This was not documented in the minutes of the meeting and the
group did not take responsibility for ensuring that this happened.
Meanwhile, the man’s partner had phoned back to see how he was. It is not
clear to whom she spoke but it appears that she did not speak to the Deputy
Governor or any member of staff on A Wing. She told the investigation team
that the person she spoke to was very unhelpful and dismissive of her
concerns.
Shortly after, the cellmate returned from Court and was relocated back to the
cell with the man. He was not located in Healthcare as agreed in the Suicide
Prevention Team meeting. On entering the cell, the cellmate immediately
discovered the man hanging.
The man left a note which said that no one was responsible for his death and
apologised to prison staff for lying to them. He said that no one could help
him and he wanted to die.
This report makes a total of 14 recommendations.
5
CONDUCT OF THE INVESTIGATION
1. The investigation was conducted by a member of the Prison Service’s
London Area Manager’s Office. The investigation was led by one of my
senior investigators.
2. During the course of initial inquiries, the investigation team were shown
around the prison and visited the cell where the man died. They also
reviewed all the relevant documentation and established a chronology of
events. Notices were issued to staff and prisoners telling them of the
investigation and offering them the opportunity of contributing.
3. One of my Family Liaison Officers contacted the man’s family and offered
them the opportunity to meet with her and the senior investigator to
discuss the purpose of the investigation and to raise any concerns or
questions that they would like explored and addressed. A meeting took
place with the man’s mother, on 14 December 2004. A separate meeting
took place with the man’s estranged wife, also on 14 December 2004.
The man’s partner detailed her concerns in a telephone conversation on
24 November 2004. The man’s father met my investigator, through his
representatives, after the draft report was issued.
4. The investigation team met with the Chairman of the local Prison Officers’
Association (POA), and the Chair of the Independent Monitoring Board
(IMB) to tell them about the investigation process. Sixteen members of
staff and eight prisoners were interviewed during the course of the
investigation. All members of staff were offered the opportunity of being
accompanied by a work colleague or Trade Union official.
5. The investigation team also contacted Her Majesty’s Coroner to tell him of
the nature and scope of the investigation. The Coroner provided a copy of
the Post Mortem report of 29 September 2004. This recorded the cause of
death as ‘hanging, self-suspension’. There was no evidence of any third
party involvement. The report said that there was no evidence of any
natural disease that could have caused or contributed to the man’s death
or that he had been subjected to an assault or restraint. There were signs
of old injuries, which were superficial scars, on the man’s left upper
forearm consistent with previous deliberate self-harm.
6. The investigation team had a telephone conversation with the police officer
responsible for investigating the incident on behalf of the Metropolitan
Police. He was advised of the scope of the investigation. He was offered
the co-operation of the investigation team and the sharing of any
information which might be relevant to his inquiry.
7. I am grateful to the doctor from Lambeth Primary Care Trust, who
undertook a clinical review of the healthcare provided to the man while at
Brixton.
6
BACKGROUND INFORMATION
The man
8. The man was born on 21 October 1981, and was 23 years old when he
died. He was remanded into custody at Brixton on 21 September 2004.
He had been convicted of two offences against his wife, assault causing
actual bodily harm and threats to kill. He was remanded into custody to
await Probation Service reports before being sentenced. He suffered from
depression for which he had been prescribed medication before his
remand into custody.
9. The man’s mother told the investigation team that the man’s father had
taken her and their two children to Bangladesh in 1990. She returned to
England without the children and she and her husband subsequently
divorced. The man’s father remarried when the man was 14 years old.
The man and his sister returned to England from Bangladesh when they
were teenagers and later resumed contact with their mother. The man’s
mother said that he suffered from depression and high blood pressure.
She believed that the events of his childhood might have caused some of
the depression, having been taken from a comfortable life in London to
Bangladesh, and subsequently separated from her. She also said that he
would not take medication for his condition. She had spoken to him in
May or June 2004 and had sensed something wrong in his voice. He told
her that he was depressed and she told him to see his GP.
10. The man’s father provided a statement to the investigation team. He said
that he was the first born child in his family and was loved dearly by all the
family especially by himself and his brother (the man’s uncle).
11. The man’s estranged wife told the investigation team that she had been
married to him for four years, having known him for approximately five
years. She described their relationship as a violent one. She had split up
with him in June 2004 after finding out in December 2003 that he was
having an affair. She said that she had not confronted him about the affair
immediately, as his grandmother had become ill and subsequently died
and she did not want to upset him further. When she finally confronted
him he denied the affair. She then asked for a divorce and she believes
this led to him threatening to kill her and his subsequent arrest.
12. The man had worked as a health advocate at a local hospital. A colleague
of his told his estranged wife that he mentioned to her some time in August
2004 that his neck hurt as he had tried to kill himself but his partner had
stopped him. His colleague also told him personally to get help. His
estranged wife had also witnessed attempts of self-harm and suicide by
him. She believed that he always made such attempts when somebody
was around to stop him. She suggested he might have done this in
Brixton in the belief that he would be saved. She described him as being
childlike and not able to talk openly about his feelings. She said that he
always needed someone with him and did not like to be alone.
7
HMP Brixton
13. Brixton is a local prison and its main function is to serve the Inner London
and Southwark Crown Courts, holding remand and recently convicted
prisoners. Convicted prisoners have an initial interview and are then
categorised and allocated to another prison with facilities appropriate to
their sentence and sentence plan needs.
14. The prison consists of four main residential units plus the Healthcare
Centre. The accommodation consists of 449 cells, mostly occupied by two
prisoners in each cell. The Healthcare Centre has 36 available beds. On
28 September 2004, Brixton held 768 prisoners. A Wing, where the man
was located, held 260 prisoners.
15. The local strategies for the care of prisoners at risk of self-harm at Brixton
are in accord with national policy. The local policy for the prevention of
suicide is published within the prison and is available to both staff and
prisoners. The establishment employs a full-time Suicide Prevention Co-
ordinator, a Senior Officer, who holds regular meetings with all
departmental area representatives. A number of initiatives in the
prevention of both self harm and attempted suicides have been
implemented. One such initiative is a dedicated telephone number for
friends or relatives of prisoners to phone the prison if they have any
concerns about a prisoner. This is the ‘at risk line’ and telephone calls to
this line are recorded on an answer machine which is checked four times a
day. Calls received are logged and a record is made of any actions taken
in response. Messages left can be checked by staff from any telephone
within the prison by dialling the at risk telephone number. This facility has
been in operation since the end of August 2004.
16. The training manager for Brixton, was interviewed to establish the amount
of training that staff in Brixton received in Suicide Prevention and First Aid.
He confirmed that he had been in the role since June 2004 and that
training records relating to staff training before that are very sketchy. He
was not surprised to learn that an officer told the inquiry that he had not
received any first aid training for over 14 years. He said that first aid
training is not available for every officer but is for new first aiders and there
are refresher courses for those already trained. Refresher courses are
every three years, to keep first aid certificates up to date. He said that
emergency aid or heart start training is given to all new prison officers. He
confirmed that CPR training had been carried out recently, which was
targeted to certain members of staff, mainly healthcare staff. He said that
Brixton did have sufficient staff trained in first aid to fulfil the requirements
of health and safety and that those staff did receive continued training.
However, there is no system in place to prevent these trained staff being
off duty at the same time.
8
17. Records show that there has been another self inflicted death at Brixton,
in April this year, which my office is investigating. There do not appear to
be any common issues identified in that investigation (although that report
is not yet finalised).
9
THE EVENTS LEADING UP TO THE MAN’S DEATH
The man’s custody at Pentonville and reception at Brixton
18. The man was received into custody at HMP Pentonville on 17 August
2004 from Thames Magistrates Court. He was remanded for offences of
actual bodily harm and threats to kill. The accompanying Prisoner Escort
Record (PER) from the court to the prison did not indicate on the risk
categories that he was suicidal or likely to self-harm. The word
‘depression’ was recorded under ‘further information about risk’ but this
entry was not clarified with any other information or explored further by the
interviewer.
19. During the first reception health screen assessment, the man was asked
whether he had ever taken medication for mental health problems. He
said that he had been taking Fluoxetine, an anti-depressant drug, but that
he had stopped taking that a few months before. Pentonville did not
obtain his GP medical records to clarify this point and he was not referred
for a mental health assessment. When asked if he had ever tried to self
harm, he said that he had taken an overdose in 2000 in prison. He had
not mentioned any previous period of custody when interviewed for his
prison record. To clarify this point, Prison Service computer records were
checked by the investigation team. They showed that a man with the
same name had been in custody at Feltham in 2000. He had been the
subject of an open F2052SH (which is a form for monitoring prisoners who
may be suicidal) when he was released from Feltham. The records did
not indicate why the F2052SH had been opened. It was not possible to
confirm, however, that this was the same man who was in custody at
Brixton.
20. The man said that he did not have any current thoughts of self harm or
suicide. He was assessed as being mentally stable, and did not express
any negative thoughts. He asked to see the prison doctor as he needed
something to help him sleep and he did not want to take Fluoxetine any
longer. No reason was given. He was then seen by the prison doctor who
recorded that he was ‘somewhat low’. The doctor prescribed a once only
dose of Zopiclone to help him sleep. The man was located on normal
location within Pentonville. There are no incidents noted in his records
from Pentonville to say that there was any cause for concern regarding his
mental state or physical wellbeing during his time there.
21. The PER for the man’s transfer from Pentonville to Thames Magistrates
Court on 24 August did not indicate any known risks of suicide or self-
harm. The case was committed for trial at Southwark Crown Court on 21
September. The man returned to Pentonville that day. Again there was
no cause for concern noted.
10
22. On 21 September, the man was convicted, and remanded in custody to
return to court on 19 October after Probation Service reports had been
prepared. The PER for his transfer from Southwark Crown Court to
Brixton again did not note any known risks of suicide or self-harm. The
man was processed through reception at Brixton as a transfer from
another establishment rather than as a new reception. The only
documents to follow him from Pentonville were his PER and medical
record. The Inmate Medical Record (IMR) completed at Brixton noted,
‘Seen on reception from Pentonville via Southwark Crown Court. JR’d
status. Fit and well.’ A cell risk assessment form and a first night in
custody questionnaire were completed. Neither assessment raised any
issues of concern. The man was located on A Wing (A2-22) where he
remained until 24 September 2004, when he was relocated to cell A2-03,
where he shared a cell.
Incident with the man’s cellmate: early morning on 28 September
23. At 1.17am on 28 September, the man called night patrol staff to his cell
where they found that his cellmate had tried to hang himself by a ligature
from the cell window bars. An officer, officer A, entered the cell and cut
the ligature from around the cellmate’s neck. The man supported the
cellmate’s body while this was done.
24. The cellmate said in interview that he was located in cell A2-03 with the
man on 27 September. He said that the man told him that he had a
girlfriend whom he loved. He could tell from the way that the man spoke
that he was heartbroken at being away from her. The two men then
chatted for a while. The cellmate showed the man photographs of his wife
and son. The cellmate said that at about this time he made up his mind to
hang himself. When the man fell asleep, his cellmate tied a ligature onto
the cell window bars and stood on a chair and attempted to hang himself.
The noise of the chair moving woke the man and he grabbed the cellmate
and held him by the legs, supporting him until an officer came into the cell
and cut the ligature from his neck.
25. Officer A said in interview that he heard the man banging on the cell door.
He ran to the cell, looked in, and saw the cellmate with a ligature around
his neck. The man was supporting him, although the cellmate was
standing up of his own accord. Officer A entered the cell, cut the ligature
from the cellmate’s neck and the cellmate was removed by a member of
medical staff for assessment. Officer A then took the man out of the cell to
a Listener’s suite and spoke to him for about 40 minutes. He asked the
man what had happened and whether he was alright and the man said he
was fine. Officer A said that he subsequently asked the man whether he
wanted to talk to anyone and the man declined, again saying he was fine.
Officer A could not remember whether he had specifically asked the man
whether he wanted to talk to a Listener or a Samaritan. (A Listener is a
prisoner specially trained by the Samaritans to assist other prisoners by
listening to their problems.)
11
26. The man told Officer A that he did not have any problems with being in
prison and was more concerned about his cellmate. After the cellmate had
been seen by medical staff, Officer A asked him if he wanted to go back to
the same cell. He replied that he did. He then asked the man whether he
wanted to return to the cell with the cellmate. The man said that he would
go back to the same cell and would talk to the cellmate. Both men were
then locked into the cell. The cellmate was placed on a F2052SH. Officer
A observed both men every 20 minutes, initially up to about
3.30am/4.00am, when he saw them talking to each other. He checked
again some time between 4.30am and 5.00am and they were both asleep.
The investigation team did not find any record of this.
27. Officer A woke the cellmate at 6.15am as he was scheduled to go to Court.
He went back to check that the cellmate was up and found that both men
were awake and they confirmed they were fine. He passed on the
information about the incident to the day staff by way of a note in the Wing
Observation Book. The note in the Wing Observation Book reads, ‘Was
alerted by cellmate that this inmate was trying to hang himself. Sealed
pack was broken to gain entry to cell. He (the cellmate) had ligature tied
around neck and affixed to window frame. Was cut down using big fish.
After being seen by medic and given sleeping medication was relocated
into cell. Was offered observation cell but he said he preferred not to be
alone. Was very apologetic afterwards. F2052SH raised.’ No mention
was made of the man’s intervention or of any support offered to him.
28. The cellmate left the prison that morning to attend Court. The man was
left alone in his cell.
12
Staff action later on the morning of 28 September
29. Another Senior Officer on the Wing, Senior Officer C, started duty at
around 7.45am on 28 September 2004. He said that he was not aware of
the incident with the cellmate until he read the entry made by Officer A in
the Wing Observation Book. He did not speak to Officer A about the
incident as he (Officer A) had gone off duty by this time. There were no
instructions left for him about further action to be taken in respect of
support for the man. In fact, no mention was made in the Wing
Observation Book of the man’s intervention with his cellmate. Senior
Officer C said that if a cellmate had been very distressed by such an
incident or was himself on a F2052SH form he would expect that they
would probably get follow up counselling. His understanding of this
situation was that Officer A had spoken to the man after the incident and
the man had confirmed that he was fine. There were no concerns for his
wellbeing.
30. Senior Officer C did not carry out any follow up action for the man when he
came on duty. He said, ‘In an ideal world I would have liked to have been
able to have had the time to go and see him, but running a wing such as A
Wing, it is just not possible. To be honest with you in hindsight after this
one I would like to think that in that situation, if it was to occur again, I
would put everything else on hold to make sure the other prisoner was ok.’
31. Another officer on the Wing, Officer B, also started work at around 7.45am
on 28 September and received a briefing from the wing manager before
going to A2 landing. He was unable to remember the exact content of the
briefing but vaguely recalled that he was aware of an incident with the
cellmate. He said that he did not receive any specific instructions
regarding the man but would generally have kept an eye on him as part of
his normal duties. He said that he had little interaction with or knowledge
of the man but he recalled him as being quiet, spending most of his time in
his cell reading.
32. An officer, Officer C, worked on A2 landing with Officer B on the morning
of 28 September. He also attended the morning managers’ briefing and
was told about the incident with the cellmate. He confirmed that he had
not received any specific instruction in respect of further support for the
man. He had not known the man as A2 landing was not his normal
landing. He did not have any interaction with the man that morning.
33. The Suicide Prevention Officer, said that she was on duty on A Wing on
the morning of 28 September. She was told by the Duty Governor that the
cellmate had attempted to hang himself on 27 September. The Duty
Governor told her that everything had been dealt with and that the man
was going to be offered support and looked after that day (28 September).
She said that normally she would have walked the wing as part of her
morning duties, but that morning she had a visitor from Prison Service
Headquarters and was not able to do so.
13
34. The Suicide Prevention Officer’s understanding of the support offered to
the man immediately after the incident with his cellmate was that Officer A
spoke to him and he told him that he was fine. She understood that the
man was offered the support of prison Listeners but he declined this
support. She did not receive this information personally from Officer A.
35. In summary, it appears that the man was given no specific support by staff
on the morning of 28 September after Officer A went off duty.
Prisoners’ concerns and staff response in the afternoon of 28
September
36. Senior Officer A worked on A2 landing on the afternoon of 28 September
2004. She said that, while prisoners were on association, the man
approached her and told her about the incident with the cellmate during
the early hours of that morning. Senior Officer A sympathised with him
about how awful it had been for him. The man wandered off after the
conversation.
37. It seems that other prisoners were concerned about the man. A prisoner,
prisoner A, said that the man had approached him after his cellmate had
gone to Court. The man asked him if he could arrange for another Bengali
prisoner to move into his cell with him. Prisoner A then arranged for
another prisoner, prisoner B, to move into the cell with the man. This cell
move was authorised by Officer B.
38. During association, prisoner B said he moved his belongings into the cell
with the man. Shortly after this, the man told him he was going to hang
himself. Prisoner B told prisoner A of the conversation, and refused to
stay in the cell with the man.
39. Prisoner B also went to see Senior Officer A in the wing office. He told her
what the man had said, and that he could not move into the cell with the
man after all because he had said that he was going to kill himself. Senior
Officer A said at interview that she thought prisoner B must be mistaken as
it was the man’s cellmate who had tried to kill himself, not the man. She
put this to prisoner B. She said prisoner B told her that he had spoken to
the man in his own language and he was still concerned that the man was
going to kill himself.
40. Senior Officer A said she then went to speak to the man in his cell and he
told her that he was fine. She told the man about prisoner B’s concerns
but he still maintained that he was fine. Senior Officer A still thought that
prisoner B must have been confused so she went back and spoke to him
but he was still concerned about the man. She said that she was not
exactly happy that everything was fine with the man after speaking to him,
but the man had assured her that he was alright. She spoke also to
prisoner A, and he told her that he had spoken to prisoner B and that
prisoner B was concerned that he would be blamed if the man harmed
14
himself. He told Senior Officer A that it would be helpful for the man to
have a cellmate who spoke the same language.
41. Prisoner B never actually moved into the cell with the man. He said that
he told prisoner A that the man was still on his own in the cell and prisoner
A tried to get another Bengali prisoner to move into the cell.
42. Senior Officer A said she spoke to Senior Officer B, and told him about the
prisoners’ concerns about the man. She said that Senior Officer B then
went to see the man. He concluded, as she had, that the man was fine.
43. Senior Officer A next saw the man at unlock for evening meal, although
she could not recall whether he collected his meal that night. When she
was locking up after the meal, she saw that the man’s door was still open
and he was sitting in his chair. She asked him if he was alright and he
said yes. She told him that, if he did need someone to talk to, there were
people in the Prison Service-not necessarily prison officers- who would
help if he wanted. He told her that he was fine.
44. Finally, another prisoner, prisoner C, said at interview that he found a razor
blade in the man’s cell. He said that he had been in a cell with the man
when prisoner B came in and told them that the man had said that he was
going to take his own life. He said that both he and prisoner A then went
next door into the man’s cell to talk to him. Prisoner A carried on talking to
the man while prisoner C looked into the cell bin and saw a razor blade.
He removed this to prevent the man from harming himself with it. Officers
then started locking prisoners back in their cells. He said he showed
Senior Officer A the razor blade from the man’s cell and told her that the
man was serious about taking his own life. He said that Senior Officer A
did not seem to be interested and did not even take the blade from him.
He then put the blade in the bin in the man’s cell. When the police
interviewed him later he said they retrieved the bin with the razor blade in
it. Senior Officer A denied this. She said that no prisoner told her that
they had found a blade in the man’s cell, or showed her any such blade.
The police investigation has been unable to confirm whether a razor blade
was found in the bin in the man’s cell.
45. At the point that prisoners were locked up, the man remained in his cell
alone.
Telephone calls made by the man to his partner on 27 and 28 September
46. The investigation team listened to a number of telephone calls made by
the man, to his partner during his period in custody. Several of these
contain references to intentions the man had expressed to cause himself
self harm. It is clear from the telephone calls that the man believed that
his partner had been lying to him and had been seeing other men. In a
telephone call he made on 27 September he told her ‘to move on’.
15
47. On 28 September at 3.02pm, the man made a telephone call during which
he criticised the clothes his partner told him she was wearing and the fact
that she had been to a hairdresser. He again told her to find another man
and to get her mother to find her one. He said that he was not coming out
of prison and that he could not be with her and did not want to live. Later
on he said, ‘probably if I go to heaven, but I doubt it, if you commit suicide
you go to hell.’ He ended the telephone call by saying ‘make yourself feel
better because I will as well, I’m going to kill myself, that will make me feel
better, goodbye, goodbye’. His partner replied, ‘No please, no don’t, no,
no.’ The man said, ‘I will, alright, you know, I don’t lie, I don’t lie. I will kill
myself and it’s only for your love because I can’t have it, okay.’
48. The man made his next call to his partner at 3.22pm. During this call he
was extremely upset and continuously asked her why she had lied to him.
He talked again about being unhappy about her clothes and hair. He said
during that call, ‘I am sitting in here thinking about, trying not to kill myself
every day.’ When she told him she had had her hair coloured he said, ‘I
can’t take it, why are you doing this to me, why?’ He later said, ‘Hope you
are satisfied, but you will only see my dead body.’ He continued, ‘Do me a
favour, give me a thousand pounds. I think that’s how much it costs for the
grave funeral. I want to be buried next to my gran.’ He then said, ‘That’s
why I want to kill myself because there is no way I can be with you.’ The
man ended this call by telling his partner that he wanted her to shave her
hair off and then became upset when she refused to do so. The man
made his last call to his partner at 3.40pm. He again told her to shave her
hair off and that he intended to take his own life. The man made a total of
six calls on 28 September between 2.48pm until his final call at 3.47pm
when he phoned to check his balance, which confirmed that he had used
all his money in his telephone account.
Telephone calls from the man’s partner and action taken by Brixton in
response
49. The man’s partner told my Family Liaison Officer about the telephone
contact she had with the man and subsequently with Brixton on 28
September. She said that it was normal for the man to be up and down
about his situation, but that on 28 September he had sounded different to
her. She became concerned for his wellbeing. She said that he had
sworn on God in one of the calls, which is something he never did. He
had been crying and told her that he loved her and could not live without
her any longer. She told him that she loved him and that they had to be
strong together and she needed him in her life. She said that he cried at
just hearing her voice and he was worried because he did not know how
long his sentence was gong to be and thought he might not be able to
complete his sentence. He told her to move on but she refused and told
him she would wait for him. He also said ‘goodbye’ and ‘farewell’,
something he had never said before.
50. She said she was so worried about him that she telephoned Brixton at
around 4.00pm to tell them about her concerns. They said they would
16
phone her back. She phoned back at 5.00pm as she had not heard from
them. She said that the person who answered the phone that time
shouted at her and was extremely unhelpful. The investigation team has
not identified the person who spoke to his partner on that occasion. The
man’s partner did not use the prison ‘at risk’ telephone number so the calls
were not recorded. She felt that Brixton did not take her concerns
seriously and took her warnings as a joke. She said that she was very
upset when she telephoned Brixton and cried and begged them just to
watch the man.
51. The Duty Governor on 28 September 2004 took the first telephone call
from the man’s partner. He said that he had just finished a meeting
(probably a suicide prevention team meeting) at around 3.30pm and he
received a call from somebody who said she was worried about her
boyfriend who seemed suicidal and she was concerned that he might ‘do
something silly’. He could not recall the exact wording she used. He
asked her to give him some details, which she did. She told him her
boyfriend’s name, gave his prison number, and said that he was located
on A wing. He told her that he would get in touch with A Wing and the
matter would be taken forward from there. He said that she seemed to be
quite happy with that. It seems that the man’s partner was expecting a call
back after this telephone call but there is no record of her telephone
number in the Duty Governor’s notes of the telephone call.
52. The Duty Governor said that he immediately phoned A Wing after this
telephone call and spoke to another officer on A Wing, Officer D. He said
that he told Officer D to get the Senior Officer on A Wing to talk to the man,
to get the man’s details and his prison number and when he had assessed
the situation to ring him back. He said that he phoned A Wing again at
about 4.00pm and spoke to Senior Officer C. Senior Officer C told him
that he had passed this message on to another Senior Officer on duty,
Senior Officer B.
53. Senior Officer B went to talk to the man at around 4.00pm after he had co-
ordinated the wing for the serving of tea. He said that he went into the
man’s cell and told him that there had been a telephone call from
somebody outside the prison who was concerned about him. Senior
Officer B did not know the name of the person who had called at that point.
He asked the man how he was feeling and the man said that he felt fine,
that there was nothing wrong with him at all. He said that he did not know
anybody who would phone up from outside, that he did not have any
relatives close by. Senior Officer B asked the man about his relatives and
the man said that his father had left his mother and his mother had moved
away and he did not have any contact with them. He said he could not
think who would be phoning up about him. Senior officer B discussed his
living circumstances and explained to him how to apply to keep the
tenancy of his council flat. Senior Officer B left feeling that there was no
problem with the man.
17
54. Senior Officer B then spoke to Senior Officer A, who confirmed that she
had also spoken to the man and she agreed that he seemed fine. She
said that she had spoken to him because his cellmate was very concerned
about him. Senior Officer B then went back into the cell to speak to the
man again, because of what Senior Officer A told him about the cellmate’s
concerns. He spoke to the man for around 15 minutes. They chatted
generally about Bengal. He said that there was no evidence that the man
had been crying and he had no concerns about him after their
conversation. He said at interview that he did recall that prisoner A had
mentioned concerns about the man and he told him that he had spoken to
the man and he was fine. He said that he did not consider putting another
prisoner in the cell with the man as he had absolutely no concerns about
his wellbeing. He did not give any instructions to staff working on A Wing
in respect of the man. He discussed the man with Senior Officer A after
this second conversation with him and they both felt that he was fine. This
is confirmed by Senior Officer A as detailed above.
55. Senior Officer B wrote in the Wing Observation Book as follows, ‘We
received a call from Victor 3 who in turn had received a call from an
outside party voicing concern over harming himself. Myself and Senior
Officer A have spoken to him separately and both of us have no concerns.
He has assured both of us that he is fine and he states he has no thoughts
of self harm.’
56. The Duty Governor spoke to Senior Officer B around 5.15pm. Senior
Officer B confirmed that he had spoken to the man, and that he did not
consider he was suicidal.
57. Senior Officer C also spoke to Senior Officer B when he returned from
talking to the man. Senior Officer B told him that the man did not know
who had phoned up, did not recognise the person’s name and said that he
was fine. Senior Officer C phoned the Duty Governor and gave him that
information and the Duty Governor confirmed that he had already spoken
to Senior Officer B. Senior Officer C told the Duty Governor that he was
going to talk to another prisoner on A Wing with the same surname as the
man just in case the telephone call was relating to him.
58. It is not clear whether the Duty Governor was aware of the concerns
expressed to Senior Officer A by prisoners about the man’s wellbeing.
The Duty Governor did not phone the man’s partner to let her know the
outcome of Senior Officer B’s conversation with the man.
59. The Suicide Prevention Officer, said that she did not know about the
telephone calls from the man’s partner until three days later. She
explained that the man’s partner did not use the ‘at risk hotline’, which
prisoners’ family and friends can phone if they have concerns about a
prisoner, and which she monitors. There is no record that these calls had
been received on the hotline and they must have come through the main
switchboard. This means that they would have been received directly by
either the Duty Governor or the Orderly Officer to deal with. The suicide
18
prevention officer said that as the telephone calls did not come through the
at risk helpline she would not necessarily have been included in this. She
said that she would probably not have become aware that a call had been
received until checking the Wing Observation Book the following day, if an
entry had been made. No mention about the man had been made to her
directly as a result of the telephone calls from his partner.
Events on the evening of 28 September
60. As noted earlier in this report, the man’s cellmate, had left the prison early
in the morning of the 28 September to attend Court. During the afternoon
of 28 September, before the cellmate returned to Brixton, the prison held a
Suicide Prevention Team Meeting. There is no note in the minutes of that
meeting of any discussion relating to either the cellmate or the man. The
Suicide Prevention Officer, said that the incident with the cellmate had
been discussed at this meeting and that it was agreed that the cellmate
would be relocated to Healthcare on his return from court that evening. No
member of A Wing staff attended this meeting.
61. Senior Officer B was the Senior Officer in charge of A wing on the evening
of 28 September when the cellmate returned from his court appearance.
He said that he would have been made aware of the incident involving the
cellmate during the early hours of that morning. He was not, however,
aware of any decision to relocate the cellmate to Healthcare on his return
from court, as apparently decided during the Suicide Prevention Team
meeting earlier the same day.
62. An officer on the wing, Officer E, was on a training course for most of 28
September, and he returned to duty on the wing at around 4.30pm. His
role then was to manage the wing movement desk - that is, to receive
prisoners from reception and allocate them to cells within the wing. He
said an officer from reception brought the cellmate back to A wing
following his court appearance and the cellmate asked to be located back
in his old cell, A2-03. That cell was available at the time so he asked
another officer, Officer F, to locate the cellmate there. As far as he was
aware, Officer F locked the cellmate back into his previous cell. He said
that he was not aware that the cellmate had tried to hang himself early that
morning, and he had not been given any instruction to locate him in
Healthcare.
63. Officer F did indeed escort the cellmate back to his old cell. Officer F, too,
was not aware of the decision of the Suicide Prevention Team meeting to
locate the cellmate in Healthcare. There is a question as to whether,
before the cellmate was allowed to enter the cell, Officer F looked through
the door observation panel to see what might confront them on opening
the door.
64. The cellmate said that, when he returned from court to Brixton, he was told
that he was to return to the cell where the man was located. When he
returned there the cell was dark and he could not see the man. He lit a
19
cigarette, turned on the light and saw the man hanging by a ligature
attached to the cell window bars. He ran to the door and called for the
staff to help. Three or four minutes later a member of staff came to the
cell.
65. Senior Officer B said that he had been standing on the first floor landing
when at around 6.50pm he heard banging from the landing above. He ran
upstairs to see where the banging was coming from. He opened the cell
door and found the cellmate crying and shouting, in total shock. The
cellmate came out of the cell and Senior Officer B saw the man hanging.
Officer F entered the cell behind him. Senior Officer B could not
remember whether he personally shouted for a Code 1 emergency at that
stage. The Code 1 call is logged at 6:51pm. Officer F supported the man
and cut the ligature. He thought he might have then shouted for a Code 1
emergency, although this could have been done automatically by another
member of staff as he recalled that the healthcare response was very
quick. Senior Officer B said that Officer F tried to resuscitate the man until
healthcare staff arrived.
66. Brixton’s Protocol for Medical Response Codes describes a Code 1
emergency as: life threatening conditions (e.g hanging (unresponsive),
severe chest pain, heart attack, severe bleeding, no pulse or breathing). A
code 1 emergency was called in this case. Healthcare staff carry out the
roles of Hotel 6 and Hotel 3 in responding to medical emergencies as
described in the protocol. Hotel 6 is first on call for medical emergencies
and should proceed immediately to the site of the emergency to assess
the patient and start basic life support. Hotel 3 should also respond as
quickly as possible, to take over the co-ordination of the scene.
67. The Contingency Orders for dealing with an attempted suicide, serious
injury or an apparent death of a prisoner, state that officers discovering the
incident should take the emergency equipment (ambu bag equipment)
from its agreed area of storage on the wing to the emergency. Officers
should then carry out emergency help and first aid while waiting for
healthcare staff to arrive, including resuscitation if there are no signs of
breathing.
68. Although it is not mentioned in the Protocol for Medical Response Codes,
the full resuscitation equipment bag is located in the healthcare wing and it
is understood by healthcare staff that Hotel 3 is also responsible for
bringing that equipment from the healthcare wing to the emergency.
69. The investigation team was not able to interview Officer F because he was
absent on long-term sickness. A memo he submitted after the incident
confirmed that, when the cellmate returned from his court appearance he
located him in cell A2-03, with the man. He confirmed the events that
followed as detailed by Senior Officer B and that he attempted to
resuscitate the man.
20
70. Officer E, said that about five seconds after the cellmate was put into the
cell he heard a lot of banging and screaming coming from the cell. He saw
that Officer F was already on the landing and Senior Officer B walked up
the stairs to the cell. Officer E said he followed closely behind Senior
Officer B, Senior Officer B opened the door and the cellmate came out of
the cell. The cellmate was very distressed and was crying. Senior Officer
B turned the cell light on and Officer F followed him into the cell. They saw
the man hanging. Senior Officer B supported his body and Officer F cut
the ligature. Officer E said he did not enter the cell himself as there was
no room. He made a call to the Communications Room informing them of
a Code 1 incident and called another officer to deal with other prisoners
who were trying to get into the cell to see what had happened. The
cellmate was taken to the Listener’s room and Officer E asked a prisoner
who was training to be a Listener, to look after the cellmate until a trained
Listener arrived.
71. A Senior Officer on A Wing, Senior Officer D, was carrying out the duties
of Assistant Orderly Officer that night. He said he responded immediately
to the emergency call and he saw Officer F in the cell and the man lying on
the floor. Senior Officer D was not sure whether Officer F had carried out
any CPR and there were no nursing staff on the scene. He heard later
that CPR had been carried out but, as staff believed life had expired, they
stopped administering it. Medical staff, the doctor and a Principal Officer
carrying out duties as an Orderly Officer, arrived later.
72. A Senior Officer on B Wing, Senior Officer E, heard the alarm call over the
radio and made his way to A Wing and was directed to the incident. He
said he arrived at practically the same time as Senior Officer D and saw
the man lying on the floor. Senior Officer B and Officer F were in the cell.
They said they thought the man was dead. He, too, did not recall seeing
any CPR being carried out at this stage. He checked with the Emergency
Control Room whether the ambulance was on its way and was told that it
was. On the way back to the incident he saw a nurse on her way up the
stairs, Nurse A. He told her that she would need an ambu bag so he went
into the office on A Wing and with a little difficulty found the ambu bag.
The nurse took the ambu bag and carried on upstairs.
73. Nurse A covered emergency response duties on 28 September (call sign
Hotel 6). She confirms the account given by Senior Officer E. She was
the first member of healthcare on the scene. She said she received a
Code 1 emergency call to A Wing and ran to the wing. When she got to
the stairs she saw Senior Officer E and asked him what the problem was.
He said there had been a hanging and confirmed there was no ambu bag
at the scene. She went to the wing office where the ambu bag should
have been, but could not locate it there. Senior Officer E helped her to
look for the ambu bag and said that he would look in the office next door.
She then telephoned her colleague, Nurse B, to attend the scene. She
then went to the cell and saw two officers there. She could not remember
whether either of the officers had been carrying out CPR at the time she
arrived. The ambu bag was located in the second office and arrived at the
21
cell shortly after. Seconds after Nurse A entered the cell, Nurse B arrived
and together they checked the man’s vital signs and commenced CPR.
They concluded there was no sign of life and the doctor arrived shortly
after.
74. Nurse B confirmed he received the call from Nurse A to attend the scene.
He asked if another Nurse, Nurse C (call sign Hotel 3) had arrived on the
scene yet and was told he had not. He therefore asked staff to make sure
the ambu bag was there. He telephoned D Wing where Nurse C
answered almost immediately. He told him there was a hanging on A
Wing and that they needed the full resuscitation kit and ambu bag there.
Nurse B then ran straight across to A Wing and arrived at the scene
around 6:53. He saw the man lying on the floor, and Nurse A was in the
cell. Nurse B said that he arrived in the cell around 6:53 and the man felt
cold as though he had been dead for some time. He did not see any CPR
being carried out when he arrived. He could not find any signs of life. He
commenced the basic process of clearing the man’s airway. There were
no signs of breathing. He described in detail how he attempted to
resuscitate the man with Nurse A. He said that Nurse A gave external
chest compressions and that they both continued that at a rate of 15
compressions to two breaths. They started CPR at around 6.55pm, within
four minutes of the initial emergency call. When Nurse C arrived, Nurse A
told him to call the duty doctor urgently. The doctor arrived within a few
minutes. Nurse B continued CPR with Nurse A while the doctor assessed
the situation. They then took a break from CPR for the doctor to examine
the man. The doctor pronounced the man dead at 7.04pm. The man had
been given nine minutes of CPR.
75. In Nurse B’s opinion the delay in Nurse C and the equipment arriving had
not caused a detriment to the man’s treatment. He said that in this case,
he did not think that it would have made any difference to the man’s
survival if the equipment and Nurse C had arrived earlier. However, it
could make a difference in another case.
76. Nurse C was Hotel 3 Nurse on 28 August. He said that he responded
immediately to the emergency call and made his way to collect the
resuscitation bag. As he was leaving, he answered a telephone call from
Nurse B asking him to attend the scene as quickly as possible. He told
Nurse B that he had been on his way to the scene when he was called
back to answer his phone call. The Investigation Team noted that the
member of staff who undertakes this role (Hotel 3) is not provided with a
radio.
77. An officer, Officer G, was working in healthcare on 28 September. He said
in a memo that he was sitting in the landing office with Nurse C when
Nurse C received the Code 1 emergency call. He said that Nurse C did
not make any effort to move when the call came through. It was not until
Nurse C answered the telephone call asking him to go immediately to the
scene that he collected the emergency resuscitation equipment and left
22
the office to go to the incident. This contradicts the account given by
Nurse C.
78. The Duty Governor, said that there was no doctor present when he arrived
at the scene shortly after 6:54pm and the man’s body was covered with a
sheet, apart from his feet. He said that he did not see CPR taking place.
79. A Principal Officer, was undertaking Orderly Officer (Oscar 1) duties in the
prison. She confirmed that when she attended the incident she saw the
Duty Governor coming down the stairs and he told her that the man was
dead. Shortly after that, a doctor arrived and she directed him to the
incident. She saw a male nurse meet the doctor at the entrance to the
cell. She then looked in the cell and saw that the man’s body was covered
with a quilt.
80. The prison’s incident report did not mention any prisoner witnesses but the
investigation team discovered that three prisoners (Prisoner D, Prisoner E
and Prisoner F) said they were present and had evidence relevant to the
investigation. Prisoner D, who at the time of the incident was training to be
a Listener, said that it was clear to him, before the incident, that the man
was depressed. He said that the man only came out of his cell for his
dinner. He had introduced himself to the man and told him he could talk to
him at any time but the man never spoke to him. On the night of the
incident he heard loud banging on a cell door. He then saw Senior Officer
B run up the stairs and heard a cell door being opened. Senior Officer B
shouted for A Wing to be locked down. He thought there must have been
a self harm incident so he ran up the stairs with towels and followed Senior
Officer B into the cell. He cannot remember much after that but recalls
that he saw the cellmate on the floor, shouting and screaming, and that
Senior Officer B cut the man down. Prisoner D then took the cellmate to
the Listener’s suite and stayed with him until a trained listener arrived.
81. Prisoner E and Prisoner F returned from court at the same time as the
cellmate. Prisoner E said that he heard banging coming from the man’s
cell and he saw Senior Officer B entering the cell and the cellmate
immediately came running out of the cell. Prisoner E said that Senior
Officer B ran into the cell and he ran in after him where he saw the man
hanging with a ligature tied to the cell window bars. Officer F then came
into the cell and ushered him out. He started vomiting outside the cell and
shortly after an officer locked him into a cell.
82. Prisoner F said that he saw Officer E unlock the man’s cell and saw the
man hanging in the cell. Officer E then radioed for assistance and tried to
clear the landing of prisoners. He said there was a delay in cutting the
man down. He is the only witness to mention this. He also said that some
prisoners did not move back to their cells so he tried to help Officer E to
deal with this. He was then locked back in his cell.
83. These prisoner witnesses were not asked to confirm whether CPR was
administered to the man while they were observing the incident.
23
84. A doctor employed by Brixton as a locum doctor at the time of the incident
pronounced life extinct. He refused to be interviewed on the advice of the
Medical Defence Union. The investigation has found that the doctor did
not complete the relevant paperwork following the man’s death. That is,
he did not adequately document the actions he took or his final diagnosis
of the man’s death. He is no longer employed by Brixton.
The note left by the man
85. The man left a note in which he said, ‘No one is responsible for my death.
No one is to blame. I sincerely apologise for lying to the officers on the
landing. I lied because this is not a cry for help. No one can help me. I
just want the pain to stop and the only way is death. I simply want to be at
peace.’
CLINICAL REVIEW
86. Lambeth Primary Care Trust (PCT) is responsible for the provision of
health care services in Brixton. In accordance with procedures agreed
with the NHS, the investigation team advised the PCT of the man’s death.
The PCT then arranged to undertake a clinical review of the healthcare
provided to the man while at Brixton. A doctor undertook the review.
87. The doctor’s report is attached, and makes a number of recommendations.
The clinical review looked at issues relating to management of the prison,
rather than just clinical matters, and there is therefore some duplication
with my own investigation. There is also some overlap between some of
the clinical review recommendations and my own conclusions and
recommendations.
CONSIDERATION AND CONCLUSIONS
88. The man was received into Pentonville on 17 August 2004. There were no
concerns of self-harm or suicidal thoughts raised through the PER. He
said that he had attempted suicide four years previously and that he had
been taking anti-depressant medication which he had stopped taking, and
he did not want to be prescribed that medication again. He was described
by the doctor as being ‘in low mood’ and prescribed a once only
prescription of medication to help him sleep. This is not uncommon for a
prisoner received into prison and this in itself would not normally require an
increase in that prisoner’s level of supervision. Neither the healthcare
worker nor the doctor felt that the man was at risk of self harm or
experiencing suicidal thoughts, and it was not felt necessary for the prison
to contact his medical practitioner to obtain a current medical/mental
health history. This information was available to Brixton when the man
arrived there. He was found to be fit and well and was placed on normal
location. As with Pentonville, no effort was made by Brixton to contact the
man’s medical practitioner to obtain information about his current
medical/mental health. Information and Practice (IAP) 1/2002 clearly
24
states that efforts should be made by the prison to obtain previous
information about a prisoner’s medical history. In view of the man’s
previous history of depression, I judge that Brixton should have carried out
a more thorough medical examination on reception, including obtaining
information from the man’s GP and immediately referring him for a mental
health assessment.
Recommendation: The Primary Care Trusts for Brixton (Lambeth PCT)
and Pentonville (Islington PCT), in partnership with those prisons,
should be asked to develop a policy for ensuring a prisoner’s past
medical history is obtained in a timely manner.
Recommendation: The Primary Care Trusts for Brixton (Lambeth PCT)
and Pentonville (Islington PCT), in partnership with those prisons
should be asked to ensure that those prisoners with an identified mental
health history receive a timely and appropriate mental health
assessment, in order to formulate an appropriate multi-disciplinary plan
of care.
89. It is clear that there was a strong group of Bengali prisoners on A Wing,
where the man was located. This group attempted to engage with the man
and to support him during his time in custody. It appears from the
conversations with his partner that he had some concerns about the length of
the sentence he would receive but he did not raise these concerns with staff.
No evidence was found to indicate that the man was the victim of bullying
while on A Wing or that he had sought any medical help for his previously
reported depression.
90. During the early hours of the morning of 28 September, the man’s
cellmate attempted to commit suicide by hanging. It is clear that the man’s
quick action at the time played a crucial part in saving the cellmate’s life.
Night staff responded to this incident quickly and both the man and the
cellmate were taken out of the cell and received some support. The man
spoke to Officer A after the incident and Officer A asked him if he wanted to
talk to anybody else, which he declined. The Orderly Officer, together with
medical staff spoke to the cellmate and he was placed on a F2052SH. Both
men were then located back to the same cell.
91. The support that the man received immediately after the incident therefore
appears to have been adequate and he was offered the opportunity to speak
to somebody. However, it is not clear whether it was explained to him that he
could talk to a prison Listener or the Samaritans. Also no consideration
appears to have been given to placing the man on a F2052SH form. The men
were located back to the same cell after what must have been a very
traumatic experience for both of them.
92. Officer A used the Wing Observation Book as a means of communicating
to staff who came on duty the next morning about what had happened.
However, the entry in the Observation Book was lacking as it did not fully
mention the role the man played in the incident with the cellmate. When staff
25
came on duty for the main day shift on 28 September, at around 7.45am,
most of them became aware of the incident with the cellmate, but there was
confusion in respect of further support for the man.
93. The wing manager, Senior Officer B, thought that, as the man had been
offered the services of Listeners and declined this, there was no need to offer
further support. The suicide prevention co-ordinator, said that further support
should have been offered by the wing manager. No further support was
offered to the man and he was located back to the same cell with the
cellmate. Of course he could have asked for help at any time, but considering
the role he had in assisting the cellmate, staff should have been more
proactive in supporting him. There was a clear lack of co-ordination between
managers, with the assumption that others would support him. In fact, the
man was initially left alone in his cell when the cellmate went to Court later
that morning.
Recommendation: The Governor should remind staff that entries in Wing
Observation Books must be worded to enable effective communication
between Wing staff on hand over between shifts or that a proper oral
hand over is undertaken between shifts.
94. When the cellmate went to court on the morning of 28 September,
arrangements were eventually made for a Bengali prisoner, prisoner B, to
move into the cell with the man. When prisoner B was moving into the cell, he
said that the man told him that he was going to hang himself. Prisoner B
immediately approached other Bengali prisoners on A Wing, prisoner A
prisoner C and they went to speak to the man. Prisoner C said that he
recovered a razor blade from the man’s cell and gave it to Senior Officer A.
These prisoners are adamant that they told Senior Officer A about their
concerns as to the man’s intentions and that they were worried that he might
kill himself. The police investigation has not been able to establish whether a
razor blade was recovered from the man’s cell bin. The man clearly did not
want to be left alone in his cell and I commend the action of the prisoners in
trying to ensure this did not happen and raising their concerns with staff.
95. These prisoners describe Senior Officer A’s reaction to their concern as
dismissive and non-caring. It seems there may have been some confusion
about the incident with the cellmate. The fact that a number of prisoners
approached Senior Officer A with concerns might have led her to open an
F25052SH or at least ensured that the man was not left alone in his cell.
96. Senior Officer A denies that any prisoner showed her a razor blade. She
said that she decided to speak to the man as a result of the concerns of the
prisoners and found him to be fine. I do not doubt this to be the case but it is
surprising in light of the telephone conversations the man had with his
girlfriend later on. The allegation that Senior Officer A did not take any action
in respect of the razor blade is a serious one. However, in light of her denial
and the fact that the police could not say if the razor blade was recovered
from the man’s cell, I do not believe that this is a matter that can be taken
further.
26
97. The man telephoned his partner several times during the afternoon of 28
September. It is clear from these telephone calls that he was in an extremely
distressed state. He appears to have convinced himself that the relationship
was over or was rapidly deteriorating. His partner was very worried after
these telephone calls and she phoned Brixton twice to express her concerns.
She did not use the ‘at risk’ hotline and it is unclear whether she knew the
number for it. The Duty Governor confirms that he took one of those
telephone calls. The man’s partner was expecting the prison to phone her
back but the Duty Governor did not make a note of her telephone number
when he took the call. In response to the telephone call and concerns raised
by the man’s partner, the Duty Governor contacted A Wing and asked for the
Senior Officer to talk to the man to assess the situation and to report back to
him. I consider this action was correct and appropriate.
98. Senior Officer B went to the man’s cell and spoke to him at length. The
man told him that he did not know the person who had phoned and appeared
to be fine. Senior Officer B then spoke to Senior Officer A who told him about
the prisoners’ concerns for the man. He then went back into the man’s cell to
talk to him again. He was again satisfied that the man was fine.
99. I accept that, following these conversations, Senior Officer B was content
that the man was alright. However, basic precautionary measures were not
taken at this stage. Information had been received from two independent
sources (the man’s partner and prisoners) that the man intended to harm
himself. Senior Officer B had a number of options for action he could have
take
• He could have implemented F2052SH monitoring procedures.
• He could have arranged for the man to be seen by the establishment’s
doctor or other medical staff on duty.
• He could have offered the man the services of a Listener.
• He could have issued instructions for the landing staff to conduct
regular watches on the man over a short period, as happened the
previous morning.
• He could have ensured that the man was located with another prisoner.
100. None of the above actions were taken. The man acknowledged in his
suicide note that he was determined to kill himself and no one was
responsible for his death. However, given the warnings received from two
different sources it is difficult to avoid the conclusion that preventative action
should have been taken.
Recommendation: A training needs analysis should be carried out to
cover training in suicide awareness, risk assessment and prevention.
101. I commend the use of the ‘at risk’ hotline for concerned relatives and
friends. However, this system could be improved if calls were answered
personally rather than by an answer machine. In this case it was not used. It
would have been good practice for the Duty Governor to have phoned the
27
man’s partner back after enquiries had been undertaken following her call.
This might have prompted the man’s partner to express further concern if she
had been told that the man was denying that he knew her. The Duty
Governor could also have made sure that she knew the telephone number for
the ‘at risk’ hotline.
Recommendation: The Governor should remind staff that, when issues
of concern are expressed by families or friends of prisoners, the prison
should relay the result of any subsequent enquiries to the concerned
family member or friend.
102. A number of initiatives have been implemented at Brixton’s to reduce the
risks of both self harm and suicide. I note, however, that the Suicide
Prevention Officer’s post is a singleton post and it is not clear who has the
responsibility for covering the duties of this post when the officer is absent.
Recommendation: The Governor should review arrangements to provide
cover for the Suicide Prevention Officer when that officer is absent.
103. There was a Suicide Prevention Team Meeting during the afternoon of
28 September. It appears the incident with the cellmate was discussed at that
meeting and that it was agreed that the cellmate should be relocated to
Healthcare on his return to Brixton that evening. This was a sound decision
particularly as the cellmate was concerned about what sentence he would
receive. It seems that the team took responsibility to make sure this
happened. Despite this, there is no record of this decision in the minutes of
the meeting and in fact the cellmate was not relocated to Healthcare. He was
returned to the cell with the man. A prisoner who arrived back from Court with
the cellmate said that the cellmate was depressed when he came back from
Court. It is clear that there was a breakdown in communication. This not only
failed to locate the cellmate to Healthcare on his return from Court but also
ended with him being relocated back into the same cell as the man.
Recommendation: The Governor should remind members of the Suicide
Prevention Team that actions recommended in meetings should be
clearly minuted and conveyed to relevant staff.
104. The cellmate called staff to help when he discovered the man suspended
in the cell at 6:50. Officer F and Senior Officer B say that they responded to
the incident and entered the cell without delay at 6.51, that the man was
supported and the ligature was removed. It appears that CPR was then
started by Officer F and continued until medical staff arrived at which point
they took over. They make no mention of any prisoners in the vicinity at the
time. According to prisoner witnesses this was not the case. Two prisoners
said that they actually went into the cell when the man was discovered and
another says that there was a delay in cutting the man down.
105. I have been unable to conclude which version of events is correct. I
accept that staff attended the incident and that medical staff were called to
assist almost immediately. Officer F has said that CPR was commenced and
28
continued until medical staff arrived. Senior Officer B cannot recall whether
CPR was definitely undertaken by Officer F. Likewise, neither Senior Officer D
or Senior Officer E, Senior Officers who arrived at the scene before the
medical staff, are able to confirm that CPR had commenced and was ongoing.
This is particularly relevant as Nurse Ai (Hotel 6) said that she tried to obtain
the ambu bag and other equipment from the wing office before she went to
the incident. There was further delay as she made a telephone call to Nurse
B (Hotel 3) in reception, to ask him to attend the incident. It is not clear
whether CPR was ongoing during this time. Nurse A said that she did not
recall CPR being carried out when she entered the cell.
106. Nurse B also said that he did not see CPR being carried out when he
arrived on the scene. There is no doubt that CPR was started immediately
when healthcare staff arrived and that every effort was made to revive the
man. However, a significant amount of time could have been lost before CPR
was commenced.
107. Another concern is that the man was clearly covered by a sheet or a quilt
before the doctor arrived. This was confirmed by the Duty Governor, who
says that he arrived at the scene shortly after 6.54. This was also confirmed
by the Principal Officer who arrived at the scene just after the Duty Governor,
and by the doctor himself. If this is the case it would suggest that CPR had
definitely been stopped before the doctor arrived and declared life extinct.
However, this evidence is contrary to what was said by the nurses who
attended.
108. It is impossible to know exactly what happened during the incident and
whether CPR was commenced at the earliest opportunity and continued, as
there are many contradictions in incident statements. However, I have
concern in respect of the response from Hotel 3 (Mr C) and his alleged delay
in responding to the incident as explained by another member of staff. It is
not clear whether, if the resuscitation equipment had arrived earlier, it would
have made any significant difference in this case because when it was
delivered it was not actually used. What is of concern is that it could make all
the difference in a future incident.
Recommendation: I acknowledge that the accounts given by officer G
Nurse C are contradictory. However, the Governor, in partnership with
Lambeth PCT, may wish to consider undertaking his own inquiries into
the matter as another member of staff has said that Nurse C did not
respond immediately to the code 1 alert on 28 September 2004 when
carrying out Hotel 3 duties.
Recommendation: The Healthcare Manager/Lambeth PCT should review
the training of healthcare staff and issue guidance regarding their
responsibility and the authority they hold when responding to medical
emergencies. This should include all protocols in place for dealing with
prisoners who are suspected to have attempted suicide.
Recommendation: The Governor should ask his Healthcare manager to
29
ensure that ambu bags are appropriately located within the prison and
that relevant staff are aware of their location to make sure they are
brought to the scene at the earliest opportunity.
Recommendation: A training needs analysis should be conducted to
cover the issues raised in this report in respect of first officer at the
scene of a serious incident. This should include procedures while
awaiting the arrival of healthcare staff, as well as emergency
resuscitation procedures to be carried out.
109. Nurse B was not given a radio when covering Hotel 3 duties and this
could have contributed to the delay in his response to the incident as he had
to be telephoned to respond. At a time when there is reduced medical cover it
is unacceptable that available medical staff are not provided with radios to
enable their assistance to be requested much easier.
110. Two instruction documents are in use by the prison which explain to
healthcare staff and discipline staff how to deal with medical emergencies.
These are a Protocol for Medical Response Codes and Contingency orders
for dealing with an attempted suicide, serious injury or an apparent death of a
prisoner. These instructions do not fully correspond with each other and do
not contain a full description of the role of Hotel 3 and Hotel 6, particularly in
respect of ensuring that the full emergency resuscitation equipment is brought
to the scene.
Recommendation: The Governor should consider the feasibility of
issuing all Healthcare staff with radios during evening duty periods and
at other times when medical staffing numbers are reduced. This should
be supported by issuing revised guidance for healthcare and discipline
staff to detail the role of Hotel 3 and Hotel 6 in responding to a medical
emergency.
111. A doctor employed by Brixton as a locum doctor at the time of the
incident is no longer employed by the establishment. On the advice of the
Medical Defence Union he refused to be interviewed for this investigation. He
pronounced life extinct but did not complete the relevant paperwork as he
failed to note any action taken or his final diagnosis.
Recommendation: A copy of the report should be sent to Lambeth PCT
with a view to their considering undertaking their own investigation into
the failure of the doctor to appropriately complete medical records in
accordance with the requirements of the General Medical Council
(GMC).
112. All concerns within the clinical review have been addressed apart from
the issue of healthcare staff not being trained in emergency resuscitation
procedures beyond the use of an airway and then ambu bag ventilation. The
clinical review recommends that consideration be given to training all
healthcare staff in emergency intubation procedures after incidents resulting
in possible airway collapse or obstruction. Whilst it is not considered
30
appropriate to train staff in emergency intubation, consideration should be
give to all healthcare staff being trained in CPR and the use of Automatic
External Defibrillators.
Recommendation: The Healthcare Manager/Lambeth PCT should
consider training all healthcare staff in CPR and the use of Automatic
External Defibrillators.
RECOMMENDATIONS
ESTABLISHMENT:
1. Recommendation: The Governor should remind staff that entries in
Wing Observation Books must be worded to enable effective
communication between Wing staff on hand over between shifts or that
a proper oral hand over is undertaken between shifts.
2. Recommendation: A training needs analysis should be carried out to
cover training in suicide awareness, risk assessment and prevention.
3. Recommendation: The Governor should remind staff that, when
issues of concern are expressed by families or friends of prisoners, the
prison should relay the result of any subsequent enquiries to the
concerned family member or friend.
4. Recommendation: The Governor review arrangements to provide
cover for the Suicide Prevention Officer role when that officer is absent.
5. Recommendation: The Governor should remind members of the
Suicide Prevention Team that actions recommended in meetings should
be clearly minuted and conveyed to relevant staff.
6. Recommendation: I acknowledge that the accounts given by Officer
G and Nurse C are contradictory. However, the Governor, in partnership
with Lambeth PCT, may wish to consider undertaking his own inquiries
into the matter as another member of staff has said that Nurse C did not
respond immediately to the code 1 alert on 28 September 2004 when
carrying out Hotel 3 duties.
7. Recommendation: A training needs analysis should be conducted to
cover the issues raised in this report in respect of first officer at the
scene of a serious incident. This should include procedures while
awaiting the arrival of healthcare staff, as well as emergency
resuscitation procedures to be carried out.
8. Recommendation: The Governor should consider the feasibility of
issuing all Healthcare staff with radios during evening duty periods and
at other times when medical staffing numbers are reduced. This should
be supported by issuing revised guidance for healthcare and discipline
staff to fully detail the role of Hotel 3 and Hotel 6 in responding to a
31
medical emergency.
HEALTHCARE:
9. Recommendation: The Primary Care Trusts for Brixton (Lambeth
PCT) and Pentonville (Islington PCT), in partnership with those prisons,
should be asked to develop a policy for ensuring a prisoner’s past
medical history is obtained in a timely manner.
10. Recommendation: The Primary Care Trusts for Brixton (Lambeth
PCT) and Pentonville (Islington PCT), in partnership with those prisons
should be asked to ensure that those prisoners with an identified mental
health history receive a timely and appropriate mental health
assessment, in order to formulate an appropriate multi-disciplinary plan
of care.
11. Recommendation: The Healthcare Manager/Lambeth PCT should
review the training of healthcare staff and issue guidance regarding their
responsibility and the authority they hold when responding to medical
emergencies. This should include all protocols in place for dealing with
prisoners who are suspected to have attempted suicide.
12. Recommendation: The Governor should ask his Healthcare manager
to ensure that ambu bags are appropriately located within the prison
and that relevant staff are aware of their location to make sure they are
brought to the scene at the earliest opportunity.
13. Recommendation: A copy of the report should be sent to Lambeth
PCT with a view to their undertaking their own investigation into the
failure of the doctor to appropriately complete medical records in
accordance with the requirements of the General Medical Council
(GMC).
14. Recommendation: The Healthcare Manager/Lambeth PCT should
consider training all healthcare staff in CPR and the use of Automatic
External Defibrillators.
32