Individual at Bullingdon

Investigation into the circumstances surrounding the
death of a man at HMP Bullingdon
in March 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2009
This is a report into the circumstances of the death of a man at HMP Bullingdon in
late March 2008. Prison staff discovered the man hanging in his cell. He had
attached a noose around the cell window when it was open and then closed the
window to secure the noose in place. Despite attempts by staff to administer cardio
pulmonary resuscitation (CPR), and the attendance of paramedics, he was
pronounced dead shortly after 9.30am.
I offer my sincere sympathy and condolences to the man’s family and friends for their
loss. I must also apologise for the delay in completing this report.
The investigation was carried out on my behalf by two of my investigators. A clinical
review of the man’s healthcare at HMP Bullingdon was conducted by the Oxfordshire
Primary Care Trust (PCT) Clinical Governance Lead on behalf of Oxfordshire
Primary Care Trust. I am most grateful to the clinical reviewer for his review.
I would also like to thank the Governor and staff of Bullingdon for their co-operation
and assistance. Particular thanks go to the liaison officer for her help throughout the
investigation process. I would also like to thank the Lead for sex offender, cognitive
and motivational programmes for the Prison Service to whom my investigator also
spoke in order to gain a better understanding of the Sex Offender Treatment
Programme (SOTP).
The man had arrived at Bullingdon from HMP Leyhill as a category D prisoner to
complete some outstanding work on an SOTP which had been identified at his
parole hearing as a necessary condition for his release. In total, he had been at
HMP Bullingdon for approximately 13 months before his death. Despite having
completed the SOTP in approximately eight months, the man was waiting to be
assessed at the end of the programme. This meant that he was unable to return to
open conditions at Leyhill. As the delay in his transfer continued, so did his
frustration. On 12 February 2008, an Assessment, Care in Custody and Teamwork
(ACCT) document was opened after the man said he had tried to hang himself
because of this frustration.
Six weeks later, on the day before his death, the man received feedback from the
prison psychologist in respect of the SOTP work he had undertaken. Soon
afterwards, he telephoned his sister and expressed concern about what he had been
told.
I make eight recommendations in this report, including five derived from the clinical
review (the clinical reviewer makes three additional recommendations). Two of my
recommendations are national and directed at the Prison Service (they relate to the
management of prisoners transferred temporarily between establishments to
complete the SOTP and the support offered to them).
I also note that following the man’s death, the hot debrief highlighted areas of
concern and that the Governor immediately put in place an action plan to review and
rectify the relevant prison procedures. I have been particularly disappointed to learn
that the officer who discovered the man had not been issued with an anti-ligature
knife, despite a Prison Service-wide instruction to that effect. This resulted in a short
delay before the ligature was removed.
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SOTP assessments are mainstream, day-to-day business for the assessor. (I mean
this in no sense disrespectfully or to suggest that they are conducted other than
professionally and sensitively, but as a simple statement of fact.) However, for the
prisoner involved such an assessment is a critical (and frequently stressful) event. I
will share my report with the Lead for sex offender, cognitive and motivational
programmes for the Prison Service so she can consider the learning for Prison
Service staff who conduct SOTP assessments and those who commission risk
assessments externally.
Given the timing of events, there must remain some doubt as to whether the man
intended to take his own life or had hoped to be discovered.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2009
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CONTENTS
Summary 5
The Investigation Process 7
Background
HMP Bullingdon 9
Key Findings
Prior to the man arriving at HMP Bullingdon 12
The man’s transfer to HMP Bullingdon 12
Events on the day before the man’s death 20
Events on the morning of the day the man died 22
After the man’s death 24
Post Mortem 26
Issues Raised in the Investigation 28
Conclusion 33
Recommendations 34
Annexes
1. Clinical Review
2. Parole Board hearing outcome (June 2006)
3. Sex Offender Treatment Programme post programme review (November 2007)
4. Structured Assessment of Risk and Need Assessment
Interview Transcripts
Documents considered during investigation
1. Inmate medical records
2. Wing history sheet
3. Cell Sharing Risk Assessment
4. First Reception Heath screen document
5. ACCT document
6. Post mortem report
7. Death in custody contingency plans
8. Prison incident log
9. Staff incident statements
10. Governor’s Hot Debrief meeting note
11. Parole Board documentation
12. E-mail correspondence regarding transfer from Bullingdon
13. Psychology notes
14. Telephone conversation transcript between the man and his sister
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SUMMARY
The man was convicted of rape and murder in 1993 and sentenced to life
imprisonment. He had progressed through the prison system, and had reached
category D status and open conditions at HMP Leyhill. During this time he had
undertaken a number of courses, including the Sex Offender Treatment Programme
(SOTP), to address his offending behaviour. He had also been released on
temporary licence (ROTL) on various occasions.
Following a Parole Board hearing, mid February 2007, the man transferred back to
HMP Bullingdon, a category B closed prison, where he occupied a single cell. The
Board had decided that he should undertake further intensive work on part of the
SOTP that he had not yet completed before consideration could be given to his
release. Prior to arriving at Bullingdon, the man also spent a short time at HMP
Shepton Mallet.
The man completed the SOTP programme in November 2007 and waited for news
of when he would return to open conditions at Leyhill, via Shepton Mallet. (This
route was necessary as, following completion of the SOTP, the man had to undergo
a penile plethysmograph test (PPG, a measurement of sexual arousal patterns that
can indicate whether an individual still has difficulty managing offence-related sexual
thoughts). Shepton Mallet has the facilities to conduct this test.)
However, Shepton Mallet could not accept the man back because of population
pressures and refurbishment work that was being carried out. This caused a delay
in the man’s transfer. He became frustrated and depressed and admitted to staff
that he had tried hang himself with shoelaces on the night of 11/12 February 2008.
An ACCT document was immediately opened and support was offered to him.
On 14 February, the man was seen by a psychologist who was commissioned by the
prison to conduct a routine assessment interview following the completion of his
SOTP. This session lasted approximately two hours.
The ACCT document was subsequently closed on 18 February as the man’s mood
had improved. No issues were raised at the post closure review of the ACCT held
on 27 February.
The man was then seen again by the psychologist on the morning of the day before
his death. The purpose of the meeting was for the psychologist to provide feedback
on the results of the assessment interview in February. The feedback would then
form the basis of a report surrounding his sexual offending called a ‘Structured
Assessment of Risk and Need’ (SARN) report. The psychologist explained his
findings, detailed the progress the man had made and identified further work that he
believed the man still needed to complete. Their meeting had ended just as the
prison lunchtime was to begin and the man was escorted back to his cell. Soon
afterwards, the man approached an officer on the wing and asked if it was possible
to see the psychologist again that afternoon. A telephone call was made to the
SOTP unit, but the psychologist had already left the prison.
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Later that afternoon, the man telephoned his sister. He said he was frustrated, and
believed that the feedback he had received from the psychologist was negative. He
thought that this would have a detrimental impact on his return to open prison
conditions, and ultimately his release from custody. He said he felt lonely at
Bullingdon and had no support there. The conversation ended with the man
becoming upset.
The following morning, the man collected his breakfast shortly after 8.45am. An
officer on the wing commenced the morning accommodation fabric checks (AFC) at
around 9.45am, and saw the man on the wing landing. About 15 minutes later, the
same officer arrived to check the man’s cell. He went into the cell and found the
man hanging from the window. Staff and paramedics attempted to resuscitate him,
but sadly they were unsuccessful.
This is the third apparently self-inflicted death to have occurred at Bullingdon since
April 2004 when I began investigating all deaths in prison custody. The
circumstances of the two earlier deaths have no direct relevance to the death of the
man.
My report includes eight recommendations.
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THE INVESTIGATION PROCESS
1. My investigator was appointed to lead the investigation into the circumstances
of the man’s death. He opened the investigation in April 2008 when he visited
HMP Bullingdon. He met the Governor, Deputy Governor and representatives
from the Prison Officers’ Association (POA) and the Independent Monitoring
Board (IMB). He was shown around the prison by a governor, Head of
Residence, who appointed an officer as the liaison point for the investigation.
My investigator also spoke with the Clinical Manager.
2. The Oxfordshire Primary Care Trust (PCT) Clinical Governance Lead, was
appointed by the PCT to conduct the clinical review. Although the review was
delayed, I thank the clinical reviewer for the work he has carried out. The
clinical review is annexed to this report.
3. My investigator issued notices inviting staff and prisoners to contact him with
any information they felt might be relevant to the investigation. There was no
response to these notices. However, my investigator conducted several
interviews with staff throughout May and June 2008, accompanied by his
colleague, a fellow investigator.
4. One of my Family Liaison Officers spoke and wrote to the man’s sister, his next
of kin, to invite her involvement in the investigation process. The man’s sister
was able to provide some valuable insights and raised the issues and concerns
listed below. I hope that this report addresses the issues she feels were
troubling the man throughout his time in Bullingdon.
• The man’s sister said that there was a marked change in the man’s mood
once he had been transferred back to closed prison conditions. He was an
outdoor person, and struggled in the physically confined environment at
Bullingdon which he found claustrophobic in comparison to other
establishments. He had described the prison to her as being noisy and like
a school playground. Before this, he had progressed through the prison
system to a point where he appeared more positive and had good contacts
and a support network. He had been told that he would be at Bullingdon for
a much shorter time than it ended up being, and would also be back at
Shepton Mallet before Christmas 2007. The man’s sister believed that this
uncertainty and lack of accurate information had contributed to his
depression.
• When he arrived at Bullingdon, the man stopped his family and friends from
visiting as he did not want to subject them to the formality of prison visits.
The man’s sister had tried to encourage him to let the family visit him as she
felt that the lack of visits might be adding to his problems, but the man had
refused. He wanted to protect them from the bad memories associated with
closed conditions in the past.
• The man had also told his sister that an element of the rehabilitation
programme he was undergoing at Bullingdon had caused him to look at his
past and what had caused him to commit his offence. His memories were
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extremely troublesome. His sister described the man as tying himself in
knots, especially as some of the meetings had apparently lasted some two
hours. The man felt this was too long and extremely tiring.
• The man’s sister also believed that the man had received mixed messages
from the psychology unit. On the one hand he was told everything was okay
and that it looked good for the Parole Board. He was then told that he
needed to do more work examining his past and in particular to look at the
death of his parents. Both of the man’s parents had died during his time in
prison. It was over three years since his mother died, yet he was
encouraged to have bereavement counselling which it was suggested
should continue after his release. The man’s sister felt that the man was
reconciled to his parents’ deaths and found them particularly difficult to
discuss. He was being put under pressure to reconsider these feelings.
The man’s sister felt that these sessions had overwhelmed the man and led
to his depression. They had impacted on his state of mind, and exerted too
much pressure on him. She felt these sessions were the “straw that broke
the camel’s back”.
• The man had told his sister that the level of support from staff available at
Shepton Mallet was very different to that at Bullingdon. At Shepton Mallet,
the prison was geared up to working with lifers and the man was
encouraged to be very open and to discuss his feelings no matter how raw
these were. Staff were trained and used to dealing with these kinds of
things. At Bullingdon, the man felt staff were not sure how to tackle things
and therefore could not talk to him in the same way. He could not inflict on
them what he needed to offload. He had kept a journal but was not really
able to discuss his thoughts.
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BACKGROUND
HMP Bullingdon
5. HMP Bullingdon is a modern prison that can accommodate up to 963 prisoners.
There are five wings made up of both single and shared cell accommodation.
The majority of prisoners are category C, although some category B prisoners
are received from the local courts.
6. Bullingdon has a 24-bed inpatients healthcare facility, with clinical care
available at all times. The outpatients facility delivers a daily triage system,
referring prisoners to a doctor as necessary. Medication is also dispensed from
the facility. A General Practitioner is available for prisoners every weekday and
there is an on-call system at weekends and outside normal office hours.
7. In common with other prisons, Bullingdon operates a three tier system of
regime (Basic, Standard and Enhanced) as part of the Incentives and Earned
Privileges (IEP) programme designed to reward and encourage good behaviour
on the part of prisoners.
8. The prison has a range of work, education and training opportunities delivering
key and basic skills, and opportunities for a wide variety of vocational
qualifications. There are also offending behaviour programmes including the
Sex Offender Treatment Programme (SOTP), Enhanced Thinking Skills (ETS)
and Short Duration Drug Programme (SDP).
Her Majesty’s Chief Inspector of Prisons’ report
9. Her Majesty’s Chief Inspector of Prisons carried out an announced inspection
of Bullingdon in January 2008. She found that the prison had faced
considerable change over recent years and had risen to many of the challenges
of its diverse role. Overall, it was performing reasonably well.
10. The Chief Inspector noted, however, that education, work and training were
insufficient to ensure all prisoners were purposely occupied for most of the day.
Sentence planning was inhibited by a backlog of OASys assessments and
there was no custody planning for those spending a short time at the prison.
(OASys - Offender Assessment System - is a standardised process for the
assessment of offenders that has been developed jointly by the National
Probation Service and the Prison Service.)
Independent Monitoring Board report
11. Each prison has an Independent Monitoring Board (IMB), the role of which is to
ensure that prisoners are treated humanely and that there are appropriate and
adequate programmes available to prepare them for their release. The IMB
also report any concerns to the Secretary of State, and produce an annual
report about the establishment.
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12. The most recent IMB report for Bullingdon covers the period from 1 August
2006 to 31 July 2007. It highlighted that, despite the pressures arising from the
high population, the positive improvements previously made both to the regime
and the treatment of prisoners had continued. Determined efforts had been
made to ensure work and education opportunities for prisoners, although the
large number of prisoners held meant that there was insufficient work or
education for all. (This particularly applied to the sex offender prisoners held on
Edgcott Unit, where the man was located.) The IMB also raised concern that
the prison should ensure that prisoners transferred from other establishments
for the Sex Offender Treatment Programme (SOTP) were suitable for the
programme.
Assessment, Care in Custody and Teamwork (ACCT)
13. ACCT has been introduced at all prisons as a documented process to monitor
and support prisoners assessed as being at risk of suicide or self harm. (The
previous system was known as the F2052SH procedure.) Once an ACCT is
opened, the prisoner is observed at intervals determined by their perceived
level of risk.
14. Each prisoner is assessed within 24 hours of the ACCT being opened and is
then reviewed again at intervals determined by the relevant circumstances.
The ACCT guidance says that, to be effective, the review should involve the
people who know the person at risk or are involved in their care.
15. Amongst other things, the ACCT guidance states that prisoners should be
cared for in a safe environment. It is for the case review team to decide the
most appropriate place to locate an individual prisoner.
Mental Health In-Reach Team
16. The In-Reach team offers a mental health service for all prisoners who have
enduring mental illnesses. They also treat and support prisoners who have
mental health problems, offering intervention in crisis situations.
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Structured Assessment of Risk and Need - Sexual Offending (SARN)
17. The SARN is the risk report that is written after a sex offender treatment
programme of any kind is completed. The SARN is usually completed by
someone independent and not involved in the treatment of the individual.
Penile Plethysmograph test (PPG)
18. The PPG is used to measure sexual arousal and can indicate whether an
individual still has difficulty managing offence-related sexual interests. A lack of
suitably qualified staff to oversee the test has meant that PPGs are currently
only available at around ten prisons.
Prisoner categorisation
19. All adult male prisoners are classified on reception into prison and put into one
of four security categories based on the likelihood of escape and the risk to the
public if they did escape. The initial category can subsequently be raised or
lowered as the assessment of risk changes. It is not unusual for prisoners to be
moved to a lower category as their release date approaches, and life sentence
prisoners would be expected to spend time in an open prison before they could
be released on life licence. The security categories are:
• category A: prisoners who would be highly dangerous to the public, police or
national security if they were to escape
• category B: prisoners for whom the highest security conditions are not
necessary, but for whom escape needs to be made very difficult
• category C: prisoners who cannot be trusted in open conditions but who are
unlikely to make a determined escape attempt
• category D: open conditions, prisoners who can be trusted not to try and
escape.
Listeners
20. Like other prisons, Bullingdon has prisoners who support their peers as
Listeners. Listeners assist those prisoners who require additional support at
any time in their period in custody. They are provided with training from the
Samaritans. Confidentiality is a critical feature of the Listeners’ role.
Multi-Agency Public Protection Arrangements (MAPPA)
21. Multi-Agency Public Protection Arrangements (MAPPA) support the
assessment and management of the most serious sexual and violent offenders.
The aim of MAPPA is to ensure that a risk management plan drawn up for the
most serious offenders benefits from the information, skills and resources
provided by the individual agencies being co-ordinated through MAPPA.
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KEY FINDINGS
Prior to the man’s arrival at HMP Bullingdon
22. The man was arrested for rape and murder committed on a night in July 1992.
He was convicted and given a life sentence with a 12 year minimum tariff. This
was later increased to 14 years on review, meaning that the man could not be
released any earlier than July 2006.
23. The man worked his way through the prison system over the years, being held
at a number of different establishments. During this time, he also completed a
number of rehabilitation programmes to address his offending behaviour and
gained enhanced level IEP status.
24. In August 2003, the man was transferred to HMP Leyhill (a category D open
prison). This was considered a ‘Career Move’ following a Parole Board review
which identified that the man needed to undertake a booster Sex Offender
Training Programme (SOTP) and further work on alcohol relapse prevention.
At Leyhill, he was allowed the privilege of being released on temporary licence
(ROTL) on a number of occasions for town and weekend home visits whilst he
prepared for release.
25. In June 2006, the man attended his mandatory parole review hearing which
considered his suitability for release. Although the Parole Board agreed that he
had met the test for serving the latter part of his sentence in open conditions,
his release was considered inappropriate at the time because it was identified
that he had not completed an up to date Healthy Sexual Functioning
Programme (HSFP), part of the SOTP. To complete the course, the man had
to return to closed prison conditions. As a result, the man’s parole review was
deferred for 12 months. The Parole Board later informed the man that his new
parole review date would be October 2007.
26. As a consequence of the Parole Board’s decision, the man was transferred to
HMP Shepton Mallet in November 2006. This was also considered to be a
progressive move where he would continue to participate in the various
treatments as directed by the Parole Board.
27. The man remained at Shepton Mallet for around three months before a place
became available on the HSFP at Bullingdon. He transferred again to continue
with his rehabilitation programme in closed conditions.
The man’s transfer to HMP Bullingdon
28. In February 2007, the man was transferred to Bullingdon. He went though the
normal prison reception screening process and did not declare any concerns.
He admitted to making a deliberate attempt at self harm 14 years earlier, but
said he had no current thoughts of harming himself. He said he also suffered
from Post Traumatic Stress Disorder (PTSD) and lower back pain. He was
examined by the nursing staff who took a blood pressure reading and noted his
family medical history. A cell sharing risk assessment was also completed and
12
he was rated as being a low risk in terms of sharing a cell. The man was
offered the use of a telephone to contact family or friends but declined. He was
later located onto Edgcott, the vulnerable prisoners (VP) wing, where he
received his prison induction.
29. At interview with my investigators, the first officer said that she was a lifer
officer and dealt with report writing, compiling dossiers and regularly seeing the
life sentence prisoners to motivate and support them. Early March 2007, the
first officer spoke to the man who had arrived at Bullingdon with another
prisoner (from Leyhill via Shepton Mallet) to do the HSFP. The first officer said
that the lifer team were unaware that the man (and the other prisoner) were
being transferred to Bullingdon until she saw his name appear on the Prison
Service computer system. The man said that he had come to do the HSFP
course and, once he had finished it, would return to Shepton Mallet.
30. The first officer said she received no further information about the man from
Leyhill. However, she offered the man reassurance that his move back to
Leyhill was likely to be sooner rather than later. The man said he was
concerned that, if he remained at Bullingdon until his next parole review
(October 2007), he would not have been able to have had any further periods of
ROTL. This could then have a negative impact for him when he next appeared
in front of the Parole Board.
31. Late in March, the man’s solicitors wrote to the Head of Psychology, to request
a copy of his Structured Assessment of Risk and Need (SARN) sexual
offending report. They were anxious to receive all of the man’s post
programme reviews. Leyhill confirmed that they would accept the man back,
subject to the content of these reports, and approval from the Pre-release
Section of the Ministry of Justice. The solicitors’ letter concluded that the man
was “keen to return to Leyhill in good time before his panel in October next”.
32. At interview, the Head of Psychology told my investigators that the role of the
psychology team was to deliver the treatment to the man, and that they had no
real power to have him transferred. However, she sent an e-mail to Shepton
Mallet requesting information as to whether the man could be transferred back
to them. She told my investigators that Shepton Mallet said the prison was
being refurbished and a transfer was not possible at that time.
33. The first officer told my investigators that she saw the man quite frequently
when she was on the wing. The man appeared pleased to be at Bullingdon
doing the HSFP because he was progressing through his life sentence plan and
towards his release from custody.
34. Early April 2007, staff observed that the man had returned from his SOTP in a
tearful manner, having had a bad session. Although this was noted in the staff
observation book so staff were aware that they should monitor him, there is
nothing noted to suggest that he was offered any specific support.
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35. The man’s solicitors wrote to the Parole Board on 20 April and requested a
deferment of the oral hearing that had been listed for October 2007. This was
granted and a new date of October 2008 was scheduled.
36. Throughout April and May 2007, no concerns were raised about the man’s well
being. He was described by staff as a quiet, respectful individual who had
gained employment in one of the workshops.
37. In July, the man experienced problems in the workshop and was moved to work
on the wing as a painter. He told staff that he had a lot on his mind and had
referred himself to the In-Reach team. A second officer noted the wing history
sheet to say that the man appeared “very unsettled” on the wing at that time.
38. Over the next months, the man settled down. While he was described by staff
as “quiet and a loner,” he maintained contact with his sister and mother in-law
by writing letters. In conversation with the second officer, the man said that he
was happy and the SOTP counselling sessions were going well. Staff
commented that the man was a reliable and hard working prisoner on the wing,
who could be left unsupervised to carry out his tasks. It was noted in his wing
history sheet that his category D and enhanced status level were well deserved.
39. On 11 July, a trainee forensic psychologist and SOTP Treatment Manager
contacted two Community Psychiatric Nurses (CPN), the first nurse (CPN1) and
second nurse (CPN2), requesting an urgent In-Reach team assessment for the
man. The man had had a SOTP session with the trainee forensic psychologist
and SOTP Treatment Manager that day, and she described his behaviour as
intimidating and aggressive. The trainee forensic psychologist and SOTP
Treatment Manager said that she had found it necessary to end their session
prematurely. She felt that the man was anxious and was not coping with the
move from an open to closed prison or with the intensive work she was
undertaking with him.
40. The man was remorseful after the incident with the trainee forensic
psychologist and SOTP Treatment Manager and asked to be referred for further
counselling sessions. The referral was immediately acted upon by the prison.
The prison counsellor attended Bullingdon on Thursday mornings to see
prisoners and she began counselling sessions with the man.
41. The Head of Psychology told my investigators that the man’s progress was a
“difficult treatment journey”. She said the decision was made to suspend the
man’s SOTP because of the incident that had taken place with the trainee
forensic psychologist and SOTP Treatment Manager. The Head of Psychology
had reviewed video evidence of the session and felt it was the appropriate thing
to do. The trainee forensic psychologist and SOTP Treatment Manager had
also told the Head of Psychology that she felt unable to continue working with
the man. The Head of Psychology therefore made the decision to continue the
man’s therapy with a different therapist and appointed another trained facilitator
within the department.
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42. At the In-Reach referral meeting held late in July 2007, the man’s case was
assessed following the incident with the trainee forensic psychologist and
SOTP Treatment Manager. The meeting concluded that there was “no obvious
role for mental health In-Reach, to be passed on to the prison doctor for
advice.” The prison doctor then assessed the man on 8 August. The doctor did
not believe that the man was suffering from any psychiatric disorder but that the
problems he was experiencing were “part and parcel of the group dynamic
process that when handled properly would be therapeutically beneficial.” It was
concluded that no further action was required.
43. On 9 August, the prison counsellor concluded her counselling sessions with the
man. He had had three in total. She wrote to the therapy facilitator after the
man’s last session, and provided her with an overview of the sessions. She
described the man as very distressed at first but over time he was able to clarify
certain issues. He had talked about his disturbed childhood and mentioned the
breakdown in communication he had had on the course. This was something
he wanted to rectify so he could return to the work he was doing on the SOTP.
44. The man resumed his HSFP with the therapy facilitator mid August 2007. The
therapy facilitator introduced herself to him and explained the aims and content
of the sessions they would have. She said in interview that the man was very
co-operative throughout, and had acknowledged that he needed to focus more
to be able to deal with the tasks on the programme.
45. Over the next few months, the other prisoner who had arrived at Bullingdon
with the man completed his SOTP programme and was returned to Shepton
Mallet.
46. The first officer said that the man had become frustrated with himself, knowing
that he had been close to possibly being released before the incident with the
trainee Forensic Psychologist and SOTP Treatment Manager. He had also
said he had concerns about having to do the PPG assessment when he
returned to Shepton Mallet. Shepton Mallet was apparently the only prison in
the vicinity that could conduct this assessment, as Bullingdon did not have the
facility. The Head of Psychology said that it was usual to have to undertake the
PPG test before and/or after completing the HSFP.
47. The man eventually attended around ten HSFP sessions, each one lasting
approximately one hour and 30 minutes. He concluded his HSFP in early
November 2007. A post programme review was held late in November
attended by the Resettlement Manager, the therapy facilitator (Tutor), the first
officer, the man and, by teleconference, the Case Manager.
48. At the review meeting, the man said that the HSFP was the most intensive
piece of work he had ever done, and it had changed his beliefs about sexual
issues and relationships. He agreed that in the past he had not dealt with his
emotional problems and these had ultimately built up throughout his life. He
also informed the panel that returning back to closed conditions (at Bullingdon)
had been a “massive blow” to him.
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49. The review panel acknowledged that the man had worked hard on the
programme, was motivated and had produced some good work. The therapy
facilitator also agreed that the man now had a better understanding of himself
and the issues surrounding his life. She was still concerned that the three
counselling sessions the man had completed were not sufficient to deal with the
issue of his control over his emotions. Furthermore, the first officer did not feel
that the man had done as well as he could on the programme. The first officer
believed that he should return to open conditions before his parole hearing and
consideration should be given to close supervision on his release.
50. The panel identified that, in order for the man to achieve the objectives of the
course, “further exploration of any remaining deep seated, anger and bitterness
that might be triggered by frustration/rejection” needed to be done. This work
was considered appropriate through individual counselling in open conditions
and on release. That said, the panel also noted that a risk report (based on the
SOTP he had completed) needed be carried out before the man’s Parole Board
hearing in October 2008, and which would be key to their decision about his
release. The Case Manager said that she felt the man had made a definite
step forward and she looked forward to receiving his risk report on which she
would base any further reviews.
51. The Head of Psychology said at interview that the man had completed his
course in November 2007, and as such there was no particular reason for him
to now remain in Bullingdon.
52. At interview with my investigators, the first officer said that the man had felt
disillusioned after he completed the HSFP, which he thought had not gone well.
He was also worried that he might fail his forthcoming PPG test which he was
due to take following completion of the HSFP. The man had been informed he
would do the PPG test at Shepton Mallet. The first officer said the arrangement
had been made by the psychology department and not the lifer team.
53. The first officer said that she contacted Shepton Mallet to establish whether the
man could be transferred out of Bullingdon to another establishment where he
could undertake the PPG assessment. However, this proved not to be
possible. My investigators contacted the Prison Service’s Population
Management Section to ask whether any formal transfer requests had been
received for the man during his stay at Bullingdon. None was received.
54. On 18 January 2008, the second officer noted in the man’s wing history sheet
that he remained quiet and continued to work effectively as a wing painter.
Having completed the HSFP, he was now awaiting assessments by other staff.
55. In a conversation with the second officer very late in January, the man
appeared confused as to why he had not yet been transferred back to Shepton
Mallet. The second officer said he hoped to clarify this for the man soon. At
this point, the man had been at Bullingdon for almost a year. The following day,
the man submitted a complaint asking when he would be transferred back to
Shepton Mallet. He received a response to his complaint in writing two days
16
later which said that Shepton Mallet was being refurbished and it was not
possible for him to return there at the present time.
56. At around 9.30am on 12 February 2008, the man spoke with a Senior Officer
(SO) when his cell was unlocked. The man admitted to trying to hang himself
the previous night with shoelaces. He said that he had attempted to take his
life because of frustration at not being transferred out of Bullingdon. He
reiterated that he was a category D prisoner and had now completed his HSFP
which was the reason he had been transferred to Bullingdon. The man said he
was fed up of seeing other prisoners being transferred out before him. He was
aware that the first officer had contacted Shepton Mallet about his status, but
nothing seemed to have come of this. The man also said that he had put in a
healthcare application form three weeks previously, but had not been seen yet.
57. An ACCT document was opened immediately by the first Senior Officer and
these issues were recorded as possible trigger points for the man harming
himself. The Senior Officer noted that the Head of Psychology should contact
the wing prior to issuing the man with his SARN and that he needed support to
get through his depression. He made arrangements for the man to work in the
gardens for the morning to try and take his mind off things.
58. At interview with my investigators, the Head of Psychology confirmed that the
opening of the ACCT document took place after the man’s SOTP treatment
finished. Her team (psychology) did not routinely or actively get involved in
supporting prisoners on ACCT, but she was later made aware of the opening of
the ACCT when the man was seen by a psychologist who was commissioned
to carry out an assessment.
59. An ACCT assessment interview was carried out around an hour after the man
had revealed he had harmed himself. As well as the man, the third officer, a
second Senior Officer (Safer Custody Officer), the first officer and a
representative of the Mental Health In-reach Team attended. The man told the
ACCT review members that he had been feeling depressed recently as it had
been the anniversary of his parents’ deaths as well as being his son’s birthday.
Although he was happy to see a doctor, the man said he did not want to take
any medication. He disclosed that he had previously been diagnosed with
PTSD and a routine referral was made for him to see CPN2.
60. The first officer said she was concerned about the man at the meeting. He was
upset, crying, and had said he was depressed about remaining at Bullingdon.
He also said he had nothing to live for. The ‘Concern and Keep Safe Form’
(which contains details of the issues relating to the man’s risk of harming
himself, and an action plan to address them) was noted by the third officer in
the man’s ACCT document. He added that the man believed that the
rehabilitation programmes he had undertaken, as well as the thought of the
forthcoming PPG test, had all had an effect on him.
61. An action plan was put in place to support the man, under which he was to be
observed and talked to by staff during the morning, afternoon and evening
shifts. During patrol state (when prisoners are locked in their cells), staff were
17
to check on him hourly (at irregular intervals). The man was also offered the
choice of being relocated into a shared cell, but declined. He was also
reminded about access to Listeners at any time should he require it. The man
said that, although his mood was low, he had no intention of taking his own life.
62. An In-Reach referral meeting was held on 13 February, at which the man’s
referral was passed onto CPN2. At this time mental health services in the
prison were undergoing a reorganisation and CPN2 was taking on a new role.
She was to transfer to the forensic team, although would still manage cases
such as the man’s. It was hoped that this transition would not cause a
disruption to the service the In-Reach team offered.
63. The following day (14 February 2008), the man was interviewed by a Chartered
Forensic Psychologist who conducted a SARN assessment interview. At
interview, the Chartered Forensic Psychologist told my investigators that he
was commissioned by the prison as an independent psychologist to report on
individuals who had completed SOTPs. In respect of the man, the Chartered
Forensic Psychologist said that he had had access to his records prior to
meeting him for the first time.
64. He described the man as a prisoner who had spent a large part of his sentence
engaging positively in addressing his offending behaviour. The man had
completed a number of courses at different prisons including the core
programme of the extended SOTP, and was now been required to complete the
HSFP.
65. During their interview, they discussed the man’s offence, his SOTP progress
and other issues. The Chartered Forensic Psychologist concluded that there
were no “obvious problems” with the man. He was aware that the man was on
an open ACCT but the man said he was okay to continue with their session.
The Chartered Forensic Psychologist described the man’s mood as “fine”. The
man himself attributed his recent attempt to harm himself to delays with his
transfer from Bullingdon. During their interview, the Chartered Forensic
Psychologist said that the man gave the impression that he was to be
transferred back to Leyhill.
66. In interview, the Chartered Forensic Psychologist confirmed that the SARN
interview with the man covered all aspects of his life and was a very lengthy
assessment lasting around two hours. He told the man that, once he had
written his assessment up in draft, he would re-visit him in prison and let him
know the results.
67. An ACCT case review was conducted at 11.00am on mid February. Three
members of staff (a third Senior Officer, the third officer and a fourth officer)
attended with the man. The man said he was feeling much better and working
in the garden was going well. He had talked to his sister on the telephone,
which had helped him a great deal, and he no longer wished to harm himself.
He was aware of the support networks that were available to him. As the man’s
mood appeared much better, the ACCT document was closed.
18
68. On 21 February, the man was assessed by a second prison doctor. The doctor
noted that he had been depressed on and off for the last year. He had
completed the HSFP which made him think about himself and his disturbed
childhood. His sleep pattern was good, as was his appetite, but his
concentration and memory were poor. She commented on his diagnosis of
PTSD and attributed this to events in his childhood. Following her interview
with the man, the second doctor discussed the situation with the CPN2 who
informed her that she was due to see him at some point soon.
69. The first officer said she came into contact with the man twice in the period
after the man’s ACCT document was closed. On both occasions, he appeared
a little bit more upbeat. She told the man that Shepton Mallet had no space to
take him back, but they were trying to do a “swap, a one for one” with one of
their prisoners, as soon as possible.
70. In accordance with the ACCT procedures, an ACCT post closure review
meeting was held on 27 February. The third officer noted that the man
appeared more settled than he had been previously. He was working part-time
in the farms and garden and was also a wing cleaner. His mood had improved
and he had had contact with his former mother-in-law and sister by telephone
and letter. The ACCT therefore remained closed.
71. On 4 March, The second officer made a note in the man’s wing history sheet. It
said that the man was a category D prisoner on enhanced IEP and still awaiting
a transfer out to Shepton Mallet. He was described as having had a mixed past
month where his mood was often low, although his work in the garden and
farms appeared to be helping him. The second officer wrote that it was very
frustrating for the man to be in this position.
72. It was noted in the man’s medical records that CPN2 planned to see him on 5,
17 and 18 March. However, due to other patients’ needs, the appointments
had to be postponed. She was unaware that the man’s ACCT document had
been closed.
73. A member of the Independent Monitoring Board visited the lifer team on Arncott
unit on 6 March for a general update on prisoners. The first officer brought the
man’s case to his attention. She explained that the man had come to
Bullingdon to undergo the intensive SOTP. He had completed this and was
now waiting for a move back to Shepton Mallet. The first officer told the
member of the Independent Monitoring Board that the man was distressed by
the delay and admitted to wanting to harm himself whilst on Edgcott unit. The
member of the Independent Monitoring Board later raised the first officer’s
concern with a governor.
74. My investigators found e-mail correspondence that showed that the governor
immediately followed up the first officer’s concern. The correspondence
detailed Bullingdon’s frustration at not being able to transfer the man back to
Shepton Mallet and made reference to him harming himself. Earlier
correspondence had also been received from Shepton Mallet (dated 12
February) which stated that they were unable to take the man as they had
19
reached their maximum population capacity. Shepton Mallet said they hoped
they would be in a position to do a ‘one for one swap’ with Bullingdon very
soon.
75. At interview with my investigators, the first prisoner (a fellow prisoner) said that
he was aware of the man’s frustration at not being returned to open prison
conditions. In a conversation on 26 March, the man had told him that he had a
meeting two days later that he hoped would provide closure for him. The first
prisoner said that he later found out that the meeting the man attended did not
go as well as he had hoped.
Events on The day before the man’s death
76. The Chartered Forensic Psychologist had arranged to speak to the man to
feedback about his assessment on the day before the man’s death. He saw the
man that morning at about 10.30am and proceeded to provide feedback for
approximately one hour.
77. The Chartered Forensic Psychologist told my investigators that, as part of the
process, he had interviewed other prison staff who knew the man quite well.
He found that the man had been in prison for a “long time, was fairly stable,
kept himself to himself, and was considered a model prisoner and easy to
manage”. The Chartered Forensic Psychologist therefore did not envisage any
particular difficulties with delivering the man’s feedback, as he was someone
who had completed a number of programmes in custody already.
78. He was also aware of the incident that had resulted in the man’s SOTP being
postponed for a while and they discussed this. He spoke to the man about his
risk levels, and the circumstances where his risk level might be elevated and
those in which he could maintain a lower level of risk. They then discussed the
Chartered Forensic Psychologist’s recommendations which covered the issues
that had been raised in his assessment and the possible ways the man should
address them.
79. The Chartered Forensic Psychologist’s feedback amounted to nine
recommendations and included some further work which he believed the man
should do. This included a booster SOTP programme, which was normally
completed within 12 months of a prisoner’s release. In his opinion, the man
was a very experienced lifer who knew that things did not move quickly in the
prison environment.
80. The man talked about his past relationships and also that he suffered from
PTSD, something the Chartered Forensic Psychologist was unable to comment
on as he had not seen any records relating to this diagnosis. The man also had
a query about past PPG assessments he had done. He was unclear whether
the assessments conducted showed a decline in deviant fantasies or evidence
of a profile of deviant fantasies. Unfortunately, the Chartered Forensic
Psychologist was unable to locate any of the results in the man’s records to
confirm this.
20
81. The man gave the Chartered Forensic Psychologist the impression that he was
not shy about raising concerns or expressing whether he was happy or not.
The man’s belief was that he would leave Bullingdon once he had completed
the SOTP and return to a category C or D establishment. The Chartered
Forensic Psychologist said that it was not uncommon, in his experience, for
some offenders to do further SOTP work in the community following release.
The Chartered Forensic Psychologist said that he would only recommend the
work the man needed to complete and it would be for the Prison Service to
decide when and where this would be done.
82. The man also told the Chartered Forensic Psychologist that he was to return to
Shepton Mallet to complete the PPG test. He gave no indication that the test
was causing any anxiety, nor did he allude to not receiving adequate support
from prison staff.
83. The Chartered Forensic Psychologist told my investigators that the man
seemed fairly positive when he delivered his SARN assessment feedback. The
man had been open about a number of the issues regarding his previous
relationships and his behaviour. Some issues he agreed with and some he did
not. The man also talked about his outburst with Trainee forensic psychologist
and SOTP Treatment Manager during the SOTP and wanted to make amends
for his behaviour. He said that he was looking forward to moving to Leyhill,
where he had previously enjoyed ROTL.
84. The Chartered Forensic Psychologist said that throughout the meeting the man
raised no particular issues that were causing him concern. When the meeting
ended, the Chartered Forensic Psychologist assured the man that he would
receive the typed report the following week.
85. The Head of Psychology told my investigators that the man’s SARN
assessment showed he had made good progress in understanding his
offending, and had acknowledged many of the risk factors that he needed to
manage if he was to reduce the risk of re-offending in the future. She described
the report as “positive”, along with the fact that it recommended the further work
which was to be undertaken in the community and managed by the Probation
Service.
86. In interview, the fourth Senior Officer said that she would facilitate the
movement of prisoners to and from various programmes they attended within
the prison. When the man had his assessment with The Chartered Forensic
Psychologist, she escorted him to and from the meeting. The man gave no
indication to her that he had any concerns before or after he had met with the
Chartered Forensic Psychologist.
87. A fifth officer told my investigator that in the six months he had worked on
Edgcott wing the man had not caused staff any great concern. He was aware
that the man was participating on a SOTP, and staff with knowledge of this
would generally offer support if needed. However, staff tended not to talk to
prisoners in detail about their SOTP because they themselves would not
necessarily know the full extent of what occurred in their sessions. In general,
21
wing staff were not informed what types of SOTP sessions prisoners were
having.
88. The fifth officer recalled that the man had an interview with the psychologist
from the SOTP unit on the Friday morning. Later in the afternoon, the man
spoke to the fifth officer and said he had some outstanding issues that he
needed to discuss with the psychologist. The fifth officer telephoned the SOTP
unit and was told that the psychologist had already left the prison. They agreed
to arrange an appointment for the man the following week. The information
was relayed to the man who appeared to respond positively. The fifth officer
said that the man appeared to be fine and he reminded him of the services of
the Samaritans telephone line and Listeners. When the fifth officer finished his
duty later that day, he did not report any concerns about the man.
89. The Chartered Forensic Psychologist confirmed to my investigators that he left
the prison early in the afternoon after a session with another prisoner. He was
unaware that the man wanted to see him again and nobody contacted him that
day to tell him. The Head of Psychology confirmed that her department had
received a telephone call from staff on the man’s wing to this effect.
90. Later that day, the man telephoned his sister. The content of this conversation
was not known to the Prison Service at the time. He told her he had seen the
Chartered Forensic Psychologist earlier that day and that a draft of the SARN
report had been completed and fed back to him. The report was to be typed up
the following week when the man would receive it and have the opportunity to
read and respond. He also said that the meeting with the Chartered Forensic
Psychologist was cut short because the lunchtime period had approached and
he had to be returned to his cell. When this occurred, the man felt that they had
not fully concluded their discussions.
91. The man said that one of the issues raised in their meeting was that there
appeared to be no actual report of him ever being assessed as suffering from
PTSD. The Chartered Forensic Psychologist had said the man might need to
see a psychiatrist to talk about this issue. The Chartered Forensic Psychologist
had also told him that a risk assessment would need to be carried out as part of
the Multi Agency Public Protection Arrangements (MAPPA) process and that
the man would have to participate on an anger management course.
92. The man told his sister that he felt as if the goal posts were being moved in
respect of him completing his rehabilitation work. Their conversation continued
in a negative manner with the man telling her, “I’m like dangling in mid air,” and
“I’ve given my all and I can’t give any more.” He said he had made further
disclosures about his past behaviour in the SOTP sessions that he had not
previously taken responsibility for. These in turn had brought to light other
issues during his assessment. The man felt as if he had “dug a hole” for
himself and that this had “set him back”.
93. During the telephone call, the man’s sister said that she felt he was “winding
himself up” and should just wait until the following week when he would receive
the SARN report. She offered to visit him but he declined. The man said that
22
he felt lonely and had no one talk to about what he was going through. He
referred to the wing staff at Bullingdon and said that they were not trained to
deal with individuals on SOTP unlike those in previous establishments he had
been in. He was starting to lose faith with the things staff were telling him. He
was on a wing that had very limited facilities and, as someone who liked to
keep busy, he found this frustrating. The man said he would “grit his teeth” and
just wait for the outcome.
94. The man also said that he had spoken with his solicitor who felt that he should
not have been transferred back to closed prison conditions. The telephone call
to his sister ended with the man saying that he had to go because he was in the
middle of the wing and had started to get upset. My investigator found no
record of any concerns raised about the man for the remainder of the evening.
Events on the morning of the day the man died
95. The fifth officer started duty at 7.30am the next morning. He completed a roll
count and at that time the man was asleep in bed. Other staff soon arrived and
the wing was unlocked for breakfast at around 8.30am. For the remainder of
the morning until lunch time (11.45am -12.20pm), cells were unlocked and
prisoners had a period of association. The fifth officer said he began his
accommodation fabric checks (AFC) (a daily check on the locks, bolts and bars
in each cell) which all prisoners were familiar with.
96. The fifth officer said he observed the man on the landings talking to other
prisoners. The man then went to collect his breakfast pack and return to his
cell. The fifth officer described him as a “very compliant prisoner” who
generally seemed fine.
97. At about 8.45am, whilst checking the cell opposite the man’s, the fifth officer
saw the man on the landing. He continued checking the cells on the other side
of the landing until a prisoner asked him for help to complete a form. The
request took around five minutes and delayed the AFC checks. The fifth officer
resumed the AFC checks and went to six more cells before getting to the man’s
cell, each cell taking about two minutes to be checked.
98. When the fifth officer arrived at the man’s cell, the door was not fully closed. It
was around 15 minutes since he had last seen the man. He entered and
immediately saw the man hanging by a ligature that had been hooked over the
window hinge. The fifth officer said that his first instinct was to use a fish knife
(a tool designed to cut through ligatures) to release the ligature so that cardio
pulmonary resuscitation (CPR) could be carried out. However, as he had not
been issued with a fish knife, he shut the cell door immediately and left to
summon help and assistance from other staff. While heading to the central
office to do so, he used his radio to call a “Code 1” emergency (alerting all staff
to a life threatening situation) which was picked up by the Communications
Office and transmitted throughout the prison on the radio network.
99. At interview with my investigating officers, the fifth Senior Officer said she was
working in the central wing office when the fifth officer came running in and
23
shouted, “the man is dead.” The sixth officer told my investigators that he was
outside the office when he heard the fifth officer shout this. Immediately
afterwards, the emergency message ‘Level 1 Edgcott’ was broadcast over the
radio network. The fifth Senior Officer and the sixth officer immediately
followed the fifth officer to the man’s cell. When the fifth Senior Officer arrived
at the cell and entered, she saw the man hanging from the bed sheet from the
window. The fifth officer supported the man’s body whilst the sixth officer used
his fish knife to cut the ligature. The man was then laid on the floor. The fifth
officer, who was first aid trained, said in interview that the man showed no signs
of life.
100. The fifth Senior Officer said that as the officers ran into the cell, they had
forgotten to “shoot the bolt” so that the cell door would not lock behind them.
They were aware that other prisoners were milling around on association and
unfortunately the door did shut. The fifth Senior Officer began to bang on the
cell door to alert other staff responding to the alarm to their whereabouts as
they approached the cell. They also pressed the cell bell.
101. In the meantime, the fifth and the sixth officers tried to make as much space in
the cell as possible to assess the man. Although he had not had any CPR
refresher training in some time, the sixth officer immediately checked the man
for signs of life. He found no pulse or signs of breathing and so commenced
cardio pulmonary resuscitation (CPR) at the rate of 1:30 (one breath to every
30 compressions). The cell door was very quickly opened by the seventh
officer, Healthcare Officer (HCO) and the first nursing sister entered the cell.
The first Principal Officer was the orderly officer (codenamed Oscar 1, and in
charge of the prison) and he also arrived at the man’s cell. The fifth and the
sixth officers then left the cell. The seventh officer escorted all prisoners who
were on the landings back to their cells.
102. The Health Care Officer and the first nursing sister were in Dalton Unit when
they heard the level one emergency call over their radio at around 9.03am. As
they were very close to Edgcott Unit, they immediately shut the hatch in the
treatment room, picked up all the emergency equipment (such as oxygen, air
masks, a defibrillator and intravenous fluids) and ran through to Edgcott. At
interview with my investigators, the Health Care Officer said they arrived at the
man’s cell within two minutes and were briefed about the situation as soon as
they arrived.
103. The first nursing sister went into the cell first. The man was still fully clothed,
lying on the floor with his head facing the door. The first nursing sister told my
investigators that she could see ligature marks around the man’s neck and he
“looked dead”. She immediately inserted an airway into his mouth. The Health
Care Officer placed the defibrillator pads on the man’s chest and waited for its
instruction. The defibrillator machine indicated that there was no cardiac
activity and CPR should be continued. The Health Care Officer continued with
CPR using the ambu-bag to pass air into the man’s lungs. The first nursing
sister carried out chest compressions. The fifth Senior Officer assisted them by
holding the man’s head.
24
104. The first nurse soon arrived at the man’s cell. At interview with my
investigators, the first nurse said that she was assigned as the first response
nurse for the prison and responded to the emergency call. When she arrived at
the man’s cell, she took over from the first nursing sister and carried out chest
compressions. The first nursing sister asked for the prison doctor to be called.
The prison doctor arrived within two minutes and injected adrenaline into the
man’s arm.
105. The Principal Officer waited outside the cell directing staff as necessary to
conduct various duties and ensuring all prisoners were locked in their cells. He
spoke to the fifth and sixth officers as they left the cell, offering them support.
106. Despite CPR and adrenaline being administered, the man still showed no signs
of life. The defibrillator machine also showed that there was no heart activity.
Healthcare staff continued with CPR, which the fifth Senior Officer said lasted
for around 20 minutes. The ambulance paramedics arrived at approximately
9.30 am. CPR was continued until the man was formally pronounced dead at
9.45 am.
After the man’s death
107. The prison’s death in custody contingency plan was activated immediately and
the necessary agencies, including the police and the IMB, were notified. The
duty care team was available for the staff who had found and attempted to
resuscitate the man. All prisoners who were being monitored on ACCT plans
were reviewed. Arrangements were made for the man’s body to be removed
from the prison.
108. When the man had arrived at Bullingdon, his next of kin had been recorded as
his parents. It was soon discovered that their details were out of date as his
parents had died some time ago. The man’s sister was then contacted.
Because she lived in Doncaster, some considerable distance from Bullingdon,
police local to her were contacted and asked to break the news of the man’s
death. A governor, the Head of Prisoner Community (Head of Residence), later
telephoned the man’s sister. So too did a chaplain, who offered pastoral
support and contact numbers.
109. At 11.30am, the first governor and head of residence chaired a hot debrief
meeting (a meeting held immediately after an emergency has occurred with
those individuals involved) and a number of issues were raised. One was
regarding psychologists’ interviews and SOTP meetings being conducted a
Friday. It was thought that, as there were fewer SOTP staff available over the
weekend, if a prisoner subsequently needed extra support or specific SOTP
information they would generally have to wait until the following Monday.
110. The hot debrief also identified that staff had responded quickly to the
emergency alarm. The seventh officer raised her concern that she felt that
there had been few members of staff available on the landing to return
prisoners to their cells. The eighth officer said that the batteries in the radios on
Blackthorn Unit had not been recharged and so staff were unaware that there
25
was an alarm. A second Principal Officer, who was located on Spur 2 of
Edgcott Unit, said the staff there were also unaware that an alarm had been
raised as none of them had a radio. The Governor raised action points for both
of these issues to be addressed immediately. The Governor also reiterated that
a mandatory decision was already in force that all staff were to carry fish knives
and he would re-issue a notice to staff to this effect immediately.
111. The day after the man’s death, the chaplain, again telephoned the man’s sister
to offer further support and assistance in respect of arranging the man’s funeral.
The governing Governor also wrote a letter of condolence to the man’s family.
The man’s sister subsequently agreed that the chaplain should conduct the
man’s funeral service. Over the next couple of weeks, the chaplain met with
the man’s family to discuss and arrange his funeral. The funeral was held on
17 April and was attended by the prison governor. The prison offered to
contribute to the costs.
112. A memorial service was conducted in the prison which was well attended by
staff and prisoners. The chaplain later wrote to the man’s family to say that a
donation from prisoners had been made to the Shannon Trust. (The Shannon
Trust runs the award-winning peer mentoring Toe to Toe programme which
encourages and supports prisoners who can read to give one-to-one tuition to
those who have literacy problems.)
26
Post Mortem
113. The post mortem report concluded that the cause of the man’s death was
hanging and he was not under the influence of alcohol or any other substance.
27
ISSUES RAISED IN THE INVESTIGATION
Clinical care
114. The clinical review was undertaken by the Governance Lead Oxfordshire PCT,
and is annexed to this report. The clinical reviewer reviewed the man’s medical
records, had access to transcripts of interviews with Bullingdon staff, and
viewed other documentation. The clinical reviewer has made eight
recommendations that will be shared with the PCT for their action. I have
referred to five of these recommendations which seem to me the most
pertinent.
115. The clinical reviewer comments that the standard and completeness of the
man’s clinical records was “just adequate”. Staff failed to update the man’s
summary sheet with details of an attempt of self strangulation in 1994, or his
admission of wanting to harm himself that had resulted in the opening of the
ACCT document in February 2008. The clinical reviewer also comments on the
lack of detailed information given on a referral document completed by trainee
forensic psychologist and SOTP Treatment Manager.
116. Whilst it is unlikely that more detailed and complete records would have
prevented the man from harming himself, the importance of good record
keeping cannot be overstated.
The Head of Healthcare should ensure the standard of clinical record
keeping on EMIS (prison medical computer records) is improved and
every attempt is made to ensure medical records are both summarised on
admission, and kept up to date subsequently. If other contracted services
fail to meet the required standards of documentation, action must be
taken by the contracted service.
117. Upon arrival at Bullingdon, the man underwent the First Reception Health
Screen. This is an opportunity for staff to identify all health concerns that might
need attention while the prisoner is in their care. During the screening, the
man’s blood pressure was recorded as slightly raised. This was not followed
up, even though it was recorded that his father had suffered from ischaemic
heart disease. Again, I share the clinical reviewer’s concerns and agree with
the recommendation made.
The Healthcare Manager must ensure that if the healthcare screening
examination finds an abnormal result it should be followed up
subsequently. The Healthcare Manager needs to ensure staff are suitably
trained, and audits are in place to ensure this happens.
118. The man had also told staff that he had made an application for a healthcare
appointment three weeks prior to the opening of his ACCT document. My
investigator found no record of this. I made a similar recommendation following
the death of a prisoner at Bullingdon in December 2004, and so I am
disappointed that this issue has been raised again.
28
The Healthcare Manager needs to ensure a clear process exists, and is
documented, for the management of healthcare applications, and that this
process is communicated to staff and prisoners.
Opening and closing of the ACCT
119. I agree with the clinical reviewer’s findings that the ACCT was managed with
diligence, care and compassion, and its closure after six days appears to have
been appropriate. The post closure review confirms this. However, CPN2
appears not to have been informed that the ACCT had been closed although
the information might have affected the prioritisation of her case load.
The Governor should remind staff that, when an ACCT is closed,
information should be passed to all staff who have a role in the
management of the patient.
The man’s contact with Mental Health In-Reach team
120. The man’s mental state was of concern and he was referred to the In-Reach
team. It is very evident that CPN2 intended to assess the man but, due to the
reorganisation of the mental health service within the prison, this did not
happen.
121. The clinical reviewer highlights his concern that, during this transitional period,
three clinical posts were unfilled and so the service might not have been
properly managed. This resulted in an inadequate mental health service being
available to the man at the critical time leading up to his death.
122. It is impossible to say whether higher staffing levels might have prevented the
man’s death, especially given that those with whom he did have contact did not
assess his situation as being critical. It remains a possibility, however, that
some risk assessment, or other intervention, during the days leading up to his
death might have made a difference.
The Head of Healthcare should ensure that, should there be a need for
any further reorganisation of its services, a clear transition plan, with
adequate or enhanced staffing, needs to be in place to ensure as much
continuity of care as possible.
The man’s completion of SOTP programme and his failure to transfer from
Bullingdon
123. It is evident from my investigation that the man had worked hard and
progressed through the prison system to a point where he believed his release
from prison would come in October 2008. He expected his transfer from Leyhill
to Bullingdon to be short term. Indeed the man had told his family that he
expected to back at Leyhill by Christmas 2007.
124. At his stage of his sentence, the man might not have expected the SOTP to
have been so intensive. The course certainly raised deep rooted issues with
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him, and ultimately affected his progress. The closed prison surroundings no
doubt added to this. Nonetheless, he completed the SOTP in November 2007,
nearly five months prior to taking his life.
125. It is not clear whether the man had to remain in Bullingdon in order to have the
SARN assessment which did not take place until February 2008.
126. Shepton Mallet confirmed that they were not in a position to accept the man
back into their custody. However, the actual management of this process is a
little clouded. My investigators found little documentation showing that attempts
had been made to arrange a transfer for the man to a different prison. Whether
this would have been possible or not is not known. However, it is disappointing
that the management of the transfer process appears to have been so hit-and-
miss and undocumented. The man’s expectation was clearly that his stay in
Bullingdon would be temporary. This expectation became difficult to manage
because staff themselves they were not fully briefed on the man’s situation
when he arrived, and were unable to provide any definite information to him on
a regular basis.
The Prison Service should ensure that the process of moving to a more
secure prison to complete short treatment programmes is properly
managed and that all parties are kept up to date on progress. Agreement
for the return should be made before the initial transfer.
Delivery of SOTP and feedback
127. One of the issues raised by staff concerned psychologists’ interviews and
SOTP meetings being conducted on a Friday, a day set by the psychology unit.
It was felt by wing staff that that there were fewer SOTP staff available over the
weekend period and, if a prisoner subsequently needed extra support or
information, they generally had to wait until the following Monday.
128. A similar situation applied to the appointment between the Chartered Forensic
Psychologist, as an externally commissioned psychologist, and the man. The
Chartered Forensic Psychologist was only in the prison for a limited time and
was not available for any follow up communication with the man or to speak
with the Head of Psychology.
129. When using external psychologists, it would be useful if their findings were
shared with the prison psychology unit after the initial assessment and before
they are fed back to the prisoner. Although this may have occurred, there is no
record of the information being passed on. Given that the Chartered Forensic
Psychologist made a number of recommendations in respect of further work the
man should complete, it might have prompted staff to ensure that further
support was made available to him after he had received this information from
the Chartered Forensic Psychologist. In turn, this might have assisted in
reducing his fears.
130. Following the man’s death, I am pleased to record that the Head of Psychology
has now agreed that SOTP meetings will no longer be delivered on Fridays.
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This will mean that there will be a greater number of staff available for support
of prisoners undergoing any SOTP activity.
131. With the benefit of hindsight, there are some indicators that additional support
would have been helpful for the man. It was known he found the SOTP course
difficult, an ACCT document had been closed only recently, and he was
frustrated with the delay of his transfer. My investigator found nothing
documented on the man’s files to indicate that a risk assessment had been
undertaken to assess the possible impact that returning to a closed prison could
have on him. There was also nothing describing what arrangements were in
place for offering support outside of his SOTP group and individual sessions. I
think this should form part of the delivery process of such programmes.
The Prison Service should consider the level of additional special support
available to prisoners both during and after completion of SOTP.
Basic life support training
132. The man was an experienced prisoner and aware that staff carry out daily
AFCs. He observed the officer carrying out AFCs on his landing only 15
minutes before he was discovered in his cell. Whether the man’s intention was
to be discovered before any serious harm could occur will never be known.
However, the clinical reviewer highlights that it is important that all staff have
relevant and up to date first aid and CPR training and I reiterate this. I note that
the sixth officer commenced CPR at the rate of 1:30 (one breath to every 30
compressions). I intend no personal criticism of the sixth officer but the current
guidelines advise that the appropriate ratio is two breaths to every 30
compressions.
The Governor should remind staff of the current guidelines on CPR and
assess the levels of first aid and CPR training.
Staff response to the emergency alarm
133. The hot debrief identified that staff had responded quickly to the emergency
alarm. The seventh officer raised her concern that she felt that there were
insufficient staff available on the landing to assist in returning prisoners to their
cells. The eighth officer said that the batteries in the radios on Blackthorn Unit
had not been recharged and so staff there were unaware that there was an
alarm. The second Principal Officer, who was located on Spur 2 of Edgcott
Unit, said the staff were also unaware that an alarm had been raised as none of
them had a radio. The Governor issued action points for both of these issues to
be addressed immediately. I reiterate their importance.
The use of fish knives
134. Following the issue of Prison Service Instruction 32/2006, it became mandatory
with effect from 20 November 2006 for uniformed staff in closed and semi-open
establishments to be provided with and carry on duty their own personal issue
fish knife. It is disappointing to say the least that this had not been fully
31
implemented at Bullingdon at the time of the man’s death. However, I am
pleased to note that, following the hot debrief, the Governor immediately
determined to re-issue a notice to staff to this effect.
Next of kin details
135. The man’s parents were recorded as his next of kin when he arrived at
Bullingdon. His parents had in fact died by this time, which suggests that it was
very unlikely that these details were checked on his arrival. It is imperative that
next of kin details are kept up to date to avoid unnecessary delays in informing
relatives when a death occurs.
136. In a number of my investigations I have found that next of kin information was
inaccurate, and I have recommended establishments introduce a process for
reviewing the details. I am pleased to note that the Governor has already listed
this as an action point following the hot debrief held after the man’s death.
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CONCLUSION
137. The man had worked hard to attain category D status. It was unfortunate,
albeit appropriate, that it was identified that he needed to carry out further
rehabilitation work to address his offending behaviour by completing a course
that was only available in closed conditions. His transfer to Bullingdon was
clearly going to be demanding, and this was evidenced by his outburst during
an SOTP session and his attempt to harm himself.
138. I believe it would have been appropriate had the man received more
personalised support during this process. However, what was also
fundamental to the man’s plight was his uncertainty as to when he would leave
Bullingdon and return to Leyhill. Unfortunately, staff were unable to lessen his
anxiety as they themselves appeared unable to influence his transfer.
139. It is necessarily uncertain whether the man intended to take his own life. He
had seen an officer on the landing and, given his knowledge of prison AFC
checks, would have expected that officer to arrive at his cell, approximately ten
minutes later. Unfortunately, the officer was delayed by around five minutes.
There was a further short delay because the officer in question had not been
issued with a cut-down tool, despite a Service-wide instruction to that effect.
140. The SOTP and other offending behaviour programmes are an important way in
which the Prison Service delivers on its responsibility to reduce reoffending and
protect the public. However, this report can be read in part as an essay in how
these programmes are received by prisoners themselves – especially, perhaps,
when they are long into their sentence.
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RECOMMENDATIONS
1. The Head of Healthcare should ensure the standard of clinical record keeping
on EMIS (prison medical computer records) is improved and every attempt is
made to ensure medical records are both summarised on admission, and kept
up to date subsequently. If other contracted services fail to meet the required
standards of documentation, action must be taken by the contracted service.
The Prison Service have accepted this recommendation.
2. The Healthcare Manager must ensure that if the healthcare screening
examination finds an abnormal result it should be followed up subsequently.
The Healthcare Manager needs to ensure staff are suitably trained, and audits
are in place to ensure this happens.
The Prison Service have partially accepted this recommendation.
3. The Healthcare Manager needs to ensure a clear process exists and is
documented for the management of healthcare applications and that this
process is communicated to staff and prisoners.
The Prison Service have accepted this recommendation.
4. The Governor should remind staff that, when an ACCT is closed, information
should be passed to all staff who have a role in the management of the patient.
The Prison Service have accepted this recommendation.
5. The Head of Healthcare should ensure that, should there be a need for any
further reorganisation of its services, a clear transition plan, with adequate or
enhanced staffing, needs to be in place to ensure as much continuity of care as
possible.
The Prison Service have accepted this recommendation.
6. The Prison Service should ensure that the process of moving to a more secure
prison to complete short treatment programmes is properly managed and that
all parties are kept up to date on progress. Agreement for the return should be
made before the initial transfer.
The Prison Service will respond to this recommendation in due course.
7. The Prison Service should consider the level of additional special support
available to prisoners both during and after completion of SOTP.
The Prison Service will respond to this recommendation in due course.
8. The Governor should remind staff of the current guidelines on CPR and assess
the levels of first aid and CPR training.
The Prison Service have accepted this recommendation.
34