Individual at Doncaster

The death in custody of a man in
HMP & YOI Doncaster in April 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2005
FOREWORD
The sad death of this man occurred during the first weeks after I took
responsibility for investigating all deaths in custody. At the outset I would like
to offer my sincere condolences to the man's family on their loss. He was
only 20 years old. Tragically his death appears to have resulted from an
accidental heroin overdose and came at a particularly difficult time for the
family so soon after the death of his uncle and his grandmother.
Under transitional arrangements agreed with the Prison Service at the time, a
Senior Investigating Officer (SIO) was appointed by the service to conduct the
investigation. The SIO works to me for the duration of the investigation and
submits a draft report that I review and amend as necessary. This final report
is my independent examination of the circumstances leading to the man's
death.
One of my family liaison officers met the man's family and remained in
telephone contact with them throughout the investigation. A clinical review into
his care and treatment was commissioned from Doncaster Central Primary
Care Trust (PCT).
Doncaster is one of several prisons that are managed by private companies
on a contract basis. The contract to manage Doncaster is held by Premier
Prison Services and a parallel investigation into the man's death was
conducted by their investigation officer. I have read the report of this
investigation and his conclusions do not differ in any way from my own.
I would also like to thank Global Solutions Ltd for their report into the man’s
care and management at court.
This version of my report has been anonymised for publication on my website.
The annexes listed below are not published in anonymised form.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2005
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CONTENTS
SUMMARY
PART ONE
1. Background
2. The events surrounding the man’s death
3. Post incident response
4. What other prisoners said
5. The Prison’s response to the death of the man’s
grandmother
6. The Prison’s assessment of the man’s risk of suicide or self
harm
7. Liaison with the man’s family
8. The family view
PART TWO
1. Findings
2. Recommendations
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SUMMARY
This is a report into the death of a 20 year old man in HMP & YOI Doncaster
on 21 April 2004. The issues in this summary are revisited in greater detail in
the main body of the report.
The man arrived at Doncaster prison on 27 January 2004. He was
transferred to Hull prison on 30 January and returned to Doncaster on 16
March. For about a month before his death he shared a cell with another
prisoner. The man was serving a sentence of 2½ years but was also awaiting
sentencing on another matter.
The man had served three custodial sentences prior to the one he was
serving when he died. Although he was at various times judged to be at risk
of self harm and had self harmed in the past, there is no record of him self
harming while in prison.
The man had a history of drug abuse going back to his early teenage years.
At the time of coming into custody in January 2004 he was reportedly
spending £50 a day on heroin. It seems likely, however, that he had not used
any heroin between 27 January and 20 April 2004.
The man’s grandmother died on 11 April 2004. His request to attend her
funeral was not granted by Doncaster prison. His grandmother’s funeral was
held on 20 April. By coincidence this was the same day he appeared in court
on a further charge.
On the morning of 20 April 2004, the man was taken to Leeds Magistrates
Court. He returned to Doncaster prison later that day and was taken back to
his cell at about 8.30pm.
A number of prisoners, including the man’s cellmate, say that shortly after the
man was finally locked in his cell he smoked what they believed to be heroin
that he had obtained at court that day.
The following morning wing staff checked the roll and started unlocking cells
as normal. The man’s cellmate got up, went to breakfast, returned to the cell,
changed into PE clothing and went to the gymnasium leaving the man
apparently asleep on the top bunk.
At approximately 8.12am, a Prison Custody Officer (PCO) entered the cell.
The PCO was immediately concerned about the man’s condition and
summoned medical assistance. Locally employed nursing staff and then NHS
paramedics attended the scene and made efforts to resuscitate the man.
These were unsuccessful and the man was pronounced dead at the scene by
a paramedic from the South Yorkshire Metropolitan Ambulance Service at
8.31am.
The cell was then sealed and the prison followed agreed procedures in
relation to notifying the police, next of kin, the coroner and other agencies.
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The prison carried out a search in case more heroin was available on the wing
and drug tested the man’s co-defendant. They did not test his cellmate.
The toxicology report showed extremely high levels of total and free morphine
in the man's body. The cause of death is listed as heroin poisoning.
The investigation into the man’s death has revealed some weaknesses in
interdepartmental communications at Doncaster prison and there is a need to
ensure clarity when dealing with requests to attend family funerals.
Other prisoners gave evidence that the man told them that he obtained the
heroin "from a friend at court". The man's father phoned the prison on 19 July
2004 and said that he had found out who had passed the heroin to his son
and when. He gave a name and said that the drug had been given to his son
at court on 20 April. This information has since been passed to the police and
I believe they have interviewed the man in question. This inevitably raises
concerns about security and searching procedures at both Leeds Magistrates
Court and in Doncaster prison’s Reception area.
Some prisoners have shown a surprising lack of awareness of the dangers in
smoking heroin and the danger signs of possible overdose. In particular there
is some ignorance about the possible effect of taking heroin following a period
of withdrawal.
Those members of staff who attempted to revive and resuscitate the man
acted promptly and professionally. From the evidence, it seems that by the
time he was discovered it was too late to save him.
I make a number of recommendations at the end of this report, with the aim of
helping to address some of the issues identified above.
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PART ONE
1. BACKGROUND
HMP & YOI DONCASTER
HMP & YOI Doncaster is a large and modern establishment. Built by the
public sector in 1994, its management is contracted out to Premier Prison
Services. The prison holds up to 1,120 male prisoners with both adults and
young offenders amongst the population. Doncaster is a ‘local’ prison serving
courts in the Yorkshire area. Some prisoners are sentenced and awaiting
transfer to ‘training’ prisons but most are unconvicted or unsentenced and are
awaiting the outcome of court hearings.
The prison provides facilities to address a variety of issues faced by prisoners
including substance abuse, resettlement issues and health issues.
Counselling and support services are available to those prisoners who may
need them.
On 21 April 2004, the prison held a total of 1,082 prisoners of whom 822 were
adults and 260 were young offenders.
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2. THE EVENTS SURROUNDING THE MAN’S DEATH
The man was remanded into custody at Doncaster prison on 27 January
2004. He had been convicted of burglary offences but was awaiting
sentence. The man’s co-defendant on the burglary charges was already in
custody at Doncaster.
The man went through the normal induction, reception and screening
processes. During this process it was identified that he was using heroin and
that he had been the subject of F2052SH procedures on previous sentences.
The man commenced a detoxification programme on 28 January.
On 30 January, the man was transferred to HMP Hull. He stayed at Hull until
16 March when he was taken to Leeds Crown Court and received sentences
totalling 2 years and 174 days. This sentence took into consideration the
unexpired portion of his previous sentence. From court, the man was
returned once again to Doncaster.
On 24 March, the man was taken to Pontefract Police Station to be
interviewed about and arrested on a charge of attempted robbery. He
returned to Doncaster that same evening.
On 11 April, Doncaster were informed of the death of the man’s grandmother.
As is usual practice, the information was passed to the prison Chaplain. The
man was called to the Chaplaincy department the following day and the news
was broken to him in private there. The Chaplain seems to have been
unaware that he had already had the sad news during a visit from his father
the day before. The Roman Catholic Chaplain spent about an hour with the
man during which the man spoke to his mother on the telephone for about 20
minutes.
The man was seen twice more by the RC Chaplain during that week to talk
about the arrangements for his grandmother's funeral. He was advised that it
was unlikely that he would be able to attend because his grandmother had not
acted 'in loco parentis' and was therefore not regarded as a close relative.
Under Prison Service Instruction to Governors 36/1995 prisoners are only
allowed to attend the funerals of close relatives. Grandparents are not
deemed to be close relatives unless they have acted 'in loco parentis'.
The funeral was held on 20 April and the man did not attend. In any case,
coincidentally, he was due to appear at Leeds Magistrates Court on the
charge of attempted robbery.
On the morning of 20 April, the man was taken to Reception for his court
appearance. Staff say he appeared bemused and told them that he had not
thought he needed to attend court for the hearing that day. At 8.00am, the
man was collected by Global Solutions Ltd (GSL) Court Services and taken to
Leeds Magistrates Court. The Prisoner Escort Record (PER) suggests that
he spent his day at court in a routine fashion and a subsequent investigation
by GSL has not revealed anything of note either. However, interviews with
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other prisoners and later information received from the man's father suggest
that, while he was at court, he received a bag of heroin which he later took
with him into his cell at Doncaster prison.
The man arrived back at Doncaster that evening. He went through the
reception procedures and was taken to his cell on A wing. When he arrived
on A wing, he was seen and spoken to by at least two other prisoners who
enquired how he had got on at court. One was his co-defendant who said
that the man had told him he expected to get a further three years and had
seemed "wounded". Another prisoner said that when he asked the man how
he was the reply had been mumbled and he did not catch what was said.
Once inside cell 111, the man spoke to his cellmate who also asked him
about his court appearance and recalled the man saying he expected two and
a half years. The cellmate felt the man had seemed "OK " about it. The
cellmate also said that the man asked the officer who escorted him to the cell
about his canteen goods. Earlier in the week, the man had placed an order
for such things as tobacco, toiletries and snacks to be purchased from his
private cash. The goods should have been delivered that day but the man
was at court and was therefore concerned about what had happened to them.
The officer went to find out. The cellmate said that, during the officer’s
absence, the man took a cellophane package from his pocket and put it on
the cell window sill. He described it to the cellmate as "a bag". The cellmate
said he could see that it contained a white powder that looked like heroin.
The officer returned shortly afterwards to say that the canteen goods had
been locked away for safe keeping and could not be dealt with until the
following day. Once again, the cellmate described the man as seeming "OK"
about this.
The cellmate said that, almost as soon as the officer left for the second time,
the man took the foil lid from a Pot Noodle container, spread the powder onto
it and began smoking it by inhaling the smoke through a biro tube.
The cellmate said that the man fell asleep after smoking the heroin. The
cellmate turned the cell light off at about 10.30pm and also eventually went to
sleep. He said the night was uneventful. The cellmate recalled waking up and
opening the cell window at some point but that is all.
Staff carried out a roll check at approximately 6.00am. They do this by
opening the cell observation flap and counting the number of prisoners in
each cell. It is sufficient to see a person in bed asleep.
After waking those prisoners who had to be up early for court appearances or
to work behind the servery, the staff then began unlocking the other cells on
the wing for breakfast. Prisoners are not required to go for breakfast if they
do not wish to. Cell 111 was unlocked in turn. The cellmate who had got up
and dressed went downstairs for breakfast, leaving the man on the top bunk
in the cell. The cell door would once again have been locked. At this time the
cellmate said that he had noticed that the man had some bluish blotches on
his face and some hardened froth around his mouth. While he was at
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breakfast, the cellmate said he spoke to other prisoners about the man’s
condition. Another prisoner said he went to the door of cell 111 and called out
to the man but got no response.
After breakfast the cellmate returned to the cell and changed his clothing to go
to the gymnasium. Once again, he said, he assumed the man was asleep
and did not speak to him or try to rouse him. The cellmate went to the
gymnasium about five minutes later and did not return to the wing again until
after the discovery of the man’s death.
At around 8.10am, a Prisoner Custody Officer (PCO) went to the man’s cell.
Part of the PCO’s duties involve taking voluntary drug tests from prisoners
who have joined a programme designed to help them stay off drugs. The
man was a participant in that programme and had had one such voluntary test
on 8 April. This test had proved negative.
The PCO had been an officer on the healthcare unit for eight years and has a
NVQ level 2 in Direct Care Nursing. The PCO said he found the cell door
ajar. He said he called out to the man twice with no response. He went up to
the man, who was on the top bunk, and felt his neck for a pulse. He said he
could find no pulse at either neck or wrist and the man felt cold.
3. POST-INCIDENT RESPONSE
Prison records show that the PCO raised the alarm at 8.12am. He called for
medical assistance on his radio from just outside the cell and then went back
inside where he was joined within a minute by two other PCOs. All three men
lifted the man from the bunk and were about to commence resuscitation when
they were joined by a nurse.
The nurse said he too took the man's pulse and could find none. He said the
man was very cold and there were extensive blue patches on all of his visible
skin. He said he was joined almost immediately by another nurse, and she
started chest compressions while he gave the man mouth to mouth.
During the attempted resuscitation, the first PCO tried to use an oxygen bottle
but found it difficult to release the gas. He told the first nurse that he was
having problems and he looked up quickly and said that the bottle must be
empty. A second bottle was produced but not used as mouth to mouth was
continued. Later it was found that the original bottle was in fact full and there
was a second valve which had not been opened to release the gas.
The first nurse said that, after about three minutes, another nurse took over
mouth to mouth and he ran to get the defibrillator machine. The interactive
reading on the defibrillator registered no response or heart movement and
indicated that resuscitation should continue. Staff carried on with the chest
compressions and mouth to mouth until ambulance paramedics arrived on
scene at approximately 8.26am. The paramedics applied their own heart
monitor but received no response. They advised the nursing staff to stop their
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attempts at resuscitation at 8.31am. Some five minutes later the prison doctor
arrived and confirmed that the man was dead.
The Anglican Chaplain, entered the man's cell and said a prayer for him. The
cell was sealed at 8.53am. The police arrived at and took pictures between
10.42am and 10.48am and at 1.58pm the man's body was taken to the
mortuary. There was no suicide note.
4. WHAT OTHER PRISONERS SAID
Several prisoners were interviewed or made statements during the course of
the investigation.
The cellmate said that after smoking some of the powder the man lay on the
bed. He was pale and his eyes were red. He gave the man tobacco and
papers and the man smoked some of the cigarette before going back to the
powder. At one point the man looked in the mirror and said “I’m fucked” or
"fuck it" and then started smoking the powder again. The cellmate said that
while the man was smoking other prisoners were asking him to give them
some. He said that the man smoked most or all of the powder before passing
the foil under the door. The man’s actions never gave the cellmate any real
cause for concern. There was no indication or implication that the man wanted
to overdose on heroin. The cellmate said he turned the light out at 10.30 or
11pm. The man was breathing very heavily and it took him a while to get to
sleep. At some point he said he got up to open a window and said he thought
that the man had stopped making the heavy breathing noises. The next
morning the cellmate did not try to rouse the man or talk to him. He said he
thought he would be sleeping off the effects of the drug. He did notice some
bluish blotches on his face and some hardened froth around his mouth. He
said he was unaware of the man's death until told later that morning by the
Houseblock Unit Manager.
The cellmate also said that he had seen the man crying on the Sunday that
his grandmother died. He thought the man had been "clean" between 27
January and 20 April 2004 and that he was "OK" about the prospect of a
further sentence. The cellmate said that the man told him he had obtained
the heroin at court on 20 April.
The man's co-defendant was also interviewed. His view was that the man did
not cope well with being in prison. He said he thought that the man had not
been unduly saddened by his grandmother's death, nor had he expressed
anger or disappointment at not being allowed to go to the funeral. He said
that the man had a "pretty bad" drug habit before coming into prison. The co-
defendant said that the man had seemed "wounded " at the prospect of a
further sentence. The co-defendant denied any knowledge of any talk of
drugs outside the man’s cell on the evening of 20 April. He said that prisoners
had congregated outside the man's cell because that was where the ironing
board was set up.
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Another prisoner said that the man was upset but coping with his
grandmother’s death. He said he had seen the man smoking heroin on the
evening of 20 April and that the man had told him he obtained the heroin at
court. The next morning he said the cellmate had told him at breakfast that
the man looked a funny colour and was looking "rough". They went up to the
cell and shouted through the door. When there was no response they
assumed the man was "out of it". The prisoner said he did return to the cell a
short time later but did not go in and shouted to the man instead. Shortly
afterwards the PCO had entered the cell.
Other prisoners spoke as follows:
One said that he had seen the man "as high as a kite" on the evening of 20
April. He also said that the co-defendant tried, but failed, to persuade the
man to give him some of the heroin.
Another said that he was aware of the co-defendant trying but failing to get
some of the heroin from the man on the evening of 20 April.
A third prisoner said that in a conversation with other prisoners on 21 April he
had learned that the man had said that he obtained the heroin at court.
A fourth said that the man had been ‘quiet’ and that he thought this was due
to his grandmother's death and not being allowed to go to the funeral.
5. DONCASTER PRISON’S RESPONSE TO THE DEATH OF THE MAN’S
GRANDMOTHER
The prison received notification of the death of the man’s grandmother at
4.24pm on Sunday 11 April 2004.
The man also received a visit from his father on Sunday 11 April. During that
visit he told his son of his grandmother’s death.
The Roman Catholic Chaplain saw the man on 12 April. He spoke to him for
the best part of an hour and let him make a phone call to his mother. He also
arranged to see him again to provide support and to check on funeral
arrangements.
During those subsequent meetings, the man was told that it was unlikely that
he would be allowed to go to the funeral because his grandmother’s
relationship with him did not constitute in loco parentis. He was offered a
service in the chapel on the day of the funeral but does not appear to have
asked for this. Prison Service guidelines describe a close relative as husband
or wife, brother or sister, parent or child or somebody having an 'in loco
parentis' relationship with the prisoner.
The RC Chaplain said that he told the man the final decision on whether he
could go to the funeral rested with the prison Director and that his application
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to attend would be passed on once the funeral arrangements were known. It
is unclear when the funeral details were available to the prison. It is most
likely that the man was told of the arrangements in a phone call with his
mother in the Chaplaincy on 16 April. What is certain is that the necessary
form was never passed to the Director for a final decision. Whilst the man
would, as a result of the RC Chaplain's advice, have been fairly sure that he
would not be allowed to attend the funeral, he had not had a final refusal and
may have been left with some lingering hope. Certainly he does not seem to
have conveyed a message to his parents that he would not be allowed to go
to the funeral. Neither does he appear to have been aware that he was
supposed to go to court on the day of the funeral.
After his visit on 11 April, the man’s father wrote to the prison Director to
request his son’s attendance at the funeral. The man’s father faxed his letter
to the prison on the same day. When, after a few days, there had been no
reply, the man’s father telephoned the prison and was eventually told that his
son could not attend the funeral.
On Monday 19 April, the man’s father telephoned the prison to express his
disappointment and was put through to the Anglican Chaplain. They
discussed the reasons for the refusal.
The man’s father’s fax of 11 April was not registered in the Director’s office
until Monday 19 April. A reply, dated 20 April, confirming the fact that the man
would not be allowed to attend was prepared but not sent due to the man’s
death.
On 20 April, following the funeral, the Anglican Chaplain phoned the man’s
mother. He agreed to arrange for the man to be able to call his mother once
he got back from court that evening. The Anglican Chaplain went to the wing
and left a message with the Houseblock manager who agreed to pass it onto
the evening shift who came on duty at 7.00pm. This he did but, for some
reason, the message was not acted upon and the man was not offered a call
to his mother on his return from court.
The man’s father called the Anglican Chaplain at about 9.00am on the
morning of 21 April to find out why the call had not taken place.
6. THE PRISON SERVICE’S ASSESSMENT OF THE MAN’S RISK OF
SUICIDE OR SELF HARM
The man’s history is well documented within his prison records and in a pre-
sentence report prepared by a probation officer who saw him in Hull prison,
dated 1 March.
Records show that the man had self harmed on two previous occasions,
neither of them in prison. As stated earlier, the man had been subject to
F2052SH procedures on a previous sentence at Doncaster. The man told
staff who escorted him from Wakefield Magistrates Court to Doncaster on 27
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January that he might be at risk of self harm. They completed and handed
over a suicide/self harm warning form to the reception staff at Doncaster.
When questioned by the healthcare staff at Doncaster, the man again spoke
about his history of self harm as well as the fact that he was taking anti-
depressants and was feeling depressed at the time. He also said, however,
that he did not feel like hurting himself or killing himself. He was assessed as
not having any thoughts of self harm or suicide and was not put on a watch.
He was, however, put onto a detoxification programme with effect from 28
January.
When the man was transferred to Hull prison on 30 January, the staff there
noted that he had a history of self harm and that he was upset at his
grandmother's illness. They did apply F2052SH procedures but decided to
close the F2052SH booklet and cease the special supervision when they
reviewed the situation five days later.
On 16 March, the man appeared at Leeds Crown Court and was sentenced to
two and a half years imprisonment. The duty Probation Officer at court sent
an urgent fax to Doncaster drawing attention to the man’s history of self harm.
Attached to the fax was a copy of the pre-sentence report mentioned above,
which included an assessment of the man as being at high risk of self harm.
This fax was received and considered in Doncaster’s healthcare department.
Their assessment after seeing the man was that he was relaxed, he had not
self harmed for nearly two years and that no watch was needed at the time.
The healthcare department also saw the man on 11 April after his father had
told him of his grandmother's death. He said he was upset but stated he had
no intentions of self harm. He said he got on well with his cellmate and was
allowed to return to the wing.
On 12 April, he was seen by the RC Chaplain who let him call his mother and
offered to arrange a referral to prison healthcare. The man declined this offer
preferring instead to go back to his cell on the houseblock. He had further
meetings with the RC Chaplain on 13 and 16 April about funeral
arrangements and for general support. On each occasion the RC Chaplain
said that the man was asked whether he wished to go to the healthcare
centre. On each occasion, the man said that he was fine, that he had a good
cellmate and that he just wanted to go back to his cell.
Despite being told that he would not be able to go to his grandmother's funeral
the man seemed to be coping well and remained outwardly cheerful. The RC
Chaplain recalls seeing the man on the evening of 19 April when he was with
"a group of lads and very jolly ".
The RC Chaplain was not aware of the man’s history of self harm and was not
concerned that he might be at risk of self harm. He did not think special
watch procedures were appropriate as a result of his talks with him.
As noted in the previous section, the Anglican Chaplain spoke to the man’s
mother on the day of the funeral. The man’s mother has said that during this
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conversation she suggested that the man should be put on a suicide watch.
When interviewed, the Anglican Chaplain said that he did not remember her
saying this specifically.
7. LIAISON BETWEEN DONCASTER AND THE MAN’S FAMILY
The initial contact with the man’s family was as a result of the death of his
grandmother. It is clear that the man’s family, and his father in particular, were
frustrated at what they saw as a poor response from the prison to their
requests for the man to attend his grandmother's funeral.
On the day of the man’s death, the prison at first contacted West Yorkshire
police with the intention that they should break the news to the man’s family.
When it appeared that this might not happen immediately the Director asked
the Anglican Chaplain to do so. The Anglican Chaplain contacted the
Catholic priest who had conducted the man's grandmother's funeral and they
set off together. The Anglican Chaplain and the priest were held up in traffic
and did not arrive at the family home until about 12.30pm. They found that
the police had arrived at 11.00am and broken the news to the man's family.
The Anglican Chaplain spent some time with the family giving what
information he could about the circumstances of the man's death.
On 26 April, five days after the man’s death, the prison Director wrote a letter
of condolence to his mother and father. This letter was also partly in response
to a letter dated 22 April to the prison from the man’s father and mother in
which they had posed a number of questions about the circumstances of their
son’s death. The letter was addressed to the father’s address in Castleford
rather than the Wakefield address of his mother. This may explain why, at a
later date, the man’s mother said she had not had a letter of condolence.
When the prison Director was made aware of this, a second letter was
immediately sent to the Wakefield address.
The man’s family visited the prison on 27 April. They met with the Director
and the RC Chaplain. During the visit they went to the man’s cell, lit a candle
and said a prayer in the prison chapel. They were also able to take away with
them the man’s clothing and personal effects. The visit was reported to be
very positive.
The prison Director and RC Chaplain attended the man’s funeral. Since then
the RC Chaplain has contacted the man’s mother by telephone.
8. THE FAMILY'S VIEW
One of my Family Liaison Officers visited the man’s mother, father, step-father
and uncle on 24 May at the man’s mother’s home. The family was concerned
that the man had not been put on a suicide watch on his return from court on
20 April. His mother felt that the death of his grandmother combined with his
court case would have affected the man greatly. They were also concerned
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that the man’s cell mate had not been given a drug test. The man’s mother
described him as a generous, loving and sensitive person. She said that she
had received several letters of condolence from other prisoners.
PART TWO
1. FINDINGS & CONCLUSIONS
The man died after smoking heroin on the night of 20 April 2004.
Numerous prisoners have described seeing the man smoking what he told
them was heroin that night. He had been a regular and heavy user of heroin
up to 27 January but had probably not used any between that date and 20
April. The man’s tolerance to heroin would have been greatly reduced if he
had not taken any drugs during those 12 weeks. The man smoked a large
amount of heroin but there is no indication that he had an intention to
overdose on it, nor to end his life.
It seems likely that the man obtained the heroin whilst appearing at Leeds
Magistrates Court on 20 April 2004
Several prisoners have said that the man told them that the heroin was given
to him at court on 20 April. The man's father has since provided information
to the prison that appears to confirm this account. The police have since
interviewed a man in connection with this allegation.
The requests for the man to attend his grandmother’s funeral should have
been handled more effectively
It may have been unclear to the man whether the opinion offered by the RC
Chaplain that he would not be allowed to attend the funeral constituted a final
decision by the prison. The procedure for obtaining a firm decision by the
Director was not implemented correctly.
The request from the man’s father on 11 April was mishandled and led to
confusion and anger. The written reply was not sent because it was overtaken
by events.
The on-going assessment of the man’s risk of suicide or self harm was
managed correctly.
Assessments took place at appropriate times and took account of past history
as well as current risk factors. There is evidence that the man was offered the
opportunity to speak to healthcare staff on more than one occasion after the
death of his grandmother. He was allowed to make two private phone calls to
his mother.
It is very regrettable that he was not offered a call to his mother on 20 April on
his return from court. This request was passed on by both the chaplain and
the houseblock manager but was not acted upon by staff on duty that
evening.
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With one exception, the immediate response to the incident was good.
The response of those staff who attempted to revive the man was prompt and
sustained for a significant period of time. They are to be thanked for their
efforts in what must have been very distressing circumstances.
There seems to have been some confusion about the correct operation of the
oxygen cylinders.
2. RECOMMENDATIONS
1. The relevant sections of this report concerning the passing of heroin at
court should be brought to the attention of staff at Leeds Magistrates
Court.
2. A review of searching procedures designed to prevent the smuggling in of
contraband by prisoners into Doncaster prison should be carried out.
3. Doncaster should review its procedures in respect of requests to attend
funerals. Requests must be passed to the Director in a timely manner. All
interested parties should be kept in touch with the progress of funeral
requests.
4. Drug awareness advice to prisoners should include information to make
them more aware of the potential for overdosing through reduced
tolerance. Information on the dangers of smoking heroin and the signs of
overdose should be available to all prisoners and displayed on residential
units.
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