Individual at Discretionary

Investigation into the circumstances surrounding the death of a
woman in July 2004
following her release from
HMP Bronzefield earlier that day
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2004
CONTENTS
1. Introduction by the Ombudsman, Stephen Shaw CBE
2. Summary
3. Investigation methodology
4. The deceased
5. HMP Bronzefield
6. Events prior to her death
7. Emergent issues
8. Findings and conclusions
9. Recommendations
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Introduction
This is the report of an investigation into the care a woman received whilst in
prison custody before her death in July 2004 after release from HMP
Bronzefield earlier that day.
Although the woman died after leaving prison, I decided to exercise the
discretionary power included in my terms of reference to investigate her
death. My reasons for doing so were first the public concern about the
number of deaths of female prisoners. Second, the number of drug related
deaths of prisoners shortly after their release from prison. Third, that she died
so soon after her release from custody, and finally, that she had been a
prisoner at Bronzefield, a prison that had only just opened.
This investigation was conducted by one of my Senior Investigators with
whom I visited Bronzefield and met with both prisoners and staff.
The findings of this report will be considered by an advisory committee that I
co-chair with the Head of the Women's Team in the Prison Service. Our aim
is to identify any features that might be common to other deaths of women
prisoners and to promote any good practice found.
I wish to extend my thanks to the Director of Bronzefield, and her staff, for
their help and cooperation during the investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman
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Summary
The woman was arrested in June 2004 for theft and a breach of a Community
Rehabilitation Order. She was sent to HMP Holloway as a remanded prisoner
and returned there a week later having been sentenced at Magistrates Court
to a total of three months imprisonment. She had never previously been in
prison custody. The woman had been a heroin user since 1990 and also used
'crack' and benzodiazepines. She underwent a drug detoxification regime at
Holloway, which continued at Bronzefield.
In early July 2004, the woman was sentenced to a six months Community
Rehabilitation Order at Magistrates Court for charges of theft, failing to
provide a specimen and failing to appear. Instead of returning to Holloway,
she was sent to HMP Bronzefield to complete her original three months
sentence, in line with the current Prison Service protocol to allocate prisoners
to the new facility.
The woman was released from Bronzefield two weeks later and went to stay
with a friend. Later that evening she was found dead in the bath at that
address.
The cause of her death was determined by a Coroner's inquest, but the Post
Mortem examination carried out concluded that she drowned, with heroin
poisoning as a secondary factor.
This investigation has revealed gaps in Bronzefield's processes as it operated
in June and July.
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Investigation methodology
1. My investigator and I opened the investigation at Bronzefield a few days
after the woman's death. The Director and her staff produced her core file and
a number of other documents for our examination. Subsequently, notices
were issued to staff and prisoners informing them of my investigation. We
toured the establishment and met informally with staff and prisoners. Several
members of staff were also interviewed regarding the deceased woman in
particular and Bronzefield in general. All interviews were informal.
2. Letters of condolence were sent to the woman's family. The letters also
explained the purpose of the investigation and asked if there were any
concerns or questions they would like explored and addressed.
3. My investigator contacted the Coroner's Officer, to brief him on the nature
and scope of my investigation and request a copy of the Post Mortem report.
Her Majesty's Coroner in this case expressed her desire to consider this
report as part of her investigation process and my investigator subsequently
attended and gave evidence at the inquest.
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The deceased
4. The woman was 47 when she died. According to an interview with her
Probation Officer, she had a troubled childhood, going into Local Authority
care aged 14. Having left secondary education without qualifications, she
worked in retail. During that time she married. She separated from her
husband in the 1980's. Around that time, she was diagnosed as having
cervical cancer and underwent radical surgery, which appeared to have fully
cured the condition. She has three sons.
5. In 1990, she was allocated council accommodation and she allowed a drug
using friend to stay in order to help him break his habit. Unfortunately, that
situation resulted in her own addiction to heroin. For some years she was in
an abusive relationship with a partner who was also heroin dependent. Their
dependence was costing them £60 per day and their whole lives revolved
around obtaining enough money for drugs
6. In 2003, in an effort to remove herself from the local ‘drug scene’, she
moved in with friends in London. They were financially supportive of her and
she was taking Subutex on a private prescription. This drug prevents
withdrawal symptoms and nullifies the effects of any heroin taken.
Unfortunately she had resumed taking heroin before her arrest in June 2004.
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HMP Bronzefield
7. HMP Bronzefield opened on 17 June 2004. It is a purpose built women's
prison operated by UKDS, a private company who also operate HMP Forest
Bank in Greater Manchester. Whilst the deceased was at Bronzefield the
prison held 148 prisoners. It will eventually accommodate 450 female
prisoners. Accommodation is provided in three houseblocks with mostly single
cells. There are inpatient facilities in the healthcare centre, a mother and baby
unit and a special section for women with behavioural problems. Primary
health care is provided by a local GP surgery, with a doctor attending each
day on rota.
8. Bronzefield performs the role of a local prison, taking prisoners directly
from the courts. Sentenced prisoners may serve some of their sentence there.
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Events prior to the woman's death
9. The woman was arrested in June 2004 for theft and breach of a
Community Rehabilitation Order. She was sent to Holloway as a remanded
prisoner and returned there a week later having been sentenced at
Magistrates Court to a total of three months in custody. This was her first
period of imprisonment.
10. At her first reception health screen at Holloway, her medical history was
taken. She told the nurse that she was not feeling suicidal at that time,
although she claimed to have attempted to take her own life on two previous
occasions (no dates given) by means of tablet overdose. She also told of her
use of heroin, crack, cannabis and binge drinking of vodka. She was also
using benzodiazepines. A diazepam and methadone detoxification
programme began according to Holloway protocols. The methadone detox
programme was completed in mid June 2004.
11. The woman was seen by healthcare at the end of June 2004 and a Self
Harm at Risk Form (F2052SH) was opened at 15:00 hrs, as she was feeling
depressed and tearful with some thoughts of self-harm. From the entries on
the form, it would seem that her mood varied over the following two weeks. By
mid July 2004, staff at Bronzefield assessed that she could be removed from
the self-harm watch and the F2052SH form closed. There had been no
incidents or attempts at self-harm.
12. On 5 July 2004 the woman attended Magistrates Court for charges of
theft, failing to provide a specimen and failing to appear. She was sentenced
to a six months Community Rehabilitation Order. Instead of returning to
Holloway, she was sent to Bronzefield in line with the current protocol to
allocate prisoners to the new facility.
13. A First Reception Health Screen form was completed again, with similar
details to those on the Holloway document being provided. She was finding
diazepam withdrawal difficult and was taking 12mg per day on arrival at
Bronzefield. A doctor saw the woman the following day and decided to
continue the ‘detox’ regime started at Holloway. She was seen again a couple
of days later when she presented as agitated, tearful and weak. The doctor
increased the dose of diazepam to 15mg twice daily for seven days.
14. A doctor saw the woman on the day before her release and recorded her
as being much better. The doctor arranged for her to have one day’s
medication to take home with her on her release. She was given a letter for
her to take to any GP surgery to assist her to get an appointment. She did not
collect the medication prior to leaving prison.
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15. On release from Bronzefield, the woman went to stay with a friend, who
arranged for her to see a local doctor at 15:30 hrs that day, as she had no
medication. It is known that she also attended a pre-arranged appointment
with a Probation Officer later that afternoon.
16. The woman returned to her friend's home in the early evening and
decided to take a bath. She was found slumped in the bath sometime later
and pronounced dead at the scene. The Post Mortem examination found that
she drowned in the bath whilst suffering from heroin poisoning.
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Emergent issues
17. The majority of the staff employed at Bronzefield are newly employed with
no previous Prison Service experience. At the time of my visit, staff were still
being recruited and trained as the prison population increased. Posters were
on display to inform staff and prisoners of the local anti-bullying policy but no
self-harm awareness posters were evident. The prisoners with whom we
spoke expressed the view that the staff were friendly and helpful.
18. My investigator interviewed the Resettlement Advisor, who said that
Bronzefield's targets of every prisoner being seen on the first night by a
member of the resettlement team, and having a first morning interview on an
Initial Resettlement Plan (IRP) lasting between 20 – 45 minutes, were both
being met. The deceased woman had two IRP forms completed on the same
day, by two different members of staff and containing some different
responses from her. This remains unexplained. It may be that, as I was told, it
resulted from a member of staff being "over zealous". Be that as it may, it is
illustrative that in any new institution it takes a while for procedures to bed
down. My investigator was informed that the form and the policy for its use
were still evolving.
19. My investigator then spoke to a CARAT (Counselling, Assessment,
Referral Advice and Throughcare) advisor who had spoken to the woman.
She carried out the initial assessment on the houseblock. She found her very
emotional, anxious but willing to talk openly. She told the advisor that she had
been 'clean' of heroin for 10 months, had undergone detox in Holloway, was a
heavy ‘crack’ smoker as well as a heavy benzodiazepine user. The woman
was anxious regarding the level of medication she was receiving and had
spoken to the doctor.
20. The CARAT advisor said that Bronzefield had insufficient ‘detox’ trained
staff. In fact, there were no ‘detox’ nurses, only a visiting ‘detox’ doctor.
21. She saw the woman again about a week before her release. The woman
was concerned that she had no doctor to go to, as she wanted subutex as
well as her diazepam medication. She stated that she was not going to go
back to using heroin but was looking forward to smoking ‘crack’.
22. The CARAT advisor told her that she had arranged various appointments
for her post release with specialist drug advisors in the area she was
intending to live. She also specifically told her about the dangers of drug
usage after being in prison, although she was unable to give her any
literature, as it had not arrived. I attach particular importance to warning
prisoners of their reduced tolerance to drugs on release and commend the
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CARAT advisor's involvement with the woman. It is regrettable that the
relevant leaflets were not yet available.
23. The CARAT advisor was upset that a prisoner told her of the woman's
death and that, when she spoke to the prison administration department, they
had no details. She was de-briefed a few days later but felt that it could have
been done sooner.
24. At the time of my initial visit, there were two CARAT advisors in place with
another two due two weeks later. Literature and brochures regarding drug
usage and self-harm were on order and Listeners were being trained that
week.
25. My investigator spoke at length to another member of staff. She had
spoken with the woman after finding her crying one day. She had a long
conversation with her and after that spoke to her almost every day. She said
that the woman took comfort from those meetings. Unfortunately, the member
of staff had not been made aware of the requirements of the F2052SH forms,
so none of the interaction with the woman was recorded.
26. The Deputy Director told me that the large catchment area of the prison
posed difficulties with resettlement but that they were working to establish
local contacts to assist. As a private company, UKDS runs the prison under a
contract, which in this case was negotiated in March 2001. UKDS is currently
in discussion to update the contract with particular reference to the provision
of ‘detox’ services. I believe this should be given a high priority.
27. The friend with whom the woman went to stay after her release expressed
anger to my investigator at not being told that her friend was potentially
suicidal and that she had been released without any medication.
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Findings and Conclusions
HMP Bronzefield
28. The staff at the prison are mostly newly trained, yet like the staff of other
contracted prisons they appear friendly and helpful. The deceased woman
was apparently happier at Bronzefield than at Holloway and even wrote a
couple of letters of thanks when she left. However, it became obvious during
this investigation that there were still some training issues - most notably,
correct procedures for staff dealing with prisoners on an open F2052SH to be
addressed as well as some administrative procedures that were not settled
prior to the opening of the prison. The provision of detoxification services also
needed to be reviewed.
29. Conclusion - None of the training or administrative shortcomings
contributed directly to the woman's death.
Medication
30. The woman was concerned throughout her confinement within the prison
system at the level of medication given to her. The doctor increased her dose
of diazepam to 15mg twice a day when she saw her in early July, as she
appeared agitated, tearful and weak. When she saw her a week later, she
arranged for her to have three 10mg diazepam tablets (one days supply)
when she was released the following day.
31. Although given her normal morning dose of diazepam on the day of her
release, the woman left the prison without the tablets the doctor had arranged
for her. My investigator spoke to the healthcare manager regarding this. He
said that there had been staff training issues at that time and the reception
staff sometimes released prisoners without informing healthcare. Procedures
are now in place, including a member of the healthcare staff in the reception
area from 7:00 hrs, to prevent this recurring.
32. We interviewed the three GPs from the local practice contracted by UKDS
to provide primary care. They had very little experience dealing with drug
addicted patients or their medical detoxification. They were anxious for some
specialised training. A specialist ‘detox’ doctor attends four times a week and
healthcare now have three ‘detox’ trained nurses.
33. Conclusion - On and before 16 July 2004, proper procedures were not in
place to prevent mistakes such as occurred on the woman's release or to
ensure that prisoners received appropriate clinical care on release.
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Self-harm monitoring procedures (F2052SH)
34. A form F2052SH was opened for the woman whilst she was at Holloway
and remained open during her transfer to court and then to Bronzefield where
it was closed after a review three days before her release. She was not
present at the closing review. This was not in line with best practice.
35. When she arrived at Bronzefield, a First Reception Health Screen was
completed for her. There is no mention on the form that she was subject to an
open F2052SH. A supplementary form entitled 'Further reception health
checks' was also completed, stating 'received from HMP Holloway fit & well’.
Again there was no mention of the open F2052SH. My investigator
interviewed the nurse, who stated that she had not seen the F2052SH booklet
when she conducted the first reception health screen with the woman. She is
now aware of her responsibilities regarding the use of that document and
would have noted her documentation if she had seen it.
36. The Inmate Medical Record for the woman did not contain any references
to the F2052SH. On 22 September 2004, my investigator interviewed three
doctors who were the GPs who had treated her at Bronzefield. They were not
aware that she had been subject to an open F2052SH booklet and stated that
when they see prisoners on self harm watch ‘the booklets don’t usually
appear’.
37. During an interview with the Director of Bronzefield on 22 September
2004, my investigator was told that there has been specific F2052SH staff
training since July and that will continue.
38. I acknowledge the woman's friend's concern about not knowing she had
been potentially suicidal. There are confidentiality issues that would prevent
that information being divulged to other persons without the express
permission of the prisoner.
39. Conclusion - On and before 16 July 2004, some Bronzefield staff who
came into contact with prisoners were not aware of their responsibilities to
those prisoners on F2052SH booklets nor the correct procedures for their
use.
Notification of deaths
40. Both the CARAT advisor and the other member of staff interviewed who
spent time with the woman were upset that they heard of her death from
prisoners.
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41. Conclusion – On or before 16 July 2004, staff became aware of a
significant incident from prisoners rather than official sources.
Recommendations
42. Whilst I believe that the procedural, training and administrative
shortcomings detailed above did not directly contribute to the unfortunate
death of the woman, the investigation has raised some concerns about
Bronzefield's readiness to receive prisoners in June and July 2004. I list them
below along with the response of the Director
43. Prior to a new facility being opened, especially one that will receive many
drug-using prisoners, there must be sufficient appropriately trained staff in
place. Any equipment and documentation those staff might need should also
be available to them. Service Level Agreements should be reviewed prior to
opening to ensure the establishment can meet the standards laid down
ensuring the safe effective care and resettlement of prisoners.
44. Director’s response – The staffing levels and training programme were
fully approved by the Home Office prior to the prison opening. All operational
policies were submitted by the Contractor to the Home Office to schedule and
were approved prior to cell certification being issued.
45. A multi-agency policy should be developed and implemented to ensure
that appropriate and effective throughcare is available to all prisoners on
release into the community.
46. Director’s response – Bronzefield is a pilot site for the Drugs Intervention
Programme (DIP). The prison is currently putting in place arrangements to
accommodate this.
47. A policy should be developed to ensure that prisoners are given
appropriate referrals to clinical care services in the community to provide a
seamless service.
48. Director’s response – The DIP arrangements referred to above are
designed to assist in bringing together a range of agencies around those with
drugs problems who are known to services. Bronzefield’s Healthcare Centre
and CARAT’s teams will work in partnership with the community under DIP
arrangements.
49. The Director of Bronzefield should ensure as a matter of urgency that all
her staff are properly trained in the use of the F2052SH booklet.
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50. Director’s response – Training on the F2052SH system was focused on
those staff who would come into contact with prisoners. All Prisoner Custody
Officers were fully trained prior to opening the prison. The member of staff
referred to in paragraph 27 had been recruited as an Administrator and as
such had not been trained. This has since been rectified.
51. The Director of Bronzefield should ensure that staff are made aware of
significant incidents and that details of such incidents are communicated to
staff and to prisoners through official channels in a sensitive and timely
manner.
52. Director’s response – The staff briefing system is now much more robust
than it was at the time of this incident.
STEPHEN SHAW
PRISONS AND PROBATION OMBUDSMAN FOR ENGLAND AND WALES
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