Individual at Bullingdon

INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE DEATH OF A MAN AT
HMP BULLINGDON IN AUGUST 2004
Report by the Prisons and Probation Ombudsman for
England and Wales
March 2005
This is the report of an investigation into the circumstances of the death of a
man in HMP Bullingdon in August 2004.
I offer my sincere sympathy and condolences to his family who I know were
close to him.
A colleague in the Ombudsman’s office carried out the investigation on my
behalf and another colleague conducted the liaison with the man’s family.
Another officer from my office and an officer from the area office, assisted in
the early stages of the investigation. My deputy ombudsman carried out the
clinical review.
I wish to extend my thanks to staff at Bullingdon for their help and cooperation
during the investigation. I make a number of recommendations relating to
both to the series of events immediately predating this man’s death and to the
contact the prison had with his family. Both the prison and solicitors
representing him have made a number of helpful comments on the draft
report. In light of this, some amendments have been made to the final report.
The man died while in Bullingdon’s segregation unit and his is one of a
worrying number of deaths of segregated prisoners I am investigating. At
Bullingdon, not all the appropriate safeguards were being followed. However,
even if they had been, the death of this man – at the painfully young age of 23
– is a reminder of the vulnerability of all prisoners when subject to a
segregation regime.
Stephen Shaw
Prisons and Probation Ombudsman
March 2005
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Contents
Summary
HMP Bullingdon
Events leading to the man’s death
Issues considered during the investigation
Relevant recommendations from previous deaths at HMP Bullingdon
Findings and conclusions
Recommendations
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Summary
The man was 23 when he died. He had started using drugs in his teenage
years and had become a chaotic poly-drug misuser.
The man was received into HMP Bullingdon on 13 August 2004. He was due
back in court on 2 September for sentencing. He had been in Bullingdon on a
number of previous occasions.
Upon reception, he was assessed by healthcare but the correct
documentation was not completed. He was located on Blackthorn wing in a
single cell. The following day he commenced a 12-day Subutex detoxification
programme.
The man went to Oxford police station on 25 August to answer enquiries on
further crimes and remained there overnight. Whilst in police custody he was
seen by the Forensic Medical Examiner and prescribed medication to help
with his withdrawal symptoms. Due to being in police custody, he missed his
last Subutex dosage on 25 August.
On his return to prison, he asked for his Subutex. Given that the detoxification
programme had finished, and he had received drugs at the police station, he
was not given any further medication.
Having returned to the wing, he found he had lost his single cell and was
located into a shared cell. He was not happy about this. He reported that he
had lost his property from his previous cell.
On 27 August, the man refused to return to his cell and was voluntarily moved
to the Separation, Support and Challenge Unit. Healthcare did not complete a
Safety Algorithm within two hours of his reception and staff did not observe
him every 30 minutes as required. Later that afternoon he flooded his cell.
At 2.30pm the following afternoon, the man was subject to two adjudications
and received 12 days cellular confinement in total. He was unhappy about the
punishment. As a prisoner undergoing cellular confinement, he
was not observed hourly in accordance with the Prison Discipline Manual.
At 5pm the man was found hanging in his cell. Emergency assistance was
immediately summoned and attempts were made to resuscitate him. These
were unsuccessful and he was pronounced dead at 6.10pm.
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HMP Bullingdon
Bullingdon Community Prison is a category C local training prison for
convicted and unconvicted adult male prisoners, serving courts in Oxfordshire
and Berkshire. Opened in 1992, it is a ‘new gallery’ prison by design, with its
four main house blocks divided into three galleried units. The original house
blocks, A and D, have been supplemented by a fifth since April 1997. There
are single, double and triple cells. Bullingdon has a healthcare centre
providing 24-hour cover.
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Events leading to the man’s death
The man was remanded into HMP Bullingdon from the Magistrates Court on
13 August. He was due back in court on 2 September for sentence.
Upon his arrival at Bullingdon, he had a routine interview with a member of the
healthcare staff, who made comprehensive notes in the Inmate Medical
Record (IMR). However, the reception nurse did not complete a reception
healthcare screen which includes an assessment of the prisoner’s mental
health and risk of self-harm. Asked in interview about his state of mind, she
stated that she had no concerns about him.
The man disclosed to her that he was a heavy user of crack and heroin and
was receiving a daily 60ml methadone script. Although he presented with a
number of physical health problems relating to his drug use, the nurse did not
feel that they were sufficient to require inpatient care. The man asked to be
admitted to healthcare saying he had a problem with someone on Blackthorn
wing and did not want to be located there. He had been assaulted during a
previous period on remand, but it is unknown whether this played a part in his
request and there is no evidence to indicate he advised staff of this on
reception. The prisoner who had previously bullied him was not located on
Blackthorn wing.
The man was located onto Blackthorn wing and, although deemed suitable for
cell sharing, he was placed in a single cell. It is not known how he came to be
located into a single cell but, given subsequent events, it was most likely as a
result of his preference.
The following day, 14 August, the man was seen by the prison doctor and
prescribed a standard twelve-day Subutex detoxification to begin that day.
The doctor deemed him fit for ordinary location. On 18 August, the governor
agreed to a request from the police for him to be questioned about further
offences on 25 and 26 August at the police station. On 19 August, the man
completed an assessment with the Counselling, Assessment, Referral, Advice
and Throughcare (CARAT) team, again reporting heavy drug use. The
intention was to start working with him after his detoxification to enable him to
address his drug use.
On 24 August, he was visited by his probation officer and a police sergeant
from the IRIS team based at the police station. The purpose of their visit was
to assess his suitability for a Drug Treatment and Testing Order for his court
appearance on 2 September. However, he did not want to be assessed and a
report was not prepared. From their experience of him, this was not unusual
as he often fluctuated between wanting to go into rehabilitation and then not
being motivated to go. The police sergeant describes him as having been
quiet but nothing that caused them any concern.
On 25 August, he was collected from HMP Bullingdon and taken to the police
station for the purpose of clearing up some Taken Into Consideration (TICs)
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offences. During the day a psychiatrist interviewed him. This had been pre-
arranged in advance by the IRIS team, as there had been some concerns that
he might suffer from Attention Deficit Hyperactivity Disorder (ADHD).
However, the psychiatrist concluded that the man did not suffer from ADHD.
In addition, she made a general assessment of his mental health including his
risk of self-harm and suicide. The report states that he had taken two
intentional overdoses in the past due to ‘despairing of his life’ but was not
suicidal at this time. This is the only reference to past suicide attempts found
by my investigator and therefore seems unlikely that the prison were aware of
these incidents.
Whilst in police custody, the man saw the forensic medical examiner (FME)
and was given Dihydrocodeine (for withdrawal symptoms) and Diazepam at
5.35pm on 25 August and 1.10am the following morning. The man had
missed his last dose of Subutex at the prison due to being taken to the police
station. On the morning of 26 August, his mother and sister visited him. His
mother reports that he was fine although she recalled him asking for
medication. At 1.36pm the FME again saw him and he requested Subutex.
The FME did not prescribe anything and recorded ’no medication indicated at
present. Will get his routine medication on return to prison.’
At the conclusion of the two days’ inquiries, it was likely that he was going to
have 60 TICs taken into account at his next court hearing. Whether he had
any worries about this, and the additional sentence he might have received as
a result, is not known.
The man arrived back at HMP Bullingdon on 26 August at 4.35pm and was
placed in the holding cell waiting to be processed back through reception.
Whilst there he was spoken to by the orderly officer because he was kicking
the door of the cell and causing a disturbance. The man was agitated and
asking for his Subutex. He told the orderly officer that he was detoxing badly
and the officer could see that he was shaking and that his mood was erratic.
The nurse in reception was not aware that he was going to be there and
phoned through to the healthcare office for his file to be checked. She was
then able to explain to him that he had missed the last dose of his Subutex
detox the day before. The nurse had a copy of the medication sheet from the
police station and was able to see that he had been given some medication
whilst there. The nurse explained this all to him and said that he calmed down.
None of this encounter is reflected in his IMR and the only reference is in his
core record ‘seen by HCC. Reception’.
The man was then located back onto Blackthorn wing but into a double cell as
there were no vacant single cells. He was unhappy about this and asked for a
single cell. It appears that wing staff were unaware that he was on a police
production order and would therefore be returning to the prison. Under usual
circumstances, when a prisoner goes out to court or the police station this is
indicated in the wing office next to the cell number using the T-card system.
In his case, this does not seem to have happened and it was assumed that
the cell was free. However, even knowing that he was returning to the wing
would not have secured his cell if a single one had been needed for another
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prisoner. The senior officer on the wing at the time explained this to him and
said that she would try to get him a single cell if one became available. In the
meantime, he was placed in a double cell.
The man also complained that he had lost his property. My investigator has
been unable to find out exactly what this property was and what happened to
it. When he went out on his police production order it was his responsibility to
take his possessions out of his cell and back through reception. There are
large signs on the wing indicating this. The man told the wing SO that an
officer had told him he did not have to do this as he was returning.
Unfortunately, he was unable to recall which officer he had spoken with. The
man’s core record is stamped to indicate that the discharge procedure was
completed but it is not signed by an officer. There is nothing on his property
card to indicate that he took anything with him or stored anything there for his
return. If any property was left in the cell it should have been removed when
the cell was allocated to someone else and a cell clearance form completed.
There is no cell clearance form on file.
Later that evening, he rang his cell bell. The wing officer responded and the
man repeated his concerns about losing his cell and his property. The wing
officer says that the man was angry and she wrote in the wing observation
book, ‘This prisoner did not take his property to reception on a police
production order. He stayed out overnight therefore he lost his single cell and
his property is misplaced. He has threatened to kick off tomorrow and not
locate. STBA (Staff to be aware)’.
27 August 2004
The wing SO spoke again with him on the morning of 27 August and he told
her that being in a shared cell was ‘doing his head in’. He said that he was
keeping his cellmate up because he was detoxing. After lunch, the SO was
called to an incident on the wing where the man was refusing to lock up in his
cell. The SO recalls trying to persuade him not to take this course of action as
it would lead to him being taken to the Separation, Support and Challenge
Unit (SSCU). She explained that healthcare staff would be doing their rounds
later that day and he could speak to them about missing his Subutex.
However, she states that the man said he wanted to go to the SSCU.
Consequently he was placed on report for refusing an order and the SO took
him down to the SSCU. He was located into cell S109 by wing officer and
another officer. The wing officer described him as being compliant but not
especially communicative.
All new prisoners placed in the SSCU must have a Safety Algorithm
completed first by a nurse or doctor, and then the duty governor, within two
hours of being admitted onto the unit. If this is not possible, the prisoner has
to be monitored every thirty minutes until the algorithm is completed. There is
no algorithm on file for him on 17 August or any indication that he was
observed every thirty minutes.
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Later that day, the man was seen to throw food out of his cell window. When
challenged, he was abusive, and eventually moved to cell S104 where the
windows cannot be opened. In interview, another SO stated that the man
refused to take his bedding with him in spite of being told that he was going to
be locked up for the night. The wing officer recalled him banging his door and
shouting after being placed in cell S104.
At 6.25pm the man and another prisoner in cell S107 flooded their cells. This
was not done by any prior arrangement between the two men. In interview
the orderly officer, said that ‘The man had actually joined in the other
prisoner’s (sic) protest’. Both men were placed on report for this. A second
wing officer went into both cells and turned off the water supply. The man
gave an abusive response to him. The orderly officer decided not to move
both men from their cells but to let them calm down. He spoke to the other
prisoner and found him to be quite uncommunicative. He also spoke to the
man who again complained about detoxing. The orderly officer explained that
he knew his history, as he had been there when he had come through
reception two days earlier. The orderly officer described him as eventually
becoming calmer and he accepted the officer’s offer to have his bedding
returned to him. The two men remained in their waterlogged cells overnight.
Their mattresses and bedding were not wet but the floor was.
Saturday 28 August 2004
The orderly officer said in interview that, when he came back on duty in the
morning, he arranged for the two prisoners to be removed from their cells
temporarily whilst they were mopped up. He described speaking to him and
stated that he was still showing signs of detoxing but was polite and
respectful. During the morning, the wing SO spent about five minutes with the
man inducting him. She recalls that he was ‘quite dismissive’ but felt that this
was not uncommon for prisoners who are about to be adjudicated upon. At
8.30am, a prison officer issued him with his adjudication papers.
There were a high number of adjudications that day, many of which needed a
doctor to complete the adjudication paperwork. In total there were 16
prisoners on the unit that morning, ten of whom were facing adjudications.
Both the prison doctors were absent from the establishment and a locum
doctor had been called and this delayed the start of the adjudications. The
duty nurse who had some knowledge of him as she had met him a number of
times in healthcare, accompanied the doctor around the unit. The man did not
give her or the doctor, any cause for concern and the doctor wrote in the IMR
‘does not refer problems. Apparently fit’. The Safety Algorithm was
completed by the duty nurse, rather than the doctor, at 11.12am and indicated
that he was fit for adjudication and a punishment of cellular confinement. The
doctor did not complete the adjudication form, F256, as required.
The Adjudications
Given the volume of work, and the late start, the adjudications continued after
lunch and for much of the afternoon. This was unusual. The man’s first
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adjudication began at 2.30pm and related to him disobeying an order (rule 51.
para 22). Present in the room were the adjudicating governor, two prison
officers, two escorting officers, and the man.
According to the paperwork, the man pleaded guilty to the charge of refusing
a direct order, to locate into cell 229 Blackthorn wing at approximately
12.15am on 27 August. The first prison officer gave evidence and the man
was then asked why he refused the order. He explained that he was
withdrawing from drugs and that his cellmate was complaining about keeping
him up. He went on to explain, in response to the governor’s questions, that
he was still withdrawing and was no longer on a detox. In interview, the
governor said that he was aware that the man had missed his last day of
Subutex but felt that it would have been such a limited amount that it would
hardly matter. The governor explained that he would arrange for healthcare to
see him regarding a possible re-detox. He found the charge proved and the
man received five days cellular confinement and loss of all privileges, except
tobacco. Included in the adjudication paperwork was a report from the wing
that stated that he had not come to the attention of staff prior to the incident.
At 2.35pm, his second adjudication relating to the flooding of his cell and the
one’s landing (rule 51, para 17 – destroys or damages any part of a prison or
any other property, other than his own) started. Again, the man pleaded guilty
and the reporting officer presented the evidence. The man explained that he
was ‘pissed off, I couldn’t breathe’ and said he had been moved cells because
he had been throwing things out of his cell window. The case was proved and
he received a further seven days cellular confinement and seven days loss of
all privileges.
Prior to the man’s adjudication, the prisoner, who had flooded his cell at the
same time as the man who died, had his case proved against him. He
received seven days loss of gym and loss of canteen and was returned to
normal location.
After receiving his punishment, the governor said that the man said ‘I can’t do
that’ which he did not judge to be a sign of distress. When he left the room
the governor described him as a ‘very unhappy man’. The reporting officer
and two escorting officers took him back to his cell as his demeanour gave
them some cause for concern in terms of potentially being violent. The
reporting officer said that the man continued to complain about the 12 days
punishment and he wanted to contact his solicitor about it.
Three prisoners on the unit at the time were interviewed including the prisoner
that had also flooded his cell. All stated that the man was aware of the other
prisoner’s punishment and was very angry about the contrast between the two
punishments. Two prisoners recall that he was shouting, banging and ringing
his cell bell a lot and asking for a light. One prisoner in cell S106 stated that
he shouted they ‘would pay for this later, the bastards’.
After returning to his cell he shouted and banged the cell door intermittently.
The reporting officer, who was the patrolling officer, recalls that when he rang
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his cell bell, between 20 – 30 minutes after he had returned to the cell, he
responded. Given that his second adjudication started at 2:40pm and lasted
approximately five minutes, this was probably between 3:05pm and 3:15pm.
The man was asking for a light, and due to his behaviour, the reporting officer
passed him a light under the door rather than opening it as he would have
done with a calmer prisoner.
The wing was busier than usual at this time because of the late running of
adjudications. Staff estimate that adjudications finished at about 4pm and
staff then had to prepare for the serving of tea. At some point during the
afternoon, between him being returned to the cell after the adjudication and
the discovery of him hanging, the second prison officer placed his adjudication
paperwork under his door. His immediate response was to shove the papers
straight back out onto the landing, where they remained. The prison officer is
unable to recall at precisely what time this was and the reporting officer is
unable to say if he saw the papers when he went to give him the light. This
makes it difficult to know if the officer giving him the light at approximately
3.15pm was or was not the last time he was known to be alive.
The discovery of the man
The wing SO returned to the wing sometime around 4.30pm and the reporting
officer briefed her about the afternoon’s events. It was decided that they
would serve him his tea last. This was in line with the unit’s policy in dealing
with potentially disruptive prisoners, so that if there are problems it will not
affect the other prisoners.
Having finished serving the prisoners on the upper landing two wing officers
and the second wing SO were getting the prisoners out individually for their
dinner on the lower landing. The reporting officer was behind the servery on
the lower landing. At 5pm the first wing SO walked passed the man’s cell and
thought he was very quiet for someone who had previously been very vocal.
She opened the flap in the cell door and saw him hanging. The SO
immediately shouted out and opened the cell door. The two prison officers
were standing by the adjacent cell door and entered the cell immediately
behind the SO. The SO radioed for level one assistance and records indicate
that the ambulance was called at 5.04pm.
The officers supported his body and the first wing officer cut through the
ligature (a sheet) with her fish knife (a knife specifically for cutting ligatures).
The sheet had been slipped between the light fitting and the ceiling. The man
was placed on the floor and both the SO and the first wing officer felt for a
pulse but were unable to find one. Very quickly, a wing nurse arrived and her
initial assessment was that the man was unresponsive and his lips were blue.
At this point the man was moved out onto the landing to allow more room.
Almost immediately, four more nurses reached the unit and Cardio Pulmonary
Resuscitation commenced. A defibrillator was attached but the reading
confirmed that nothing more could be done. The paramedics arrived at
5.28pm and CPR was ceased. A prison doctor arrived at 6.10pm and the
man was pronounced dead.
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Post-incident response
The adjudicating governor instigated the death in custody contingency plans.
Unable to make contact with either the Governor or deputy, he eventually
spoke with Governor A who came immediately to the prison. Once the
coroner’s officer and the police had left the prison, a debrief was held with the
staff.
All the prisoners on the SSCU were spoken to and offered the opportunity to
see Listeners and offered radios or television for the night. One prisoner in
particular had been able to see the nurses working on the man and he was
taken to healthcare for the night for additional support. A notice to staff and
prisoners was issued informing them of the tragic death of this man.
Contact with the man’s next of kin
The man’s brother
One of the nurses was aware that the man’s brother was a prisoner at HMP
Bullingdon on Alpha wing. Governor A and two members of healthcare went
to break the news to him. A decision was made to take him to healthcare and
place him on a suicide watch as a precautionary measure. He remained in
healthcare for a number of days before being returned to normal location.
The man’s mother
The man’s mother and stepfather were informed of his death by two local
police officers at about 9.30pm that night. The police had very limited
information and did not seem to be aware that two of her children were in
custody. Understandably, the man’s mother and her partner were distraught
and tried to contact the prison. This involved them having to ring through to
the answering machine and wait to be connected to someone. Governor A
spoke to them but the conversation was very short.
In interview, Governor A said that there had not been any discussion about
contact with the man’s parents in advance and the task fell to him by default.
Unfortunately, this meant that when the mother phoned the prison she did not
have a direct number to call. The man’s mother was also concerned about
how the information was presented to her and the language used. Governor
A disputes this. In addition, the police told the mother that they would go and
inform the man’s father but this never happened and the mother had to break
the news to him.
The prison made arrangements for the mother and stepfather to visit the
SSCU and for the brother to receive additional visits. Governor B spoke to the
man’s parents when they visited.
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Issues considered during the investigation
The initial healthcare screening form
When the man first arrived at HMP Bullingdon, he was seen by a member of
healthcare staff for an initial healthcare screening. This is a national
assessment tool, including a section for risk assessment of self-harm and
suicide. It should be completed when any new prisoner comes into custody.
The reception nurse took comprehensive notes when she interviewed him and
recorded details of all his physical problems. However, it was only in interview
that she was able to say that she had given consideration to his mental health.
The clinical review makes further comments on this.
Inadequate entries in the Inmate Medical Record
When the man returned to the prison from the police station he had quite a
lengthy discussion with a nurse regarding his medication. None of this is
recorded on his IMR.
The police production order
On 18 August the Governor gave consent for the man to go out on the police
production on 25 August. However, it seems neither the wing nor healthcare
were aware he was going. It is not entirely clear whether the man knew in
advance. The staff on Blackthorn wing were unaware that he would be
returning and subsequently allocated his cell to another prisoner. Healthcare
did not make any arrangements for him to collect his medication in the
morning prior to his release to police custody. Furthermore, there is no
documentary evidence to indicate that his failure to attend for his treatment
was followed up.
Safety Algorithm form
Staff from the SSCU are confident that they would have phoned healthcare to
inform them that they had received him on 27 August. On this particular day,
there was no doctor in the prison and there seems to have been some
discussion about whether a nurse can complete a Safety Algorithm when
someone is first placed in segregation. PSO 1700 states that a nurse is able
to complete the algorithm. However, the man did not see any healthcare staff
on 27 August.
On 28 August, the doctor did see him but failed to complete the adjudication
paperwork or sign the algorithm.
Hourly checks
The regime for a prisoner serving a period of cellular confinement is laid down
in the Prison Discipline Manual (PDM). The PDM stipulates that an officer
must observe all prisoners who receive a punishment of cellular confinement
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once an hour. This is repeated in Prison Service Order 1700, issued in
November 2003. At the time of his death, this level of observation was not
being met. In interview, neither the unit manager, the orderly officer, or the
unit governor, the adjudicating governor, were aware of this requirement. It
seems likely that they both inherited a unit where this had not been done. In
this case, it is not possible to be entirely accurate about when he was last
seen. However, it is probable that he was not seen for approximately one
hour and 45 minutes prior to his death.
The adjudications
HMP Bullingdon’s document ‘A Guide to Adjudication Punishments’
(December 2003) outlines a range of punishments available for all prison
offences including the offence of destroying or damaging any part of the
prison. Depending on the seriousness of the offence and any mitigating or
aggravating factors, punishments range from referring the case to the
Independent Adjudicator to (at the lowest end) seven days loss of privileges.
The middle range is three to seven days cellular confinement with loss of all
privileges.
Both the man and the other prisoner flooded their cells. His punishment was
within the middle range whilst the other prisoner’s appears to be below the
minimum. To understand why the punishments were so different, my
investigator examined the guidelines document and had a long interview with
the adjudicating governor.
The adjudicating governor was asked specifically about the man and his
decision making process. He described him as being ‘very truculent’ and
having a demeanour of ‘complete disregard for the adjudication process’. He
explained that cellular confinement and loss of all privileges is a common
punishment for refusing to lock up to try and deter people from using the
SSCU as a way of getting a single cell. The governor said that he discussed
with the man whether he was prepared to go back to the wing but he was not.
The governor explained that, during the first adjudication the man, talked
about detoxing and that he had not had his last dose of Subutex. He stated
that the Diazepam given to him whilst on police production did ‘not do him any
good’. The governor believed that the man had been using drugs whilst in
custody although he did not have any evidence to support this. The governor
said that he intended to speak with healthcare staff the following morning and
see the man to discuss a re-detoxification. This would have meant that
healthcare staff would not have been contacted for at least 15 hours.
The governor explained that ‘I just gave him the award of CC because I felt
that was the place we could give him the better support’. He went on to
explain that ‘some people could view cellular confinement as a punishment
and yes it is in one extreme but I think me personally my motives for doing it
were simply because of the higher level of support that we could give’.
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In relation to the second adjudication the governor stated that whilst, he gave
consideration to the support issue, he also felt that ‘he got seven days
because he had shown absolutely no remorse whatsoever’. He added later
that ‘there was nothing that I could actually use in mitigation other than the
fact that you know he didn’t like the windows being shut but to me it was just
another example of a truculent young man that I had in front of me’.
In discussing where he viewed him on the tariff, he stated that ‘the mid range
tariff is where he well and truly sat because he didn’t satisfy anything for me to
move into the lower range’. On the other hand, the other prisoner, according
to the governor ‘was calm, he was collected, he was contrite, he was
remorseful’. He agreed to go back to normal location and left the SSCU that
afternoon.
In deciding upon disciplinary punishments, there is properly much room for
individual discretion. The local document is also only a guide. However, I am
struck by the contrast between the punishments, received by the man and the
other prisoner respectively. The governor knew that the man was withdrawing
from drugs and used this to think about the extra support he felt the man
would get by being in the SSCU. However, he may not have fully considered
the effect of drug withdrawal on behaviour, or the impact a period of cellular
confinement could have had on the man’s frame of mind. A total of 12 days
cellular confinement for the two offences is a severe penalty by any standard.
Family contact
PSO 2710 stresses that whenever possible, it is for the prison to break the
news of bereavement to the next of kin. In this case, it is unclear why this was
not done given the relatively short distance between the prison and the man’s
mother’s home. In interview, the orderly officer said that he tried to get in
contact with the chaplain but was not able to and he was conscious that
information might be leaked if they did not act quickly. According to the
investigation reports, in five of the past deaths in custody at Bullingdon the
police have informed the next of kin of the death. From interviews with a
number of the senior staff on the scene, it seems that the issue of speaking
with the family was not discussed and therefore not planned.
The day after the man’s death his family did visit the prison and saw his
brother, Governor A and the orderly officer. They also made a subsequent
visit to the prison. However, there appears to have been some confusion
about the visit and access to the establishment. The mother had been led to
believe that the family would be ‘fast tracked’ through the visitor’s process.
This appears not to have happened.
The man’s brother was allowed to attend the funeral and this seems to have
been conducted with sensitivity by the officers who accompanied him. He
was allowed to sit with family members at the front of the church and spent
time with his family throughout the day at the chapel of rest and the church.
The family were concerned that he was not told until the day before that he
was being allowed to go but this is understandable given security
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considerations. I am pleased to draw attention to the staff involved in the
brother’s attendance at the man’s funeral and to commend them for their
conduct and sensitivity.
PSO 2710 states that ‘the handling over of personal effects including all
monies held on behalf of the deceased should be done with care and
sensitivity’ (paragraph 6.2.10). The man’s brother was released from custody
some time later and was upset to be given some of the man’s possessions
when he left the establishment. He and members of his family should have
been consulted about what they wanted to happen.
The mother received a letter of condolence from the Governor dated 8
September, eleven days after the man had died. She did not offer any
financial assistance for the funeral and the man’s mother had to write
requesting some assistance. Funds were forthcoming and the family were
grateful. However, it would have been more appropriate for the prison to have
made the offer without waiting to be asked. As with the issue of the man’s
property, it is disappointing that the needs of the family were not considered
more rigorously. There are important lessons from the tragedy of the man’s
death that Bullingdon needs to take on board.
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Relevant recommendations from previous deaths at HMP Bullingdon
There have been a number of deaths at Bullingdon during the past five years.
All have been investigated but inquests have not yet been held. Each
investigation has made recommendations and three are of relevance to this
case. None appear to have been fully complied with.
‘All prisoners in the segregation unit should be the subject of regular checks
throughout their stay.’ (November 2002)
‘There should be an instruction concerning the management of prisoners who
are withdrawing and not located in the HCC.’ (January 2002)
‘Prisoners who fail to collect prescribed medication must be followed up,
particularly medication for any mental disorder or management of substance
misuse as these prisoner/patients are most at risk from deliberate self-injury.’
(November 2002)
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Findings and conclusions
Hourly observations were not undertaken following his punishment of cellular
confinement, despite this being a requirement of the Prison Discipline Manual.
Following his tragic death, local policy was reviewed and amended to reflect
this requirement.
An internal audit should be undertaken to ensure continued compliance
with the revised policy on observations of prisoners in cellular
confinement.
Safer Custody Group should remind all Governors of the requirement to
undertake hourly observations of prisoners on cellular confinement in
accordance with the Prison Discipline Manual.
The man received seven days cellular confinement and loss of all privileges
for flooding his cell. A prisoner in a neighbouring cell simultaneously
committed the same offence. He received seven days loss of gym and
returned to normal location.
The Governor of Bullingdon should remind her adjudicators of the need
for consistency and fairness in setting individual punishments.
The safety algorithm was not completed for the man when he was received
into the SSCU. The safety algorithm completed the following day was not
signed by a doctor. Nor did the doctor sign the adjudication form, F256.
The Governor should remind staff that a safety algorithm must be
completed on all new receptions into the SSCU. She should also remind
clinical staff that a doctor must undertake and sign an algorithm for the
purpose of cellular confinement, and arrange for regular audits to
ensure compliance with PSO 1700.
The police production order was the start of a sequence of events that
culminated in the death of this man. It is not clear how information about him
being absent from the prison for two days was filtered through to the
necessary units.
An internal audit should be undertaken to examine the current flow of
information regarding prisoners leaving the establishment on overnight
production orders.
In accordance with PSO 2710 consideration should be given to
communications with the deceased family. In this case this was not done and
some of the confusion and distress which coloured subsequent contact might
have been averted if staff had made contact directly.
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The Governor should remind all her managers that contact with the next
of kin must be given high priority and conducted in accordance with
PSO 2710.
The clinical review makes four recommendations.
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Recommendations
An internal audit should be undertaken to ensure continued compliance with
the revised policy on observations of prisoners in cellular confinement.
The Safer Custody Group should remind all Governors of the requirement to
undertake hourly observations of prisoners on cellular confinement in
accordance with the Prison Discipline Manual.
The Governor of Bullingdon should remind her adjudicators of the need for
consistency and fairness in setting individual punishments.
The Governor should remind staff that a safety algorithm must be completed
on all new receptions into the SSCU. She should also remind clinical staff
that a doctor must undertake and sign an algorithm for the purpose of cellular
confinement, and arrange for regular audits to ensure compliance with PSO
1700.
An internal audit should be undertaken to examine the current flow of
information regarding prisoners leaving the establishment on overnight
production orders.
The Governor should remind all her managers that contact with the next of kin
must be given high priority and conducted in accordance with PSO 2710.
Appropriate systems must be put in place to ensure that there is effective
interagency sharing of health information to enable continuity of care for
individuals as they pass from the community to prison and back again.
All prisoners newly received into custody should have a full physical and
mental health assessment on reception by a suitably qualified health care
worker using the agreed screening and assessment tool.
A healthcare worker must complete the algorithm in all cases when prisoners
transfer to the Separation, Support and Challenge Unit in accordance with
National Policy. A copy of this should be placed in the clinical record and an
entry made in the continuous medical record as documentary evidence that a
prisoner has been seen.
The staff involved in the resuscitation of the man should be commended for
their actions despite the tragic outcome.
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