Individual at Canterbury

Investigation into the circumstances surrounding the
death of a man
shortly after his release from
HM Prison Canterbury on 15 September 2004
Report by the Prisons and Probation Ombudsman for
England and Wales
February 2005
CONTENTS
Introduction by the Ombudsman, Stephen Shaw CBE
Summary
Investigation methodology
The deceased
The deceased’s family
HMP Canterbury
Events prior to the man’s death
Events after the man’s death
Findings and conclusions
Recommendations
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Introduction
This is the report of an investigation into the care a man received whilst in
prison custody before his death in Margate, Kent, on 15 September 2004 after
release from HMP Canterbury the previous day.
Although the man died after leaving prison, I decided to exercise the
discretionary powers included in my Terms of Reference to investigate his
death. Like many others within the criminal justice system, I am concerned
about the number of prisoners who die from drug related causes within a short
time of leaving lawful custody.
In fact, the investigation has shown that the man was fully and properly
warned by both prison and probation as to the dangers he might run through
renewed drug use. I am grateful for that fact and only sorry that, if the
findings of the Post Mortem are confirmed at inquest, the warnings proved
unavailing.
This investigation was conducted by one of my Senior Investigators. The
report includes one recommendation.
I wish to extend my thanks to the Governor and her staff at Canterbury for
their help and co-operation during the investigation.
Stephen Shaw CBE
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Summary
The man was sentenced to a total of 12 months imprisonment in March 2004
for offences of dishonesty. Originally held in custody at HMP Elmley, where
he completed a detoxification regime for heroin, he transferred to HMP
Canterbury in April 2004.
The man was tested for drugs the following day with a negative result. He
obtained a job in the kitchen and the staff thought well of him. He signed up
to the voluntary testing unit compact on 16 April and earned enhanced status,
which meant that he received greater privileges.
On 7 August, an officer walking past the man’s cell noticed a strong smell of
cannabis. He recommended a mandatory drug test be carried out which the
man failed due to cannaboids. The man pleaded guilty at his adjudication on
19 August and lost association, gym privileges and in-cell electricity for five
days.
A member of the CARAT's (Counselling, Assessment, Referral, Advice and
Throughcare) team saw the man on 31 August and he requested support on
release to help him stop his drug use. The man was given literature and told
about the dangers of returning to drug use after a period of abstinence.
The man told the staff at Canterbury that he was of no fixed abode and
received extra money when he was discharged on 14 September. He
reported to the Probation office in Margate later that morning. The following
day he was found dead at an address in Margate. The Coroner will determine
the cause of death but toxicology samples taken during the Post Mortem
indicate he had a mixture of controlled drugs in his system.
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Investigation methodology
1. The investigation was opened at HMP Canterbury on 8 October 2004.
The Governor and her staff produced the man’s core record and a number
of other documents for examination. Notices were issued to staff and
prisoners informing them of the investigation. Whilst being shown around
the prison, my investigator was able to speak to several members of staff
who knew the man. On a subsequent visit, staff were informally
interviewed.
2. A Family Liaison Officer contacted the man’s family and offered them the
opportunity to meet with her and the investigator to discuss the purpose of
the investigation and to raise any concerns or questions that they would
like explored and addressed. A meeting took place on 11 October with the
man’s sister and his niece.
3. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner to
assist him in his enquiries into the man's death.
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The deceased
4. The man was born in Rotherham, and was just 36 years old when he died.
He had three children from a relationship that ended a number of years
ago. According to the man’s sister, he began using ‘hard’ drugs, i.e.
heroin and cocaine, in his mid 20's when the relationship with the
children's mother broke up.
5. His sister said that the man had never really had a proper job, although
during some extended 'clean' periods - one lasting for three years - he
would get work where he could. Recently had he worked as a garden
fencer until the company found out that the man used heroin and sacked
him.
6. The man received his first conviction in his early teens and subsequently
served six periods of imprisonment for offences of dishonesty, assault and
driving matters.
7. The man told the healthcare staff at HMP Elmley that he was abusing
heroin, cocaine and benzodiazepines at the time of his latest arrest.
8. The man had lived with his sister on previous occasions and, according to
her, was going to do so again upon release from HMP Canterbury.
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HMP Canterbury
9. Canterbury is a Nineteenth Century prison that has been used for many
purposes over the years. Originally, it was a County gaol built just outside
the city limits. During the First World War, it was a Home Office archive
facility, later becoming a prison and a naval detention centre. More
recently it was a ‘local’ prison serving the courts in East Kent. It is now
used to hold short term category C prisoners, serving less than four years,
with priority given to those with a Kent discharge address.
10. It is a small prison equipped with a gymnasium, astro-turf area, kitchen,
education facilities and workshops.
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The deceased’s family
11. The man’s father still lives in Yorkshire, but his mother and sister now live
in Margate. The man’s mother was still too upset to meet with my
investigator but she was content for her daughter to do so. The man’s
sister had a number of concerns about his time at HMP Canterbury.
12. Her main concern centred on the lack of security, as she saw it, at the
prison. She was in possession of a number of letters that had been written
to the man whilst he was in custody. They were from his drug using
friends and at least one makes it clear that the man should send a visiting
order for a particular person. The idea was that another person would
pretend to be the named person and bring drugs in for him. The man’s
sister was angry that the prison had not read the letters. She also
expressed her view that prisoners should have their visits from behind
glass to prevent the passing of drugs.
13. The man’s sister expressed concern that she had noticed that not having a
photo ID did not prevent entry for visits at the prison as it did at other
establishments.
14. The man's sister was also concerned that, when he was found, he did not
have many of the items of clothing that she had given him whilst he was in
prison. During the meeting with my investigator, it was established - by
checking the prison property cards - that the man left Canterbury with the
correct clothing and his sister was content that the Prison Service was not
responsible for any loss.
15. The man’s sister had some difficulty making contact with the prison after
the man’s death. When she telephoned, she was apparently told to write a
letter, which she took to the prison on 17 September. She did not get a
reply after a week and so telephoned several times. She did then receive
a reply from the Head of Resettlement. She said that since that time he
had been very helpful.
16. As far as his sister was concerned, the man was going to stay with her
upon his release, which she expected to be on 15 September, not 14
September. She was unaware that he had told the prison that he was of
no fixed abode.
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Events prior to the man’s death
17. The man was arrested in mid March 2004 and held at Margate police
station until he appeared at Thanet Magistrates Court two days later. The
court remanded him in custody to HMP Elmley until 25 March.
18. The man saw the substance misuse team on 19 March and told them that
he abused heroin, cocaine and benzodiazepines. He began a heroin
detoxification regime using Subutex on 21 March. He completed the
regime at the end of the month.
19. The man returned to Thanet Magistrates Court on 25 March and received
a 12 months sentence for offences of dishonesty. He was located on
House Block 1 at Elmley.
20. On 7 April, the man told staff that he had received threats from other
prisoners over a recent fight in a Margate public house. He was moved for
his safety into House Block 2. On 12 April, the man was relocated into the
segregation unit due to overcrowding at the prison, and the following day
he was transferred to HMP Canterbury.
21. My investigator has looked into the concerns raised by the man's sister.
So far as the reading of prisoner's mail is concerned, prisons have to
balance the security requirements of the establishment with the human
rights of the prisoners in their care. Routine reading of all mail would not
be justified in a category C prison and is not required under Prison Service
Orders. However, at Canterbury as elsewhere, all mail is checked for
inclusions. In addition, a small proportion of the mail is read at random.
22. The issue of identification for visitors to the prison is another security/rights
balance. Not everybody is able to provide photographic identification and
in those circumstances other documentary forms of proof are accepted.
All visits to prisoners are monitored to some extent and a passive drugs
dog is used randomly at visiting times in an effort to reduce the amount of
drugs entering the prison. The man did not meet the criteria for closed
visits.
23. My investigator checked the list of persons who visited the man whilst he
was at Canterbury and established that none of the people about whom
his sister was concerned were mentioned.
24. All prisoners are subject to mandatory drug testing at prescribed intervals
and many sign up to the voluntary drug testing programme. Canterbury's
MDT (mandatory drug test) programme currently reveals a positive test
result rate of 9.7% against a target of 9.5%, mainly indicating the use of
cannabis.
25. The man provided a negative MDT on 14 April and again on 14 May. He
signed the VDT (voluntary drug test) compact on 16 April. By doing that,
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he agreed to abstain from drug use and to participate fully in the prison
regime.
26. He obtained a job working in the prison kitchen, which he enjoyed. Staff
were pleased with his work and he was liked by his fellow workers. He
was awarded ‘enhanced status’ which allowed him more privileges within
the prison.
27. On 20 May, the man refused to provide a voluntary drug test sample and
requested to come off VDT. His reasons for doing so are not known, but it
was explained to him that to do so would mean the loss of some
privileges. He agreed to remain on VDT.
28. On 5 August, the man was relocated to B wing, a move commensurate
with his ‘enhanced’ status and the VDT compact. Two days later an officer
walking past the man’s cell noticed a strong smell of cannabis and
reported the matter. The man subsequently failed a MDT for cannaboids
on 11 August, and at his adjudication hearing on 20 August he received
five days loss of association, use of in-cell electricity and reduced gym
time. He was returned to A wing, but he was allowed to keep his job in the
kitchen.
29. The man saw a member of the CARAT's (Counselling, Assessment,
Referral, Advice and Throughcare) team on 31 August. He expressed a
resolve to become drug free and asked for support to be provided once he
was released. He was reminded of the dangers of using drugs again at
similar doses as he had before he came into prison. He was also given
several leaflets and small booklets to re-iterate the message.
30. The man failed to attend a review session with the CARAT’s worker on 9
September, but did speak to the KCA UK worker the following day. KCA is
an external support organisation to which prisoners can be referred for
continued help and guidance post release. At that initial meeting he
expressed a wish to remain drug free at least as far as 'hard' drugs were
concerned. Various options for ongoing support post-release were
discussed and a follow-up appointment was arranged for 16 September
with KCA in Margate.
31. The man’s CRD (conditional release date) was 14 September 2004 and he
was released on licence. He told the prison that he had no address, which
meant that he received £94.40 when he left instead of £46.75. The man
had told staff a couple of months before his release that he had no need
for assistance regarding accommodation, so that when he later claimed to
have no address to go to there was not time to arrange anything for him
other than a post release probation appointment.
32. The man attended his appointment with the Probation Service in Margate
that morning. He told the probation officer who interviewed him that he
was intending to have a 'one day party' before going to stay with his family,
as they did not approve of his drug use. He said that they believed his
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release date was the next day. He was warned again about the danger of
renewed drug use with a reduced tolerance level.
33. The man was found dead at his friend's flat in Margate the following day.
It is the Coroner's responsibility to determine the cause of death, but a
potentially fatal blood concentration of morphine, together with other
drugs, was found in his bloodstream.
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Events after the man’s death
34. When the police in Margate were notified of the man's death they had
some difficulty making contact with his next of kin. They located an old
address for his mother and, from there, made contact at her new address,
and informed her of her son's death.
35. The prison authorities initially learned of the man's death from prisoners
and subsequently from the police. The Governor sent a letter of
condolence containing a card and a request from one of the kitchen staff
asking to be allowed to attend the man’s funeral. That letter was sent to
the old address, which had been supplied by the man as his next of kin
contact, and was in fact never received. The man’s sister has now seen a
copy.
36. The man's sister telephoned the prison seeking answers to some
questions she had. After waiting for someone to call her back, she
telephoned again and was told to write a letter. She did so and took it to
the prison herself. Her letter arrived after the letter from the Governor had
been sent. His sister’s letter then took some time to reach the Head of
Resettlement. He initially responded by telephone as the man’s sister had
only included a mobile telephone number not an address in her
correspondence. My investigator established during his meeting that the
man’s sister was satisfied with the prison's response once contact was
made.
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Findings and conclusions
37. The man's sister raised concerns regarding the reading of his mail and
visitor security checks at Canterbury. My investigator has informally
interviewed a member of the Senior Management Team and examined the
relevant regulations relating to these matters.
38. Conclusion - I am satisfied that the checks and procedures in place at
Canterbury are proportionate and comply with the relevant Prison Service
Orders.
39. Prisons are usually contacted by family members whilst prisoners are still
in custody, and there are procedures in place to route the calls or letters to
the relevant person to deal with. Unfortunately, when the man’s sister
made contact after his death her call was not dealt with appropriately.
40. The Prison Service relies on prisoners to keep their next of kin contact
details up to date.
41. Conclusion - The Governor responded appropriately upon learning of the
death of the man. Unfortunately, the prison records were out of date. If the
Governor's letter had been received, the subsequent frustration felt by the
man's family when trying to contact the prison would have been prevented.
That said, his sister's telephone call to the prison should have been routed
appropriately for her questions to be answered.
42. As a drug abuser who had undergone a detoxification programme and
enforced abstinence whilst in prison, the man was potentially at risk upon
release due to a reduced tolerance level. This risk is well documented and
the CARAT's teams in particular ensure that their clients are made aware.
My investigator spoke to the CARAT's worker who saw the man on 31
August and I am satisfied that he was correctly informed of the risks
associated with any renewed drug use.
43. Conclusion - Staff at Canterbury gave the necessary information and
support to the man whilst in prison regarding any continuing drug use by
him post release.
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Recommendations
44. The Governor of Canterbury should review the guidance and training for
her staff who answer telephone calls from the public in light of the initial
difficulties faced by the man’s sister.
45. Governor's response - I fully accept the recommendation contained within
the report and will endeavour to ensure that, with improved guidance and
training, staff handling telephone calls will be better equipped in future to
prevent a recurrence. I will also remind prisoners of the need to keep their
next of kin contact details up to date, wherever possible.
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