Individual at Channings Wood

Investigation into the circumstances surrounding the
death of a prisoner at HMP Channings Wood, at Torbay
Hospital on 13 April 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
January 2007
This is the report of an investigation into the death of a man who died whilst a
prisoner at HMP Channings Wood. On the morning of 12 April 2006, the man was
found hanging in his cell at Channings Wood. Staff resuscitated him and he was
transferred to Torbay Hospital. Sadly, he never regained consciousness and the
following day he died whilst his family were with him. The man was 30 years old.
I offer my sincere sympathy and condolences to the man's family and friends for their
loss.
The investigation was carried out by two of my investigators. One of my Family
Liaison Officers kept in touch with family members. I am grateful to the Governor of
Channings Wood and to the principal officer who acted as liaison officer for their
assistance during the investigation.
The man had spent many years addicted to a variety of drugs and had been in
prison several times. By all accounts, he was a sensitive and thoughtful person who
had tried to break free of the cycle of drugs and imprisonment. He had successfully
applied for a place on Channings Wood’s drugs therapeutic community, but could
not meet its rigorous standards. He completed the first phase of the programme, but
left after spending only two weeks in the second stage. He made several alternative
plans for his future. He died just over a month after coming off the programme.
I make five recommendations in this report. These concern the cell furniture, the
response to the emergency and informing the family about the possibility of media
interest. I am pleased to highlight three examples of good practice as well. These
relate to the prison’s reports about the man, and their contact with his family.
Most of the apparently self-inflicted deaths in prison upon which I report occur in
overcrowded local prisons. The death of this man demonstrates the importance of
the safer custody agenda across the prison estate.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2007
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CONTENTS PAGE
Summary 4
The Investigation Process 6
The man who died 7
HMP Channings Wood 8
The Drugs Therapeutic Community at Channings Wood 8
Key Findings 11
Issues 20
Recommendations 26
Annexes
1. Clinical Review
2. Transcripts and notes of interviews
3. Therapeutic Community booklet “Tackling Drug Dependency”
4. List of documents considered in the investigation
3
SUMMARY
The man died on 13 April 2006 in Torbay Hospital.
The man had been a drug user for most of his teenage years and all his adult life, in
spite of repeated efforts to break his addictions. He served a number of terms of
imprisonment for offences committed to fund his drug habit.
In October 2005, the man recognised that his drug use was out of control, and that
he had resumed offending. He surrendered himself to the police and was remanded
in custody to HMP Dorchester. He was convicted on 27 October and transferred to
HMP Exeter to await sentencing. On 30 November, he was sentenced to five years
imprisonment. He was transferred to Channings Wood on 16 December, and
immediately asked to be moved to HMP Guys Marsh in order to do a drugs course.
However, as part of his induction at Channings Wood, the man attended a
presentation about the drugs therapeutic community located in the prison. He visited
the community and learnt that the course was intensive and demanding, and lasted a
minimum of 12 months. He applied for a place and was accepted. He began the
programme on 28 December, and his aim was to end the pattern of drugs and prison
that had filled his adult years. He completed the Induction phase on 22 February
2006 and moved into Orientation, but struggled to meet the standards, particularly
being punctual and told what to do by other prisoners. After two weeks, the man
decided to leave the community, saying that the pressures were too great. For the
first 48 hours, staff and residents tried to persuade him to remain in the programme,
but he was adamant that he was leaving.
Two weeks later, the man moved to another part of the prison, and then to a single
cell where he appeared to settle in well. He met his drugs worker and was keen to
focus on education as a means of turning his life around. He also felt that he needed
some direction in his life, and the drugs worker suggested he speak to a chaplain.
Three days later, the man told the doctor that he was sleeping poorly and was
depressed, for which anti-depressants were prescribed. He attended a church
service and spoke to the chaplain who told him about an Alpha course that was
about to start.
On Wednesday 12 April, the man was unlocked as usual at 8:00am, collected his
breakfast and took it back to his cell. He then returned to the ground floor to
telephone his girlfriend. Although he spent 15 minutes on the telephone, he was
unable to speak to her and returned to his cell. Half an hour later an officer gave him
a slip to attend the gym that morning, which he took without speaking. At 9:00am,
the same officer returned to the cell and saw him hanging from the leg of his
upturned bed. She radioed for assistance and lifted his body to take the pressure off
the ligature. Other staff responded quickly to the alarm, and held him until ligature
scissors were located and used to cut him down.
Healthcare staff, aided by officers with first aid training began to administer cardio
pulmonary resuscitation (CPR). After ten minutes, they detected a faint pulse which
grew a little stronger. They continued until the paramedics arrived, by which time the
man was breathing, although he was unconscious. He was taken to Torbay Hospital
4
where he was given an x-ray and a CT scan. He remained unconscious and was put
on a ventilator to assist his breathing. His parents and girlfriend arrived, and the
following day the consultant spoke to them. They decided to turn off the ventilator
that afternoon, after which they remained with him until he died at 2.25pm.
5
THE INVESTIGATION PROCESS
1. The man died on 13 April but, because of the Easter break, my office did not
appoint investigators until five days later. The investigation was formally opened
on 21 April when my investigators visited Channings Wood. They met the
Governing Governor, a member of the Independent Monitoring Board and a
committee member of the Prison Officers’ Association. They saw the man’s cell
on Living Block (LB) 3 and were given copies of his records. During the
investigation, my investigators received full co-operation from all staff and
prisoners.
2. My investigators returned to Channings Wood from 23 and 26 May to interview
staff and prisoners. They also had a brief tour of the therapeutic community,
which is the drug treatment programme where the man spent three months. At
the end of the week, they met with the Governor to report their findings. They
returned on 21 and 22 June to spend a day in the therapeutic community,
interviewing staff and residents there and in the main prison.
3. One of my Family Liaison Officers contacted the man’s parents and arranged to
visit them with the investigator. His parents asked for information about the
telephone call the man made shortly before he hanged himself, and for details of
the therapeutic community. The man had referred to it as a course, and told his
father that it was more intense than anything he had done before. I hope that my
description of the community helps to explain his statement.
4. My investigators contacted the chief executive of the Teignbridge Primary Care
Trust (PCT) to request that they undertake a clinical review of the treatment the
man received in prison. The review was completed very promptly by the Director
of Professional Practice, and I am most grateful for her assistance.
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5. The man
5. The man was born in January 1976. He grew up in Dorset with his adoptive
parents, and a younger adopted sister. In his teens, he was diagnosed as having
bi-polar disorder, but later the diagnosis was changed to a personality disorder.
When he was 14 years old, he began to use cannabis. By 16, he was taking LSD
and amphetamines. One report states that at 16 he suffered an episode of drug
induced psychosis. He left school with some qualifications and wanted to join the
army, but by 18 was using heroin and committing offences to fund his addiction.
When he was 18, his sister died from natural causes. This had a profound and
lasting effect on him. He later claimed that he did not receive bereavement
counselling, and felt isolated from his parents. However, his parents told my
investigator that he was offered counselling but refused it. In response to his
sister’s death, he took as many drugs as he could, and consequently experienced
further episodes of psychosis. According to his parents, his behaviour was
bizarre, and he was difficult to manage and prone to spontaneous mood swings.
The man told the Probation Service that his parents found it difficult to understand
and cope with his drug addiction.
6. Eventually the man left home. However, at the time of his death his parents
visited whenever they could and frequently exchanged letters with him. He was
also supported by his girlfriend. According to his probation report it was his hope
that they could eventually settle down together.
7. In August 2002, the man was given a three year custodial sentence for his failure
to comply with a drug treatment programme. When he was released, he began to
abuse drugs again, spending approximately £40-£50 per day on heroin and
amphetamines, and selling personal items to fund his habit. The probation
records state that he felt that his habit was spiralling out of control, and he was
getting into more trouble. The man completed some drug courses whilst in
prison, notably the Short Duration Drug Programme and the longer Prison
Addressing Substance Related Offending.
8. The man handed himself into the police in February 2005, in order to receive
support in addressing his drug misuse. Three months later, he appeared at
Dorchester Crown Court and was sentenced to a Community Rehabilitation Order
of 18 months, and an Addressing Substance Related Behaviour Order, with a six
months Drug Treatment and Testing Order. However, shortly afterwards, he
breached the conditions of the Orders, and a Crown Court warrant was issued for
his arrest. In August, he appeared in court again, and was fined for theft and
trespass. His probation officer reminded him of the outstanding warrants, and
advised him to surrender to police but he failed to do so at that time.
9. In an interview with the Probation Service, the man described himself as a social
misfit. To residents in the therapeutic community, he referred to himself as a
hippy. He was variously described to my investigators as a deep thinker, an
intellectual and a person with a lot of thoughts in his head. He wrote poetry,
some of which was published in an anthology, and was a keen and talented artist.
7
HMP CHANNINGS WOOD
10. Channings Wood is a Category C training prison, built on the site of a former
Ministry of Defence base, and officially opened in July 1974. A building
programme took place in the 1980s and early 1990s, adding further
accommodation. The operational capacity is 667 men, serving a wide range of
sentences. The prison contains a specialist therapeutic community for tackling
drug abuse.
The drugs therapeutic community
11. The therapeutic community opened in November 1997. It is a partnership
between the Prison Service and Phoenix House, a national charity providing
specialist treatment services for drug and alcohol users. The community offers
an intensive, structured programme for prisoners who abuse drugs. It is housed
in one of the prison’s living blocks, and currently has space for 65 men, although
when the man was there the capacity was 90. It is staffed by prison officers and
drugs workers, all of whom have had specialist training.
12. The approach of the community is that, rather than drug dependency being seen
as a medical, psychological or social problem, it is viewed as symptomatic of
deep rooted problems within the person. Treatment is holistic and not limited to
the drug dependency, with the focus on helping men develop an insight into their
behaviour and emotions, and how it relates to their offending. The aim of the
programme is to understand their thinking and behaviour, so they take positive
steps to resolve problems rather than take drugs to mask them.
13. The community’s information booklet sums up the process as:
“Learning to be flexible and in control of feelings and behaviour. The
resident gradually becomes aware of their behaviour and learns to
control it through a wide range of situations, which mirror everyday
experience. As self-control is demonstrated, more responsibility and
status is given, and new skills (for most residents) of authority and
responsibility for others are learned.”
14. The programme differs from other drug treatment courses the man had
undertaken in its length and intensity. Other courses consist of several sessions
a week for a period of up to six weeks, during which the prisoner lives on a
normal wing and participates in the standard prison regime. Here, the residents
live in the community 24 hours a day, 365 days a year and the programme lasts a
minimum of 12 months. It is designed to provide a safe environment with a highly
structured daily routine, and demands a very high standard of behaviour from the
residents in every activity all the time.
15. Prisoners who wish to take part in the programme have to complete a set of
application forms, giving a great deal of personal information, including their drug
use, personal history, reasons for wanting to join the community and possible
obstacles to their successfully completing the programme. Other relevant
information is provided by Counselling Assessment Referral Advice Throughcare
(CARAT) drug workers, the healthcare and security departments.
8
16. There are three phases to the programme, Induction/Orientation lasting three to
four months, Primary which lasts for six to nine months and Pre-entry for three
months. Residents move at their own pace and must achieve individually set
goals before moving to the next stage.
17. The community has a hierarchical structure and there is a social contract that
prescribes very high standards of behaviour in every aspect of life. There is a
formal process whereby residents receive positive feedback from other residents
and staff. This is delivered publicly at each morning’s meeting. If behaviour falls
below the standard, other residents are expected to challenge him, first informally
and then more formally if the behaviour persists. Challenges come in three
forms:
• Negative Pull-ups when a resident is challenged about his behaviour, the
reason for the challenge is explained, accepted and action is taken;
• Sanction, which is more formal and may involve the resident writing an
essay to explain why his behaviour was not acceptable; and
• Encounter when the resident is confronted by his peers in a group setting,
the reasons are explored and support and advice is offered to the resident
who is encouraged to commit to change.
18. The community offers a varied and high level of support for residents. Each
resident has regular meetings with a personal officer to assist with prison related
issues, and a key worker to focus on treatment related matters. The key worker
sets a care plan and jointly reviews progress. Each resident also chooses two or
three other residents to form his Peer Support Group (PSG), which meets once a
week. During the Induction stage, new members are allocated a resident to be
their Buddy, and they meet three times a week to discuss any problems.
19. The residents’ day is tightly scheduled and includes two meetings and a seminar
daily, and an encounter group three times a week. Residents in the
Induction/Orientation phase spend the rest of the time in education and group
work, learning about the concepts that underpin the programme. Residents in the
Primary stage work in the community, and Pre-entry residents have community
responsibilities and also work outside the wing.
20. As residents progress through the programme, they are given positions of
increasing responsibility within the community. An important role is to be
responsible for a group of residents at an earlier stage of the programme. Each
phase has a resident nominated as the Department Head, with several team
leaders. The whole programme has a resident Chief Co-ordinator, responsible
for the day to day running of the Community. The posts holders are selected by
interviews with staff and senior residents.
21. Residents leave the community before completing the programme if they break
the rules of no violence, threats of violence, drugs or alcohol and sexual or racial
harassment of staff. Also a resident may ask to come off the programme, which
is known as taking off their badge, and is given 48 hours to consider their
decision. During this time, a member of staff will offer support as will other
residents. Residents may remain on the same wing, elect to return to the main
9
wings, or are moved as a result of operational requirements. Prisoners who
subsequently wish to rejoin the community, may apply again.
10
KEY FINDINGS
HMP Dorchester and Exeter
22. On 12 October, the man surrendered himself to the police, as he had done in the
past. He was charged with breach of his Drug Treatment and Testing Order, two
counts of burglary and two of theft. On 13 October, he was remanded into
custody at HMP Dorchester. As part of the reception process, a nurse completed
a First Reception Health Screen form. A note was made that he needed metal
work removing from the lower area of his spine. He told the nurse that he used
heroin and amphetamines weekly, and took some drugs intravenously. The man
also disclosed that he had seen a psychiatrist in 2000 for drug-induced psychosis
(a psychiatric disorder with impaired functioning which grossly interferes with the
capacity to cope with everyday life). He had been prescribed Flupenthixol
Decanoate medication to treat psychoses and related disorders.
23. When the man was asked whether he had ever tried to harm himself, he
confirmed that he had done so, both in prison and whilst out, most recently in the
1990s when he had cut his arms. However, he said that he did not currently feel
like harming himself, and he was coherent and made good eye contact with the
nurse. He told another member of staff that he did not have a fixed address, and
it was noted that this would be referred to the Resettlement Department.
24. On 27 October, the man was convicted at Taunton Crown Court and was
remanded to HMP Exeter. During the reception health check it was again noted
that he needed metal work removing from his back, as should have happened in
2003. An appointment with the prison doctor was requested. The following day,
he had a Resettlement interview during which he said that he was expecting a
sentence of a couple of years. He was also seen by a drugs worker and they
discussed different strategies to address his drug use, depending on his
sentence. The man told the drug worker that he was not using drugs, but that it
was a struggle.
25. Four days later, on 1 November, the man went to the healthcare centre
complaining of a rash under his arms and in his groin. He said that he had
suffered from the rash for about 18 months and that, while steroid cream made it
worse, E45 cream helped. Previous doctors had prescribed steroid and anti-
fungal creams and antibiotics. The prison doctor decided to refer the man to a
dermatologist, and three days later she also contacted the surgeon who had
operated on his back. He confirmed that the man needed the metal work
removed and said that the waiting list was currently six months.
26. On 10 November, an officer noted that the man spent all his time in his cell and
seemed to have no interest in working. He described him as having a bad
attitude to staff and other prisoners. At the end of November, the man was
sentenced to five years imprisonment at Taunton Crown Court for burglary. The
Prison Escort Risk (PER) form from the court recorded that he had harmed
himself while in prison previously, and also tried to hang himself whilst in police
custody. The PER form was accompanied by a Prisoner Warning Notice:
Possible Risk of Self-Harm or Suicide, completed after he was sentenced. This
11
noted that the man’s mental health might need monitoring if he received a long
custodial sentence.
27. The man returned to Exeter where a Further Reception Health Checks form was
completed. His sentence was noted, and the man was recorded as saying that it
was okay and he could deal with it. There is no record of any further action being
taken about the warning notice. It was filed in his core record, which was held in
the Discipline Office and not on the wing. The man started to attend Education,
and an officer noted that his attitude had improved and he had no problems.
However on 3 December, it was suspected that he was involved with drugs in the
prison. No specific action was taken against him, as staff were on heightened
alert in the run-up to Christmas.
The first week at Channings Wood
28. On 16 December, the man transferred to Channings Wood. The PER form said
that he was at risk because of alcohol and drug issues. It did not mention any
concerns about self harm and did not refer to the Prisoner Warning Notice from
the Crown Court. When the man transferred to Channings Wood the PER form
from Taunton Crown Court was still in his core file which went with him.
However, because it was filed away, wing staff were not aware of the warning. It
would be helpful if staff in the Discipline Office could check the files of newly
arrived prisoners for warnings such as that on the man’s PER form. However,
after his return to prison from the Crown Court, the man did and said nothing to
lead staff to believe he was contemplating harming himself.
29. The man told staff at Channings Wood that he was happy to be there, but he also
said that he would like to be transferred to HMP Guys Marsh for a drugs course.
(During a previous prison sentence, he had completed a Prison Addressing
Substance Relating Offending programme (PASRO) at HMP Dartmoor. Using
the lessons he had learned on the course, on release, he had remained drug-free
for many months.) He was told to make a transfer application. The health screen
noted that he still needed hospital appointments for both the rash and the metal
work in his back.
30. The man was allocated to Living Block 4 in order to go through the induction
process, which included a presentation about the therapeutic community which
he expressed an interest in visiting. On 21 December, a principal officer
interviewed the man, and described him as confused and not knowing what he
wanted. He went to the community and was able to talk to some of the residents.
He was impressed by what he saw, especially the artwork displayed on the walls.
On 27 December, whilst applying for a place in the community, he moved to
Living Block 1 where it is located. It was noted that he was happy to be there and
anxious to address his drug problem. Two days later, he was told that the
hospital appointments for his skin and back had been asked for.
The Induction phase of the therapeutic community
31. The man completed the application forms on 28 December and signed the
resident’s compact the same day. One sheet enquired about drug use, listed 12
12
different types and asked which ones he used and how frequently. The man said
that he used all of them, except prescribed methadone, and he occasionally used
magic mushrooms. He said that he had not used drugs during the previous four
weeks in prison, which was confirmed by a voluntary drug test. He said that he
first experimented with drugs at 14 when he used cannabis. By the time of his
arrest, he used £100 worth of drugs per day. When asked to describe himself,
the man wrote that he was just another prisoner. He said that he was ready to
address his substance use and offending behaviour as he felt ready to accept
change and find a better way of life that did not hurt anybody including himself.
He gave a somewhat muted answer when asked what he hoped to achieve in the
therapeutic community. He said that he was uncertain, but would like to be ready
to live a full, drug-free life. He hoped that nothing could prevent him from
achieving his goal and finished the forms by saying that he was desperate to
change the pattern of drugs and prison that he had been caught up in.
32. The therapeutic community programme generates a number of reports on
residents, many of which were completed by residents in positions of
responsibility. Their informative, helpful and supportive entries are impressive
and were most useful in the drafting of this report.
The Governor and Treatment Manager should commend the residents for
the high standard of their reports.
33. The reports show how the man struggled to adjust to the demanding programme
in the community. As early as week two, the landing representative noted that he
found it hard to deal with other residents pointing out his failure to keep the rules.
His buddy wrote that it was a tense week as the man had begun to identify issues
which he needed to deal with.
34. On 19 January, the man and his key worker drew up his Individual Treatment
Plan and identified six issues, including relationships and problem solving, with a
number of aims and objectives to achieve them. The man signed the plan two
weeks later, as required in the Induction phase.
35. By the end of the month, the man’s personal officer wrote that he appeared to
have settled into the community. Residents agreed that he fitted in and was well
liked. However, time keeping was an increasing problem, as punctuality was not
important to him. For example, on one occasion he was still in bed at 8.45am
although he should have been at the morning meeting. Consequently, a
Residents Review meeting took place on 1 February and the man discussed the
problem with his key worker, the resident who was his landing representative, and
two other residents. They decided that the man had a defeatist attitude and
lacked motivation. It was recommended that his time-keeping should be
monitored and he should buy an alarm clock. The programme manager accepted
the recommendation and noted that the man needed to work on his laid back
attitude. The man signed to say that he was satisfied with the review, which
galvanised him for a while and his time-keeping improved.
36. The same day, the man attended an emergency Peer Support Group meeting
because there was an altercation between him and another resident. This was a
13
residents only forum, composed of prisoners with no staff present. The other
resident had gone into the man’s cell, shut the door and asked for coffee. The
man swore at him and told him to go away. Their behaviour was discussed and
both were criticised. They agreed that things had got out of hand and apologised
to each other.
37. Over the next two weeks, the man began to find his feet and the reports talk
about him getting ready to move into the Orientation stage. Several residents
warned him that he would then have to meet even more stringent requirements
and standards of behaviour. However, they noted that, in their opinion, he would
be an asset to the group. At the end of Induction, the man wrote his ‘Life Story’,
which all residents must do and include as much detail about their lives as they
feel able to share. He admitted to his buddy that he was nervous about the
presentation, but asked several friends already in the Orientation group to come
and support him.
38. On 19 February, the man and the Induction department head completed his
Induction assessment. Again, he listed the issues to address and his goals whilst
on the therapeutic community. The department head noted that the man would
struggle in Orientation unless his attitude improved. He observed that the man’s
motivation was spasmodic, and his attitude to the programme was variable, but
that he was ready for induction. He added that the man needed to take pride in
his efforts and to find what motivated him. This second comment chimed with the
opinion of several members of staff, who also identified a lack of clear motivation.
39. Three days later, a case conference decided that the man should move on to the
Orientation phase of the programme. The man demonstrated to his key worker
and two residents that he understood the concepts underpinning the community.
They felt that he was more than ready to move to the next stage in the
programme, but they too noted that he was somewhat unsure as to his direction.
This was something that could be addressed in Orientation phase, where the man
duly moved the same day.
Orientation phase and the man’s withdrawal from the therapeutic community
40. The man’s first report in Orientation was written by the landing representative. He
noted that the man was very unsure, but was looking forward to a visit from his
girlfriend which would help resolve his doubts. The following day, 26 February,
the department head said that the man appeared to be fitting in well, but that it
was too soon to say anything further.
41. The following week, the man was again challenged to meet the required standard
of punctuality. He was given the post of Attendance Co-ordinator to try to
encourage him to be at meetings before they began. The department head’s
report included, for the first time, the number of confrontations the man received
during the previous week. He was given ten positive pull-ups when people
commended him for a particular action, and eight negative pull-ups, meaning that
his behaviour was challenged as not conforming to the required standard. The
landing representative’s report said that the man was still getting used to the new
routine. The man’s personal officer reported that he had gained a lot from the
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Induction phase and his communication skills were improving. The report quoted
a very telling phrase from the man who said that he felt “he had a big, fat addict
inside himself he has to fight.” The officer concluded by saying that the man
would need a lot of support to attain his goals.
42. In spite of the observation about improved communication skills, the man
struggled during the visits he had from his family. His parents described him as
under great strain and very tense. He had begun to look at his past life whilst
writing his life story, and had to deal with the issues involved. One of the
residents recalled the man telling him of a visit when he said some horrible things
to his girlfriend who had left early in tears. The man told the resident that he felt
very guilty and was writing to apologise.
43. By the end of the second week of the Orientation phase, the man had decided to
leave the programme. He told staff that the course placed too much pressure on
him, and he had to come to terms with aspects of his past. As with all residents,
he was allowed 48 hours to consider his decision when he spent a lot of this time
in his cell. Staff and residents tried to persuade him to stay, but he was adamant
that he wanted to leave. One of the residents spoke about how strongly the
residents try to persuade leavers to change their mind and remain in the
programme. He described it as, “we put him on a guilt trip” and how they
emphasise that the programme is what they need to get their life back on track.
But the man did not change his mind.
44. The course de-selection summary reiterated the man’s problems during the
programme, particularly his struggle with motivation. The objectives identified for
the man to take forward were:
• to see his drug worker
• to see a probation officer about his resettlement needs
• to investigate possible education courses.
45. Two weeks later, on 27 March, the man moved to Living Block 4. A week after
that, he transferred to Living Block 3 where his cell was on an upper landing
named Exe after the river. On 4 April, he again met his drug worker from Exeter,
who was now working at the prison, and they discussed what he should do next.
He expressed the need to have some direction in his life, and it was suggested
that the chaplain might know of suitable courses.
46. Three days later, he had an appointment with the doctor as he was sleeping
poorly and feeling depressed. The doctor prescribed a low dose of an anti-
depressant, and said that he would see him two weeks later. The man neither did
nor said anything to indicate that he was considering harming himself and gave
the doctor no cause for anxiety. The medication was issued to the man to keep in
his possession. There is no way of knowing whether he took it as prescribed.
47. On Sunday 9 June, the man went to a church service and stayed afterwards for a
cup of coffee. He spoke to the chaplain and told him that he felt that he needed
spiritual direction. The chaplain told him about an Alpha course which was
beginning shortly (the Alpha course looks at questions about the meaning of life
from a Christian perspective). The man said that he would like to take part and
15
this was agreed. At the end of the discussion, the chaplain thought that the man
appeared fine, and was not troubled or at risk of harming himself.
48. One of the prisoners on Living Block 3 at the time, spoke to the man two days
later and asked him how he was, to which the man replied that he was fine. The
man went on to tell the other prisoner that he was serving a five year sentence
which he was coping with. He also said that he had been in the therapeutic
community, but did not like it as other prisoners told him what to do.
12 April 2006
49. At approximately 8.00am on Wednesday 12 April, the man’s cell was unlocked
and he immediately went downstairs to collect his breakfast from the servery. He
asked whether there was any butter available and, when told no, took toast and
boiled eggs and returned to his cell. The officer who supervised the serving of
breakfast said that the man seemed quiet as usual but okay. The man did not eat
the food, and it was found untouched later that morning.
50. After collecting his breakfast, the man returned downstairs to the communal area
to make a telephone call to the house where his girlfriend was staying. The call
lasted from 8.12am to 8.27am, and a man answered the telephone. The man
who died asked to speak to his girlfriend but, in spite of holding on for 15 minutes,
he was unable to talk to her. On listening to the recording of the call, my
investigator thought that – perhaps unsurprisingly – the man sounded quite
frustrated by the time it came to an end.
51. The man returned to his cell. Just before 8.30am, an officer gave him a
movements slip to enable him to go to the gym that morning. She said that the
man was standing beside the cell table, and took the slip from her without saying
anything. She told my investigators that the cell door was ajar and his cell
appeared normal. The period after 8.30am is a busy time on the wing with a lot of
movement as men go to work, education or the gym. The investigators could find
no-one who saw the man in the next half hour and it appears that at some point
during those 30 minutes he shut his door and locked himself into the cell.
52. At 9.00am, the same officer went back round the landings to check that everyone
who should have left had done so, and to lock up those remaining on the wing.
When she reached the man’s cell, Upper Exe 49, she saw that the door was
locked, so she unlocked it and went in. She saw that the man had urinated, and
was hanging from a ligature of shoe laces attached to a leg of his upturned bed.
He had his back to the window on the far wall and was facing half left towards the
basin.
The Governor should conduct a risk assessment to consider having all
beds bolted to the floor to reduce the possibility of them being used as a
ligature point in future.
16
53. The officer immediately stepped back into the corridor and used her radio to call
for urgent medical assistance for Exe 49. Then she returned to the man and,
bracing her back against the wall, lifted him up to take the tension off the ligature.
54. Two officers were in a downstairs office and heard the call for assistance on the
radio. They ran upstairs and were directed to the cell by prisoners who were in
the corridor. They entered the cell and took hold of the man to assist the female
officer bear his weight. Some prisoners were in and around the cell, and one
brought a razor in an unsuccessful attempt to cut the ligature. One of the male
officers told them to leave the cell, and a fourth officer arrived and moved the
prisoners to the far end of the corridor.
55. A senior officer (SO) was the wing manager that day. When she heard the
emergency call, she also went to the cell. Once there, she stood on a chair and
tried to remove the ligature, but was unable to do so. She sent a fifth officer to
fetch ligature scissors from the office and a laryngeal mask. (Ligature, or cut-
down scissors have sharp blades and blunt ends and are designed to cut through
ligatures. A laryngeal mask opens up a patient’s airway to more efficiently deliver
oxygen.) The SO then felt for a pulse but could not find one. At 9.02am, she
radioed Communications to tell healthcare staff that oxygen was needed. Shortly
afterwards, she asked an officer outside the cell to contact Communications to
call for an ambulance. The Communications’ log shows that the ambulance was
called at 9.04am.
56. The fifth officer went to get the scissors from the emergency box on the wall of
the wing office. However, the box was kept locked and he was unable to locate
the key which was on its side. (The wing SO has since moved the key pouch
from the side to the front of the box.) He then ran to the office in LB4, just across
the entrance passageway from LB3, and asked the officer there for the cut-down
scissors. The LB4 officer estimated that this was approximately 9.02am, and he
took the scissors and ran to Exe 49. The ligature was cut and officers lowered
the man to the floor. The LB4 officer checked the man’s neck and leg for a pulse.
When he did not find one, he started chest compressions.
57. Very shortly afterwards, two nurses arrived with the emergency bag and oxygen.
They had been in the treatment room in the Healthcare Centre when the call for
medical assistance was received. They took the bag with resuscitation
equipment and an oxygen cylinder and went to LB3. On the way, one of the
nurses asked Communications for any further information about the nature of the
incident, but there was none. When they arrived at the cell, she observed that the
man’s pupils were fixed and dilated. She placed a mask over his nose and
mouth, and attached it to an oxygen cylinder. Then she and the LB4 officer
began to administer cardio pulmonary resuscitation (CPR). The officer performed
30 chest compressions, then paused as the nurses took turns to push oxygen
through the mask into the man’s lungs. Another officer took turns with the LB4
officer in doing the compressions. As they began CPR, one of the nurses asked
for the defibrillator (a machine that treats victims of sudden cardiac arrest by
delivering a shock to the heart), and for more oxygen to be brought.
17
58. The SO took the man’s arm and monitored it for a pulse. Two minutes later, a
healthcare officer arrived with the oxygen and the machine from the treatment
room in the healthcare centre. A nurse attached the defibrillator to the man and
followed its instructions to continue the CPR. At 9.12am, the SO detected a faint
pulse in the man’s arm and, as his heart started to beat, the LB4 officer stopped
administering chest compressions, and the nurses continued the oxygen therapy.
Three minutes later the paramedics arrived and were briefed by Healthcare staff.
The paramedics attached their own defibrillator to the man and put an
endotracheal tube (similar to the mask used by the nurses, but going deeper into
the airway) into his throat. The LB4 officer replaced the prison oxygen cylinder
with one provided by the paramedics. The man then began to take breaths, but
they were insufficient for him to breathe unaided. The paramedics took over the
man’s care and, at 9.37am, they took him down to the ambulance where they
continued treatment to stabilise him. At 9.55am, the ambulance left the prison for
Torbay Hospital, with two officers as escort.
59. As the paramedics prepared the man for the journey to the hospital, the SO
began an Assessment, Care in Custody and Teamwork (ACCT) care plan for him.
The ACCT document describes the problems facing a prisoner at risk of harming
himself and implements a plan to give him the support he needs to help him
through a period of crisis. The SO told one of the escorting officers to open the
document as he was accompanying the man to hospital. Her forward thinking is
to be commended as she set in place the support the man would have needed
had he recovered and returned from the hospital.
60. Whilst the man was being resuscitated, members of the Care Team and
chaplaincy went to the wing to offer support to staff and prisoners. Once the
man had gone to hospital, two meetings for staff were held. Those meetings are
discussed in detail in the next section of this report.
61. Staff then tried to contact the man’s next of kin. When he arrived at Channings
Wood, he had listed his girlfriend and parents, but did not provide telephone
numbers for them and Directory Enquiries were unable to provide any
information. Staff were still trying to find current numbers for his next of kin, when
his mother rang the prison. She spoke to the visits clerk and asked to reschedule
her visit booked for that afternoon. The clerk, realising that other staff were trying
to contact her, alerted the duty governor who asked a member of the chaplaincy
team to break the news of the man’s attempted suicide and offer care and
support. The clerk’s initiative and efficiency is commendable and meant that the
man’s parents were contacted earlier than would otherwise have been the case.
62. The ambulance arrived at Torbay Hospital at 10.20am and the man, who was still
unconscious, was taken to the resuscitation unit. An hour later, he was
transferred to the Critical Care Unit, sedated and ventilated. The escorting
officers informed the prison of the move. They were told that the man’s next-of-
kin had been informed and were on their way to the hospital. At 10.55am, the
man was given a scan and at 12.15pm, he was x-rayed on the ward. His parents
arrived at 1.30pm and went into the family room, where they were joined 15
minutes later by the chaplaincy staff member. They were informed that the scan
showed some brain ischaemia (dead tissue) and that the prognosis was poor.
18
Unfortunately, despite the efforts of prison staff, paramedics and hospital staff,
the man’s condition did not change over the next 18 hours.
63. The acting governor decided that, given the seriousness of the man’s condition,
no restraints should be used. Two officers were always present and they
completed a bedwatch log of events during the man’s time in hospital. The
escorts were also told to offer what support they could to his family.
64. At 8:35am the following morning, the prison chaplain arrived at the hospital to
offer support to the man’s family. Later, the acting governor also went to the
hospital and spoke to the man’s parents. By this time, his girlfriend had also
arrived and was at the bedside. The consultant treating the man met the family
twice during the morning, and the decision was made to reduce his medication
and remove the ventilator. Afterwards the family remained at the bedside until
the man died at 2.25pm.
65. The prisoners on Living Block 3 collected for a wreath for the man. Given that the
man had only been there for eight days, they collected the impressive sum of
£130. The prisoners who took it to the chaplain asked that, as well as a wreath,
there should be a bouquet of flowers for his mother. On the Sunday after the
man’s death, prayers were said for him at the prison’s church services. When the
police released the cell, the chaplain blessed it before it was used again.
66. The man’s parents asked the chaplain to conduct the funeral, which was held at a
local Crematorium. At approximately the same time, another member of the
chaplaincy team led a memorial service at the prison which about 20 prisoners
attended.
67. After the funeral, the Governor and chaplain discussed the possibility of holding
an exhibition of the man’s poems and paintings with his parents. It was agreed
that this would be a fitting celebration of the man’s life. The exhibition opened in
the prison chapel on 4 September and displayed approximately six paintings and
14 poems. The man’s parents visited the exhibition during the first week, and had
the opportunity to talk to some of the prisoners looking at their son’s work. In
November, the exhibition was displayed in Exeter Cathedral for a week.
19
ISSUES
The man’s clinical care
68. During the six months the man spent in prison, he was treated for three separate
conditions. The metal work in his back needed to be removed and the doctors
contacted the surgeon who had carried out the original procedure two years
earlier. The man was also referred to a dermatologist for a rash, and medication
was prescribed.
69. Five days before the man hanged himself, he told the doctor he was depressed
and sleeping poorly, and was prescribed anti-depressants. He held the
medication in his possession, so it is not possible to establish whether or not he
took it as prescribed. However, two days later, he spoke to the chaplain about
starting an Alpha course and appeared to be in a positive frame of mind.
70. In her report (Annex 1), the clinical reviewer concludes that in both the treatment
the man received and his resuscitation on 12 April, the care was appropriate.
The man’s stay in the therapeutic community
71. When the man began the programme in the community, he was allocated another
resident as his buddy. The buddy told my investigators that he felt the man
enjoyed being in the community. He thought that the man appreciated its open
atmosphere where residents could talk freely, both about the course and life in
general. However, he added that the man was still a private person, who found it
hard to trust others and difficult to talk about himself, his background and his drug
use. Although he did open up to the residents, he was not comfortable with this
aspect of the programme. He also had problems adjusting to two other aspects
of the programme: timekeeping and the system of confrontations, which are an
essential part of the regime.
72. The man struggled with punctuality throughout his time in the therapeutic
community. Everyone who spoke to the investigators commented on the fact that
he found it difficult to be where he ought to have been at the correct time. The
man was regularly challenged about his time-keeping, and had a formal meeting
where this was discussed.
73. The chaplain described him as a man with a creative personality, who might have
had difficulty adjusting to a structured environment. The chaplain recalled that
the man used to look into the middle distance as if his mind was on other things.
This was echoed by the treatment manager, who said that the man was very
polite but tended to be off on his own.
74. Members of staff who spoke to my interviewers doubted the man’s motivation to
participate in the therapeutic community. His drugs worker, who oversees the
Induction phase of the programme, said that the man’s motivation fluctuated
during the programme, and at times his heart was not in it. He described the man
as being caught between his past and the potential for achievement. However,
20
he said that at the end of the Orientation phase the man was beginning to adapt
to the rules and regulations, including punctuality.
75. The man also struggled with the system of confrontation used in the therapeutic
community. The rules are very detailed and demand a higher standard of
behaviour than is normal in prison. Residents’ behaviour is open to scrutiny all
the time, and their behaviour is challenged by staff and by other residents. Many
residents, and the man was no exception, find it hard to adjust to being
confronted over such things as swearing or pushing past someone in the corridor.
76. However, the man did make a positive contribution to the therapeutic community,
and residents and staff all spoke of his contribution in meetings. He quite readily
offered his opinion and advice. By the time he finished Induction, he was
described as a generous person and “a giver”. A senior resident described the
man’s contributions as insightful, good at summing up an issue and sharing his
opinion about possible actions. Staff said that sometimes his attitude, particularly
at the beginning, could be described as sarcastic. However, they also said that
he got on well with other residents
77. In conclusion, the man found it impossible to change his behaviour to conform to
the very disciplined nature of the community. For someone who viewed himself
as a hippy, the ethos and demands of the community would seem to have
required too radical a shift in his thinking. The reports from the therapeutic
community show how hard he tried to adapt to the programme’s detailed and very
demanding rules. This put him under a great deal of stress which added further
to his problems. The strain showed during his family visits, one of which ended
early because of his behaviour. By the time the man completed the second week
of the Orientation phase, he had decided to leave the programme. Once his
decision was made, he stuck to it, in spite of encouragement, support and
motivation from staff and other residents.
Leaving the community
78. When the man decided to leave the programme, he was given the usual 48-hour
period to reconsider his decision. During that time, both staff and prisoners spoke
to him, trying to persuade him to stay in the community. After leaving, he spent a
lot of time in his cell, which he is likely to have found frustrating as he needed
always to keep his brain occupied. However, hen did not change his mind, and,
although he remained on the same unit for almost three weeks, he was no longer
a member of the therapeutic community.
79. Whilst a resident in the programme, the man had a well structured support
system in place. When he left the programme, that support was no longer
available to him. However, for the man, as for all prisoners in Channings Wood,
there are a number of other sources of help and support. The prison has a
personal officer scheme and a Samaritans supported Listener scheme in place
for prisoners who are in distress or crisis and need to talk in confidence. The
chaplaincy also offers support to prisoners who approach them. I am satisfied
that, had the man wished to ask for help and support, there were a number of
21
options open to him. He spoke to the chaplain and consulted the doctor about
feeling depressed. It was the man’s decision not to approach anyone else.
80. He did have a plan of action for his return to a standard location. He discussed
his next actions with his CARAT worker and identified education as his focus for
the immediate future. At her suggestion, he spoke to the chaplain and arranged
to begin an Alpha course. On Sunday 9 April, when he spoke to the chaplain, he
appeared positive rather than someone at risk of self-harm.
81. There is no evidence available as to what caused his mood to change so radically
over the next two days. Neither did he leave any indication of why he acted as he
did.
Emergency response
82. When officers went to the man’s aid, their first priority was to support his weight to
ease the tension on the ligature. The next person to arrive tried to loosen the
knots but without success, and so asked for the anti-ligature scissors to be
collected from the cabinet in the downstairs office. The officer could not find the
key to unlock the cabinet and, rather than waste time, ran to another office to ask
for assistance. The second officer took the scissors, ran to the cell and
successfully cut the man down.
83. All this activity meant that there was a short delay of three to four minutes.
During the wait, three officers supported man to mitigate the effect of the ligature.
If the first officers at the cell had been carrying anti-ligature knives, in all
probability they would have been able to cut him down immediately. On this
occasion, the outcome might not have been different.
84. The officers interviewed described their frustration at not being able to remove the
ligature despite their best efforts. Prisoners on the wing were asked for craft
knives, and one brought a razor. It would have been better for all concerned if
officers had been properly equipped and able to sever the ligature without any
delay.
85. I am pleased that the Governor and Safer Custody Manager have already taken
steps to issue ligature knives to staff. At the time of drafting this report, 70 anti-
ligature knives have already been ordered and criteria developed for their issue.
All Principal and Senior Officers will carry them, as will other officers in direct
contact with prisoners. The Prison Service is currently drafting a Prison Service
Instruction that will make it a requirement for all officers and healthcare staff to
carry anti-ligature knives.
The Governor and Safer Custody Manager should arrange for the anti-
ligature knives to be issued as quickly as possible and all recipients to be
trained in their use.
86. When the female officer entered the man’s cell at 9.00am, she immediately used
her radio to call for emergency medical assistance and two nurses quickly
responded. They arrived within a couple of minutes of the call and started
22
resuscitation. However, they would have been better prepared if they had known
the nature of the emergency. One of the nurses told the investigator that, had
they known that man had hanged himself, they would have taken additional
oxygen and the defibrillator. As it was, both had to be requested once the nurses
knew the nature of the emergency. A further benefit of preparatory knowledge
would have been to allow the nurses to prepare mentally for the situation they
faced. They would also have had time to alert the doctor at an earlier stage.
87. Since the man’s death, the prison and senior healthcare staff have identified this
issue and the Operational Manager is working with the Head of Healthcare to set
in place a system of emergency call signs. These will mean that wing staff calling
for emergency assistance will provide information about the type of emergency.
They have also agreed that, in future, the doctor will be notified at an earlier
stage.
The Governor should ensure that the system of emergency call signs is
implemented as soon as possible, along with the requisite training for all
staff.
Debrief meetings for staff
88. Once the man had been taken to hospital, there were a number of meetings for
staff who found and resuscitated him. Prison Service Order (PSO) 2710 requires
a hot debrief meeting for all staff who attend an emergency to be held as soon as
possible after the event. Although three meetings were held later on 12 April,
none fulfilled the requirements of the Order.
89. The first one was held on the wing very soon after the ambulance left the prison.
The principal officer on duty and governor spoke briefly to staff to say well done
and inform them that they must write a statement before leaving the prison. The
staff who attended told the investigators that they did not find it beneficial. A
number felt that it was too soon for them to be praised for their actions,
particularly given the man’s serious condition. They had no opportunity to go
over what had happened and discuss the effectiveness of their response.
90. A few hours later, the governor who was in charge of the prison that day, met
some of the staff involved in the resuscitation. Discipline staff and the care and
chaplaincy teams were present at the meeting. Staff described this meeting as
more helpful, as it was not immediately after the event and there was time to talk.
However, healthcare staff were not present, and so staff did not have an
opportunity to take part in a multi-disciplinary discussion about their response.
The value of this meeting was reduced and again did not meet the requirements
of the PSO.
The Governor should set in place procedures for holding a timely hot
debrief for staff following a serious incident that comply with PSO 2710.
91. The prison has a care team, whose volunteer members provide welfare services
for their colleagues. The head of the team plans to hold an in-depth debrief at a
location outside of the prison for staff who would like to attend. The meeting will
23
be facilitated by a member of the Health and Welfare Service. This arrangement
has been followed in the past and proved to be very beneficial for staff.
92. The senior managers of healthcare met the acting governor on 13 April and held
a Significant Event Review which identified a number of issues, and they took
immediately steps to improve their procedures. The need for emergency call
signs and anti-ligature knives was recognised and staff were assigned to take
forward the identified actions. I commend the speed with which these actions
were taken.
Contact with the man’s family
93. When the man was taken to Torbay Hospital, a member of the chaplaincy team
went to meet and offer support to his parents. Another member of the team and
the governor went the following day, and remained with the family until the man’s
death. Over the course of the following week, one of the chaplains contacted
them every day, both to offer support and make arrangements for the funeral.
94. Another example of the prison’s sensitive attention was that, when the Governor
wrote to express her condolences, she used a blank card with flowers on the
front, rather than writing a formal letter on Prison Service notepaper. It was also
helpful that she informed the family of my investigation, including the name of my
investigator, which effectively prepared the way for my staff.
95. The man’s parents stressed to my family liaison officer how grateful they were to
the chaplain for his kindness and support in the days following their son’s death.
They also appreciated his hard work in organising the exhibition of paintings and
poems.
I commend the prison’s sensitive, caring and professional contact with the
man’s parents
96. However, one of the issues raised by the man’s parents was the manner in which
other family members learned of his death. The Duty Governor followed the
procedures set out for a death in custody, which include the routine publication of
a press notice including details of the offence. This is standard practice for the
prison or the Prison Service’s National Operations Unit, and is usually done when
it is confirmed that the family have been informed of the death. As the man’s
parents were present when he died, there was no need to notify them. Because
they already knew, a press release was issued and the news was quickly
reported in the media.
97. The man’s parents had, not surprisingly, not had time to inform other family
members, and so some learnt the news from Ceefax. This must have been a
shocking way to learn of the death of a family member and must have added
significantly to the distress. This is one of a number of instances where I
understand that bereaved relatives have learned details of a death from Ceefax.
It would clearly be helpful for next of kin to be advised at an early stage that a
press notice will be issued and, as details of the death may appear in the local
press and on Ceefax, for it to be suggested that they might want to contact other
24
family members quickly. I understand that staff in Prison Service headquarters
are currently working to resolve this issue.
I recommend that Prison Service staff who break the news of a death to
family members, also advise them that a press notice will be issued.
25
RECOMMENDATIONS AND GOOD PRACTICE
RECOMMENDATIONS
1. The Governor should conduct a risk assessment to consider having all
beds bolted to the floor to reduce the possibility of them being used as a
ligature point in future.
2. The Governor and Safer Custody Manager should arrange for the anti-
ligature knives to be issued as quickly as possible and all recipients to
be trained in their use.
3. The Governor should ensure that the system of emergency call signs is
implemented as soon as possible, along with the requisite training for
all staff.
4. The Governor should set in place procedures for holding a timely hot
debrief for staff following a serious incident that fully comply with PSO
2710.
5. I recommend that Prison Service staff who break the news of a death,
also advise them that a press release will be issued.
GOOD PRACTICE
6. The Governor and Treatment Manager should commend the residents
for the high standard of their reports.
7. I commend the SO for her forward thinking in opening an ACCT care
plan for the man. I commend the clerk for his initiative and efficiency in
passing the call from the man’s mother call to the acting governor.
8. I commend the prison’s sensitive, caring and professional contact with
the man’s parents.
26