Individual at Bullingdon

Investigation into the circumstances surrounding the death of
a man at HMP Bullingdon in December 2004
Prisons and Probation Ombudsman for England and Wales
June 2005
The man, who had been a remand prisoner at HMP Bullingdon, was found dead in his
cell in December 2004. This is a report into the circumstances surrounding his death.
The loss of any family member is distressing, but especially so whilst they are in
custody, and I offer my sincere condolences to his family and friends.
Two colleagues from my office carried out the investigation. I wish to thank the
Governor of Bullingdon for making the necessary facilities available to my
investigators and for the assistance of the Principal Officer and the Senior Officer.
In the course of the investigation, I asked for a clinical review to be undertaken of the
care and treatment received by the man from HMP Bullingdon. I am most grateful for
the reviewer’s work on my behalf.
This report shows that on 6 December the man made a written application to see a
doctor stating that he was feeling very very depressed. The application, which was
not processed until 9 December, was then filed away pending an appointment
scheduled for 15 December. The person/s dealing with the application did not alert
any concerns to the Medical Officer or wing management.
During the night of 27 December, two days prior to his death, he asked to speak to a
member of the Listener team. The Night Orderly Officer (NOO) facilitated his
request. However, he and the Wing Night Patrol Officer failed to record the request
in the Wing Observation Book which would have alerted wing management and staff
that the man was potentially vulnerable.
I am not satisfied that the man was cared for appropriately and have recommended
that the Area Manager undertakes two separate investigations. There are a significant
number of other recommendations, plus two examples of good practice.
Stephen Shaw CBE June 2005
Prisons and Probation Ombudsman for England and Wales
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Contents
Summary
Investigation Process
HMP Bullingdon
Findings
Recommendations for the Prison Service
Recommendations for the Area Manager
Recommendations for the Prison
Clinical Review Recommendation
Good Practice
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Summary
1. On 20 October 2004, the man was remanded into custody by East Berkshire
Magistrates’ Court on suspicion of making threats to kill and blackmail. His trial
was to be held at Reading Crown Court, on a date to be fixed.
2. Due to the nature of the alleged offence, he was subject to Prison Service Order
4400 (PSO 4400) “Protection from Harassment”. On October 29 he was
interviewed by a Probation Officer and informed that he was subject to PSO 4400
and that his telephone calls and outgoing correspondence would be monitored.
3. He completed an application form to see a doctor, which he had dated 6
December, and on which he wrote that he was very very depressed and not coping
well. The application form was placed into the wing confidential healthcare post
box and then collected by a nurse sometime later. It is unclear to the investigation
team when the application form was collected from the post box by a nurse.
However, it is date stamped as being received into Healthcare on 9 December.
4. During the night of 27 December, he made a request to the night staff to be
allowed to speak with a Listener. The NOO agreed and arrangements were made
for a Listener to be taken to see the man. However, the NOO did not inform
anyone that the man had been unlocked during the night to facilitate a Listener,
nor made an entry in the Wing Observation Book or the man’s history sheet.
5. At 08:30am on 29 December, an officer unlocked the man’s cell door and initially
thought that he was standing watching TV. She then realised that he was
suspended by a ligature from the cell light fitting.
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Investigation Process
6. On 13 January, the investigation team met with the Governor who gave an
overview of the circumstances surrounding the death. A Principal Officer was
appointed as the Liaison Officer. A number of documents were made available to
the investigation team, along with routine reports which the team wished to
examine.
7. The team was taken to the wing where the man lived and viewed the cell where he
had been found. A member of the wing management gave them a full tour of the
wing. The team was later introduced to a member of the local Prison Officers'
Association and a member of the Independent Monitoring Board.
8. A number of staff were identified whom the investigation team wished to
interview and arrangements were made for the interviews to take place. All staff
cooperated fully with the investigation process.
9. The investigation team offered the Governor the opportunity to receive feedback
at the end of each day. Significant findings were fed back immediately.
Additionally, feedback regarding healthcare matters was given to the Clinical
Nurse Manager.
10. On 8 March, one of my Family Liaison Officers (FLOs) and one investigator met
with the man’s sister to discuss the concerns of his family. Following the
meeting, a further visit to the prison was arranged to review the visiting
arrangements and to speak to a member of the family who was also in custody at
the time of the man’s death.
11. A Clinical Review was carried out. The reviewer visited the establishment, along
with my investigator, as she wished to interview a number of nursing staff and the
Clinical Nurse Manager.
12. Following the completion of the work required during the second visit, my FLO
and investigator met with the Governor and informed her of all the investigation
findings and potential recommendations.
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HMP Bullingdon
13. Bullingdon is a male establishment, which opened in April 1992, providing places
for Category C prisoners. Additionally, it performs a local function for convicted
and unconvicted adult males, serving courts in the Oxfordshire and Berkshire
area.
14. The Certified Normal Accommodation is 767, with an Operational Capacity of
963. The population breakdown is:
• Remand Prisoners, 21 percent.
• Convicted Prisoners, 79 percent.
15. In July 2003 an announcement was made that the prison would be Performance
Tested. In March 2004 the prison was successful with its bid and was granted a
five year Service Level Agreement.
16. In January 2005, the prison was re-inspected by the Standards Audit Unit. The
Executive Summary of the inspection said, two years ago, it was clear that this
prison presented the Governor and her staff with many challenges. Measured
against Prison Service Standards, performance could best be described as
mediocre. Security scored 74 percent, Standards 71 percent and efforts to run
self-audit merited an awful 48 percent. We conducted a re-visit of some of the
worst areas of concern a year later, and noted that recovery had commenced.
Following a formal Performance Testing process, the Governor and her Area
Manager signed a Service Level Agreement in April 2004. The establishment has
benefited from the creation of its own Performance Improvement Unit, which also
manages the self-audit process.
It is striking that Bullingdon Prison is a very different establishment today. Staff
and managers appear enthusiastic and committed to improving performance
further. They have already come a long way. Security now warrants a score of
83 percent, up nine percent in two years. Performance has improved even more
when measured against Prison Service Standards baselines, and 83 percent has
also been achieved for Standards, up 12 percent in the same period. Our own
research within Standards Audit Unit suggests a clear correlation between the
quality of self-audit processes and performance levels overall. This trend is
reflected here, as the score for Standards Audit has increased from 48 percent two
years ago to 82 percent today.
An analysis of the scores awarded is useful to give additional context to the
improvements that have been made. We have audited performance against 119
baselines that have been deemed to be critical by the Policy leads, across 22
different Standards selected for an audit of a local prison for adult men. Sixty-
seven baselines are being compiled with fully, and a further 26 only require minor
remedial action. There are 23 areas detailed in the summaries below for Decency
and Health, Operational Effectiveness, Regimes and Safety that do not currently
provide a safe level of assurance that those risks are being managed. There are
only three substantial remedial actions identified, reflecting poorly managed
purposeful activity monitoring and a large backlog of casework in Sentence
6
Planning. On this occasion we have found no instances of risk not being managed
at all.
The baseline for Suicide and Self-Harm was audited and found to be compliant,
bar one, which related to who is listed to offer support.
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Findings
17. In every case of a death in custody the Ombudsman issues Terms of Reference
and notices to prisoners, which he asks the Governor to display in the wings and
areas where prisoners can readily access and read them. The notice informs
prisoners that they can communicate directly, in confidence, with the investigation
team. On the day the investigation commenced, the team was unable to find any
evidence that the notices had been displayed as requested. One notice was found
under several other documents in an office tray, but they were not found in any of
the other accommodation areas. This was pointed out to the Liaison Officer who
made immediate arrangements for new notices to be displayed.
18. Prisoners received into custody at Bullingdon are interviewed in the reception area
by the First Night Officer (FNO) and reception staff. The FNO makes an initial
assessment and identifies any risk to the prisoner and others and ensures basic
information has been passed to the prisoner. The FNO interviewed the man and
did not record any concerns on the Induction Passport form.
19. Additionally, a Cell Sharing Risk Assessment (CSRA) is carried out to identify
any risk to other prisoners who may be required to share the same cell. An officer
carried out the assessment and recorded his assessment findings as low, while a
nurse assessed the risk as medium. As the man had indicated during the reception
procedure that he had been in custody previously, section two, part four, of the
CSRA should have been completed. Additionally, section four was not completed
by the Locating Officer.
The Governor should remind reception staff of the need to complete the Cell
Sharing Risk Assessment accurately. (Repeat finding, Standards and
Security Audit 17 February-7 March 2003 and Revisit Audit 5-9 January
2004.)
20. PSO 4400 “Protection from Harassment” requires the prison to monitor the
telephone calls and all outgoing correspondence of any prisoner identified as
falling within the scope of the Order. The instructions are a mandatory
requirement.
21. On 29 October 2004, the man was interviewed by a Probation Officer and
informed that, due to the nature of his offence, he would be monitored under the
terms of PSO 4400. He signed the document acknowledging that the instruction
had been explained to him. However, the Probation Officer did not sign, date or
print his/her name and therefore the investigation team has been unable to identify
who dealt with the document.
The Governor should remind the prison probation staff to print, sign and
date official documents.
22. The investigation team found that, although the man had signed the compact, the
mandatory public protection requirement to monitor mail and telephone calls was
not actioned until 24 December. This left potential victims vulnerable to further
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harassment. However, the investigation team has found nothing to suggest that he
breached the instructions given to him on 29 October.
The Governor should ensure that the mail and telephone calls of all prisoners
identified as being subject to PSO 4400 is routinely monitored. (Repeat
Recommendation, Standards and Security Audit, 17 February-7 March 2003 and
Revisit Audit 5-9 January 2004.)
23. He was initially allocated to share a cell with another prison and later transferred
to a single cell on B wing (B 2.38 Blackthorn). The man’s cellmate had come to
know the man quite well and described him as a depressed person, who would
pace all night and not sleep well. However, when the man was unlocked, he
would present a normal picture to everyone else in the wing.
24. The man’s cellmate had seen him the day prior to his death and said that he
appeared fine. He said that the man owned a bar in Thailand and had become
concerned about the tsunami. He said the man tried to speak to a wing officer
about the Asian tragedy, but received no help. The investigation team have been
unable to establish whom he tried to discuss this with.
25. The Healthcare Department had recently introduced a confidential application
system into the prison, which allows prisoners to make a request to see medical
staff without wing staff being aware of what the request refers to. Each wing has
a locked post box in which prisoners can place their completed application form
and the box is then emptied by a nurse. The nurse emptying the boxes will take
the application forms to the Healthcare Department for processing, which means
that they are required to read the application form and allocate the prisoner to the
appropriate healthcare service. The nurse issues the prisoner with an
acknowledgement slip, which informs him of the time and date of his
appointment. The nurse informs the wing manager separately of the appointment
time.
The confidential medical application system is good practice.
26. The man completed a confidential medical application form, which he dated 6
December, and posted it into the wing healthcare post box. He requested to see a
doctor and wrote I am feeling very very depressed and finding it hard to mix with
other inmates, and feel at times that they are watching me and my life in danger
and having very little sleep, if any at all. A member of the Healthcare staff
collected the application form and date stamped it as being received on 9
December. An appointment was made for the man to see the doctor on 15
December and the application was filed away. The member of the nursing staff
who dealt with the application form did not follow-up the content of the
application, or alert the wing to the man’s state of mind. A nurse said that she
believed it was her writing on the application form dated 9 December, but has no
recollection of dealing with the form in its entirety. The investigation team has
been unable to identify which member of the nursing staff dealt with the
application, as there is no tracking procedure in place. As the Governor was not
in the prison, the Deputy Governor was informed immediately of the finding. My
investigator met with the Governor at a later date to give feedback of the
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investigation findings to date. The Governor was unaware until then of the
application finding.
The Area Manager should commission a separate investigation to determine
who dealt with the man’s application, why the content was not communicated
to the wing management and why he was not referred or interviewed as a
matter of urgency.
27. The investigation team met with the Clinical Nurse Manager and discussed the
application process. She said that the boxes were emptied on a daily basis and
that one nurse carries out the processing procedure. However, when the
investigation team discussed the application procedure with the nursing staff, the
responses varied with staff saying that the wing boxes were emptied anything
from every other day up to every five days. Nursing staff also said that any one of
the nursing staff can empty the wing box and that the application form is then
placed into a tray in the wing office for processing. It was also said that the forms
remain in the tray until a nurse has sufficient time to process them, which could be
some days after they had been collected. An additional complication with the
system is that no one person has the responsibility for dealing with the forms from
start to finish. Several nurses can deal with sections of the application form,
subject to the amount of spare time available. The investigation team felt that,
whilst the confidential application system is good practice, it was not operating
efficiently, and that the use of nurses to carry out what is essentially an
administration task is a waste of valuable resources.
28. The investigation team discussed the procedures with prisoners to establish what
their expectations were regarding the collection of the application forms. It was
clear that prisoners believed that the boxes were emptied every day.
29. The team discussed this issue with the Clinical Nurse Manager who said that she
had introduced a new system following the man’s death, which would provide a
better service. However, the new system meant that not all boxes would be
emptied every day. The team discussed the new system with nursing staff, who,
in the main, were unaware of the recent changes. Additionally, prisoners had not
been notified of any change. The system is confusing and requires clarifying and
communicating correctly to staff and prisoners.
The PCT, in partnership with the establishment, should review the procedure
for prisoners making confidential applications to the Healthcare Centre and
ensure that a clear audit trail is in place to identify who has processed the
document, action taken, time and date.
The PCT should ensure that prisoners and nursing staff understand the
procedures for making a confidential application.
30. In June 2004, Her Majesty’s Chief Inspector of Prisons for England and Wales
(HMCIP) carried out an unannounced follow-up inspection of Bullingdon. The
report made a recommendation that Healthcare staff should follow-up all patients
who fail to attend healthcare appointments and rebook the appointment if
appropriate.
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31. The Inmate Medical Record (IMR) shows that the man had medical appointments
for 13 and 15 December, both of which he failed to attend. The appointment for
13 December was unrelated to the application that he had made on 9 December.
Despite the recommendation made by the Inspectorate, medical staff did not
follow-up the missed appointments. Had they done so, the missed appointments
and his application to see the doctor would have been re-examined, and it is
therefore possible that someone would have realised the importance of what he
had written and followed up the application. There is no evidence to suggest that
either of the missed appointments were followed up.
32. The investigation team discussed the procedure for missed appointments with
nursing staff. It was clear that, once an application form has been processed and
an appointment made, the form is then kept within the medical record and not
seen by the doctor until the patient arrives at the surgery. If the prisoner fails to
attend the appointment then the medical file is re-filed without any further
examination of the medical notes taking place. This means that the doctor would
not have been aware of the man’s request and his feelings at the time of writing
the application form.
Healthcare staff should follow-up all patients who fail to attend healthcare
appointments and rebook the appointment if appropriate. (Repeat
Recommendation HMCIP June 2004.)
33. My investigation team found that the systems for missed appointments and
application procedures were not robust, and the guidance to nursing staff and
prisoners regarding wing applications was confusing. This requires remedying.
34. Bullingdon has a system where anyone who is considered at risk of suicide or self-
harm is monitored using the F2052SH procedure. F2052SH is a document which
is opened on an individual prisoner and records the concern that a member of staff
has about a prisoner. The concern can be anything from an actual self-harm
attempt to a feeling that someone may harm themselves. It is open to any member
of staff to initiate the document and raise their concerns. Once the document has
been opened, the prisoner will be interviewed and invited to attend a multi-
disciplinary team meeting, whose role it is to understand what has caused the risk
and to create an action plan designed to reduce or eliminate any risk. All prison
staff have received extensive training in suicide and self-harm procedures.
35. The prison has a local Suicide and Self-Harm Prevention Strategy which had been
revised in June 2004 and which follows the guidelines of PSO2700. Under the
heading of “Opening an F2052SH” the policy instructs staff, that in all cases
where a prisoner expresses suicidal thoughts or performs an act of self-harm, an
F2052SH must be raised. The policy statement says, HM Bullingdon Community
Prison recognises that imprisonment can lead to depression, stress and feelings of
isolation. We aim to be alert to the needs of those who find it difficult to cope and
help reduce those feelings as much as possible.
36. The application form that the man raised and his comments should have alerted
the reader to be concerned for his safety, and they should have dealt with the
information as per the suicide and self-harm policy.
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37. The prison has a “Listener Scheme”, which is a system where the Samaritans train
selected prisoners to be the first contact for any prisoner who is feeling vulnerable
and at risk. The scheme is confidential and any prisoner can request to speak to a
Listener at any time of the day or night. Prisoners can access a Listener easily by
speaking to a member of staff, who will then make the arrangements for a trained
Listener to speak to the prisoner concerned. During the hours that prisoners are
locked in their cells, anyone wishing to speak to a Listener can make the request
from the night staff on duty. The NOO has the authority to unlock a Listener and
to escort him to the cell of the prisoner who is requesting assistance. The prison
has nine trained prisoners who operate on a rota system, with the scheme being
overseen and managed by a very enthusiastic Senior Officer. The investigation
team found the Listener scheme and accessing the service to be well publicised.
38. All prisons have a system where official notices and instructions from the
Governor are published to staff by way of “Notices to Staff” (NTS). They are
issued in numerical order, followed by the year of issue. An examination of the
prison Suicide and Self-Harm Strategy identified NTS 87/2003, issued by the
Governor on 18 March 2003 and which referred to Use of Wing Observation
Books. Paragraph three of the notice reminds staff that any prisoner who requests
a Listener or the use of the Samaritans phone who is not on an open F2052SH
must be recorded in the Wing Observation Book. The Wing Senior Officer to
investigate.
39. Operational Instructions, which are similar to the NTS procedure, give
instructions for staff to follow. Operational Instruction 6/2004 “Wing
Observation Book” was issued by the Governor to ensure:
• Appropriate entries are made in the Wing Observation Book.
• Follow-up action is taken and recorded.
• Relevant Standard Audit Baselines for Safer Custody are met.
• Audit trail is available for Standards Audit Unit.
• Wing SOs or I/Cs respond to all entries.
• Residential Principal Officers take direct responsibility for management of
observation books and for appropriate follow-up action that impacts upon
their areas of responsibility.
40. Paragraph 2.1 of the instruction says, there is a clear need to improve upon our
current recording of events and comments made in residential Observation Books
and to ensure that appropriate documentation is completed and followed through
to its conclusion. Paragraph 2.2 says, In general, entries should be made to
ensure staff are fully briefed on residential and prison issues whether this
concerns an individual prisoner, groups, potential problems, tangible problems or
simply “gut feelings” or instinct that staff believe should be brought to the
attention of other members of staff. No matter what type of entry, the reason for
this instruction is to ensure an adequate response is recorded and given.
41. The investigation team could find no evidence to show that the NOO recorded the
unlocking of the Listener or the man in either the NOO Occurrence Book or the
Wing Observation Book. At interview, the NOO was unable to recall unlocking
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the Listener or the man. He did though accept that the Listener’s log entry, which
recorded the request and meeting with the man, was correct. The investigation
team confirmed with the Listener that he had been unlocked by the NOO and
taken to meet the man. As this was only the third night that the NOO had ever
been in charge of the prison, the investigation team was surprised that he said that
he could not recall unlocking the Listener or the man.
42. The investigation team understand from the NOO that he had received no training
as a first line manager. Whether this is the case or not, not recording a significant
event where the night security is broken by unlocking two prisoners and not
following the instructions contained in NTS 87/2003 is a matter of concern.
43. A Senior Officer informed the investigation team that, following the death of the
man, she became aware that he had requested a Listener during the night. She
examined the Wing Observation Book to see if an entry had been made by the
NOO and confirmed that it had not. She said that instructions had previously been
issued to staff regarding the recording of anyone who requested a Listener and as
the NOO had not followed the instructions, she re-issued them. The investigation
team found the Senior Officer to be pro-active and highly dedicated to her role as
Safer Custody Manager. The failure to follow the instruction of NTS 87/2003
requires further investigation. The investigation team informed the Governor of
the finding. She was already aware of this failure from her own internal enquiries.
The Senior Officer should be commended for her work as Safer Custody
Manager.
The Area Manager should commission a separate investigation to determine
why the NOO and wing officer failed to record and notify anyone of the
man’s request for a Listener, thus failing to ensure effective communication
amongst staff.
44. An examination of the Orderly Officer Occurrence Log sheets for 25, 26 and 28
December shows that the documents had not been signed for at key times of the
day.
The Governor should remind the Orderly Officers to sign the Occurrence
Log at the completion of the roll reconciliation periods.
45. The Prison Service requires all establishments to carry out “Desktop Exercises” of
the local contingency plans for dealing with specific incidents. Desktop exercises
simulate a real event and allow the prison management the opportunity to practice
what they would do in dealing with an incident. With the exception of the
contingency plan for hostage incidents, which is tested at least annually and is a
mandatory instruction, the Governor can select any local contingency plan to test.
The Prison Service should consider making the testing of Death in Custody
contingency plans a mandatory annual event.
46. My investigators examined the establishment desktop exercise record for dealing
with a death in custody. It was noted that a recommendation had been made that
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training should be given to the Senior Officers responsible for NOO duties. The
latest exercise report is dated February 2004, with the date for the training to be
completed as April 2004. There is no record of the recommended training having
taken place. This requires remedying.
The Governor should carry out the recommended contingency plan training
for Night Orderly Officers, as identified on 24 February 2004, as a matter of
priority.
47. Prison Officers are required to carry out roll checks at specific times of the day.
Roll checks require the officer to physically see the prisoner in his cell and submit
the total to the Wing Manager, who in turn informs the Orderly Officer. The
Orderly Officer collates the full prison roll count and reconciles the prison roll.
48. At approximately 8pm on 28 December, an officer carried out a roll check and
confirmed that all prisoners were in their cells and that the cell doors were
securely locked. He had checked the cell occupied by the man, but did not recall
seeing anything unusual.
49. At 8:30pm on 28 December, an officer commenced duty as the Night Patrol
Officer on B wing. He received a short brief from the officer who had carried out
the previous roll check and then carried out a further roll check. The roll check is
further confirmation that the cell doors are locked and secure and that the prisoner
is inside the cell. This means that the officer is required to see the prisoner. The
total roll count is passed to the NOO for reconciliation and, once the prison roll
has been accounted for, the staff who have been on duty during the day are
allowed to leave the prison. A further roll check is not then carried out until
approximately 5:30am the following morning.
50. During the night the Night Patrol Officers are required to visit all areas of the
wing that they have responsibility for and to activate “Pegging Buttons”, which
are placed at strategic points around the wing. Pegging buttons, once pressed,
record that the officer has visited the area and the computer system records the
action. At the beginning of the night duty, the officer is given a pre-determined
route to follow which varies each night.
51. At approximately 5:20am on 29 December, the Night Patrol Officer began a full
roll check of B wing, which he completed by 6am. He then telephoned the NOO
with the wing roll. He said that if he is unable to see the prisoner and the
television is not on, he will switch the light on briefly to observe the cell. He
could not recall anything unusual when he checked the man’s cell. He thought
that he might have been in bed, but was unsure. He confirmed at interview that he
had observed every prisoner that morning.
52. The Night Patrol Officer explained that an Officer Support Grade (OSG) was
normally responsible for the wing night duties, but that he had been asked to cover
the duty. He said that he had worked on the wing for the previous two nights, but
that no one had asked him if he had carried out wing night duties previously. He
was asked if he had any written night instructions. He said, I only know that there
was a folder for each wing. I wasn’t exactly sure what was in it or that it was
14
required of me to read it. It’s not a duty I’ve ever done before. He said that no
one had given him any guidance in what to do on nights.
The Governor should review the night instructions and ensure that all staff
on duty at night are competent to undertake the duty.
The Governor should ensure that the Night Orderly Officer confirms that all
night patrol staff understand their role.
53. At approximately 7:30am on 29 December, the Senior Officer assisted the wing
staff in counting the wing roll. She recalled beginning on landing two and that the
man’s cell was the first one that she looked into. She said that, when she opened
the door observation flap she could see that his bed was unmade and that he was
not in bed. She could see a figure standing in front of the cell window, fully
clothed, with his back towards the door. She believed that he was looking through
the window. She closed the observation flap and continued the roll count.
54. Prior to unlocking the wing following the morning roll check, officers at
Bullingdon carry out a procedure known as accommodation fabric check (AFC).
This means that they enter each cell and check the physical security of the cell
fabric, the door locks and the window bars/grills. Once the Wing Manager is
satisfied that the security of the cells has not been tampered with, the wing is
unlocked to allow prisoners out of the cells and into the communal area of the
wing.
55. At approximately 8am, an officer entered the man’s cell and observed that he was
standing. She thought that he was watching the television and was about to speak
to him when she saw that he was hanging. She immediately shouted for
assistance. Two prisoners were the first to arrive and they assisted the officer by
lifting the man and removing the ligature and then placing him on the bed. One of
the prisoners lifted him, while the other removed the ligature from around the cell
light fitting.
The Governor should write to the two prisoners and place on record the
assistance they gave to prison staff.
56. The officer who found the man explained that she had not lifted the observation
flap to check where he was but had gone straight in to the cell. She said, I still
can’t figure out how somebody can hang themselves stood up, but he was stood up
and to me he was just stood there and it wasn’t until I went to speak to him and
realised he wasn’t just stood there. She said that his back was facing her when
she entered the cell. She went on to say, he was towards the window and he was
sort of stood so he was sort of more back to me than he was forwards. She
confirmed that his feet were on the ground.
57. The investigation team is satisfied that the view the officer would have seen
through the observation glass at that time of the morning would be that of a
silhouetted person who appeared to be standing. As the check requires the officer
to look into the cell and identify that the cell is occupied, and not necessarily to
communicate with the prisoner, it is understandable that the officer would have
15
accepted that the prisoner was in the cell and therefore moved on to the next cell.
It would not be reasonable to have expected the officer to carry out a check other
than to confirm occupation of the cell.
58. Another officer entered the cell almost immediately after the two prisoners and he
attempted to carry out CPR. However, he was unable to open the man’s mouth.
One of the officers described him as being cold to the touch. Shortly after, the
Principal Officer and two Staff Nurses arrived at the cell.
59. One of the Staff Nurses checked for a pulse. She said that she did not recall the
man being cold and thought that he was warm. She said that they were unable to
administer oxygen, as they were unable to open his mouth to insert an airway.
60. The Clinical Reviewer examined the man’s IMR in order to complete the Clinical
Review. The IMR entry shows that he appeared not to be breathing and that no
pulse or respiratory output was detected. He had a deep mark around his neck,
consistent with a ligature having been used. He also had extreme swelling around
his face and neck. An attempt was made to place a Gadel airway in his mouth, but
his mouth and tongue were excessively swollen. Two more Staff Nurses along
with the Sister joined the medical team.
61. Three Staff Nurses and the Sister made a joint decision not to continue any further
with resuscitation attempts. The prison doctor attended the cell and noted that the
man was not breathing, there was no heart sound, or neck pulse and no breathing
sounds. He noted that his face and neck were puffy. He examined the trunk and
feet. He did not notice statis down his feet. He pronounced death at 8:48am.
62. The prison doctor said at interview, I was surprised that when I arrived there,
there was no team doing CPR, yes, and I wasn’t happy to see the body on the bed.
He was asked where the body should have been. He said, it should have been on
the floor or hard surface and CPR should have been in process.
The Governor and PCT should review the actions to be taken by staff on
discovering an unconscious person. Additionally, all staff should be
reminded that CPR should preferably be carried out on a firm surface.
63. Paramedics arrived at the cell at 9:04am and left at 9:22am. The police arrived at
10:01am, followed by a Scene of Crime Officer (SOCO) at 10:55am. The SOCO
left at 11:25am. At 12:20pm, the man’s body was removed by the undertakers.
64. Amongst the cell contents, a police officer found a letter written by the man on
prison paper. The note explains his feelings at the time.
65. On 30 December the Consultant Forensic Pathologist carried out a post-mortem
on the man at John Radcliff II Hospital Mortuary. The doctor gave the cause of
death as hanging. Additionally, paragraph four of the report concludes: The
presence of multiple petechial haemorrhages and hypostatic discolouration in the
lower legs and feet indicate that the body had been suspended for a period of
some hours prior to discovery.
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66. A recent investigation at HMP Lowdham Grange has noted that prisoners there
are routinely observed at least three times during the night-time lock up period
and I have identified this as good practice. Their approach to prisoner observation
is worthy of further examination by the Prison Service.
The Prison Service should review night-time observation procedures in light
of the practice at Lowdham Grange.
67. The Clinical Reviewer examined the level of compliance and summarised:
• In my opinion the standards for Health Services for prisoners and clinical
needs were not fully met by the prison.
• Evidence would suggest that in spite of documentation to suggest that the
prisoner was depressed and anxious, there were no appropriate referrals made
to specialists such as mental health inreach, psychiatry or psychology.
• Evidence would suggest that the appointment system, which was in place at
the time of the incident, was unsatisfactory.
• Evidence would suggest that in spite of the man stating that he was anxious,
depressed and not sleeping, there was no active 2052SH form opened.
• Evidence would suggest that in spite of a new protocol “Healthcare
Application Process” which was devised after this unfortunate event, many of
the members of staff interviewed were unaware of its existence or indeed
where the policy/protocol folder was kept.
• Evidence would suggest that those members of staff who are detailed to carry
out treatments on B wing are unaware that they are also responsible for the
emptying of the application boxes, or of how frequently.
68. The Clinical Review makes several recommendations for the prison, all of which I
support.
69. All prisons are required to supply “Anti Ligature” scissors/knives for use by staff
in the event of a prisoner hanging. Some prison establishments supply staff with
fish knives, which are designed to allow the user to get underneath the ligature.
The knife has a concealed blade and the action of pushing the knife forward, cuts
the ligature.
70. My investigation team asked a number staff if they were issued with personal anti
ligature equipment. Whilst it was evident that some officers had their own fish
knife, it was not a requirement for them to carry one as part of their day-to-day
equipment. They were also asked if they knew where to find the wing anti
ligature scissors. A number of officers said that they were not aware where they
would find the equipment. This is worrying.
71. The investigation team discussed this finding with the Senior Officer a member of
the B wing management. She had worked at other establishments and was aware
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that cut down kits were available in the wings, but that Bullingdon did not have
them. Whilst she was aware of the lack of equipment, she said that she had not
raised it with the Suicide and Self-Harm team.
72. All prisons have a “Personal Officer Scheme” in operation. At Bullingdon, this
means that every prisoner is allocated two officers who act as Personal Officers,
and who have responsibility for writing reports, etc. on their particular group of
prisoners. Prisoners are informed as to who their Personal Officers are and are
able to contact them via the wing office.
73. The investigation team was unable to identify any officer who knew the man well
enough to have noticed any change in his appearance, behaviour, etc. and asked
staff to explain the Personal Officer scheme on B wing. The investigation team
was informed that it did not operate on the wing, as the turnover of prisoners made
it impossible to administer.
The Governor should introduce the Personal Officer scheme into B wing.
74. The Governor made available to the investigator a letter dated 13 January 2005
from the Head of Facilities at the prison. He informed the Governor that,
following a previous death in the Segregation Unit and an attempted suicide in the
Healthcare Centre (both incidents using the light fitting as a ligature point), a
decision was taken to seal the edge of the fittings with a hard setting compound.
The decision was taken to carry out the preventative work in the Segregation Unit
and Healthcare Centre only, as it was considered impracticable to carry out the
work to the rest of the establishment, as it would restrict the ability to carry out
maintenance. My investigator wrote to the Governor and asked if a risk
assessment had been carried out before the decision had been taken not to carry
out the work on the remainder of the establishment. The Governor said that there
was no requirement to carry out a risk assessment following a death in custody.
This was the third known occasion in the prison where the in cell light fitting had
been used as a ligature point. As a known cure to the problem had been identified,
it is difficult to understand why the ligature point was allowed to remain without
the full consideration of a risk assessment.
The Governor should re-examine the decision not to seal the light fittings in
the residential units.
The Prison Service should consider issuing fresh advice to establishments on
the sealing of all light fittings and reduction of potential ligature points.
75. As Ombudsman, I try hard to involve the family of the deceased person in my
investigations. I have staff who work as FLOs and they work closely with the
investigators and family and try to answer any concerns the family may have
regarding the care and treatment of their relative. A part of that process is for the
FLO and investigator to meet with the family during the investigation.
76. On 8 March the FLO and investigator met with the man’s sister at her home in
Hampshire. My staff were made very welcome and I am most grateful to her.
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77. She raised a number of points in relation to the man’s death. She also spoke about
issues at Bullingdon which had made visiting her brother difficult. One of the
main questions was how could the officer not have seen him hanging. I hope this
report explains this matter fully.
78. The man’s sister explained that she had experienced difficulties in arranging to
visit him. She said that the difficulty began when trying to book a visit and that it
could take several hours to get through on the telephone. She also said that, once
the telephone had been answered, the staff would not allow a visit to be booked
more than seven days in advance. As she was only able to visit at the weekend
due to work commitments, she found that once the forthcoming weekend dates
were full staff would not allow her to book the following weekend.
79. An additional area of difficulty was when she wanted to hand in a suit for her
brother’s court appearance. The visits staff informed her that she would have to
post it in, and that he would have to make an application to have a suit sent in.
She was also informed that he had to request the correct colour, otherwise he
might not be allowed to have it if a different colour of suit was sent in. She
overheard an officer informing other visitors that prisoners were not allowed to
have anything black and assumed that it was because officers wore black uniform.
80. The investigation team discussed the visiting difficulties with the Governor. I
understand she plans a review of the procedures to reduce the bureaucracy. I
welcome this and on this basis have not made a further recommendation.
81. The man’s sister had sent in a new pair of trainers at the beginning of December
which he did not receive and which were returned to her unused. The trainers
were still in the original box and had been placed in a brown sack. She was asked
how his clothing had been returned to her. She said that the clothing was in a
large brown sack and had not been washed. This was insensitive and not in
keeping with PSO 2710.
82. A member of the prison Senior Management Team was asked if the establishment
had contributed towards the cost of the man’s funeral. The investigation team was
informed that the prison had made a contribution. However, when the
investigation team met with the man’s sister, she was asked if the prison had
contributed towards the funeral costs and she said that they had not. This was
raised with the Governor by the investigator and also by the FLO with the Deputy
Governor, who sought advice from Prison Service Headquarters. Following their
advice, the prison agreed to contribute towards the funeral costs. The
investigation team understand that the prison has since paid the full cost of the
funeral.
The Governor should remind senior colleagues of the advice given in PSO
2710 “Follow-up to Deaths in Custody”.
83. I am satisfied that the care and treatment at the time the man was discovered in his
cell was appropriate. I remain concerned that important information relating to
his state of mind was not dealt with appropriately by prison staff and that he was
not considered as being at risk.
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84. The investigation team understands that the original charges of threats to kill had
been reduced to harassment. In January 2005 the case against the man was heard
in his absence and he was found not guilty.
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Recommendations for the Prison Service
1. The Prison Service should consider making the testing of Death in
Custody contingency plans a mandatory annual event.
2. The Prison Service should review night-time observation procedures in
light of the practice at Lowdham Grange.
3. The Prison Service should consider issuing fresh advice to establishments
on the sealing of all light fittings and reduction of potential ligature points.
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Recommendations for the Area Manager.
1. The Area Manager should commission a separate investigation to determine who
dealt with the man’s application, why the content was not communicated to the
wing management and why he was not referred or interviewed as a matter of
urgency.
2. The Area Manager should commission a separate investigation to determine why
the Night Orderly Officer and wing officer failed to record the request for a
Listener, thus failing to ensure effective communication amongst staff.
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Recommendations for the Prison
1. The Governor should remind reception staff of the need to complete the Cell
Sharing Risk Assessment accurately. (Repeat finding, Standards and Security
Audit 17 February- 7 March 2003 & 5-9 January 2004.)
2. The Governor should remind the prison probation staff to print, sign and date
official documents.
3. The Governor should ensure that the mail and telephone calls of all prisoners
identified as being subject to PSO 4400 are routinely monitored. (Repeat
Recommendation, Standards and Security Audit, 17 February-7 March 2003
& Revisit Audit 5-9 January 2004.)
4. The PCT, in partnership with the establishment, should review the procedure
for prisoners making confidential applications to the Healthcare Centre and
ensure that a clear audit trail is in place to identify who has processed the
document, action taken, time and date.
5. The PCT should ensure that prisoners and nursing staff understand the
procedures for making a confidential application.
6. Healthcare staff should follow-up all patients who fail to attend healthcare
appointments and rebook the appointment if appropriate. (Repeat
Recommendation HMCIOP June 2004).
7. The Governor should remind the Orderly Officers to sign the Occurrence Log
at the completion of the roll reconciliation periods.
8. The Governor should carry out the recommended contingency plan training
for Night Orderly Officers as identified on 24 February 2004, as a matter of
priority.
9. The Governor should review the night instructions and ensure that all staff on
duty at night are competent to undertake the duty.
10. The Governor should ensure that the Night Orderly Officer confirms that all
night patrol staff understand their role.
11. The Governor should write to the two prisoners who helped after the man was
found in his cell and place on record the assistance they gave to prison staff.
12. The Governor and PCT should review the actions to be taken by staff on
discovering an unconscious person. Additionally all staff should be reminded
that CPR should preferably be carried out on a firm surface.
13. The Governor should introduce the Personal Officer scheme into B wing.
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14. The Governor should re-examine the decision not to seal the light fittings in
the residential units.
15. The Governor should remind senior colleagues of the advice given in PSO
2710 “Follow-up to Deaths in Custody”.
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Clinical Review Recommendations for the prison
1. The protocol and procedural policy should be adhered to with regards to the
GP referral system.
2. All members of staff should be informed of any new protocol and policy
documents which have been introduced.
3. All staff should be informed of where the folder containing policy and
procedures is located.
4. Consider detailing a member of the administration staff to collect applications
from the wings daily and pass promptly to the identified clinician to make the
appointments.
5. A member of the clinical team should be identified to assume the
responsibility to make appropriate referrals and appointments on receipt of
medical applications.
6. A system should be adopted in order to address patients' concerns and
anxieties.
7. Members of staff should consider opening F2052SH forms on patients who
state that they have concerns for their safety, claim to be depressed or anxious,
thus raising the need to increase the levels of observation and alerting all
members of staff of the patients vulnerability.
8. The Governor should ensure that a clear auditable tracking system is in place
to identify which member of staff has dealt with any application form from
start to finish. The tracking system should require the member of staff to
print, sign and date the documents and to note any actions and outcomes.
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Good Practice
1. The confidential medical application system is good practice.
2. The Senior Officer should be commended for her work as Safer Custody
Manager
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