Individual at Dorchester

The death in custody of a male prisoner
at HM Prison Dorchester on 14 June 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
December 2005
This is the report of an investigation into the death of a prisoner at HM Prison
Dorchester on 14 June 2005. The prisoner was found hanging in his cell at
1:35pm that day. He had been in custody for only five days. A suicide note
addressed to his partner was found in his cell. The prisoner died three days
before his 65th birthday.
A post mortem examination conducted on 16 June concluded that the
prisoner’s death was caused by hanging.
The investigation was carried out by my colleague.
I also commissioned an independent clinical review of the management of the
prisoner’s health needs while he was at Dorchester. This was carried out by a
representative of the South West Dorset Primary Care Trust. I am grateful to
him for his report.
My thanks also go to the Governor and staff at Dorchester for their help and
co-operation during the investigation.
During the brief time that he was in custody, the prisoner gave no indication
that he was contemplating taking his own life. The investigation has found
that little could have been done by staff to prevent his death. After the
prisoner was found hanging in his cell, prison staff and paramedics made
determined and sustained efforts to revive him. Their efforts are worthy of
praise.
This published version of the report does not contain any of the original
annexes.
Stephen Shaw CBE December 2005
Prisons and Probation Ombudsman
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Contents
Part One: 1. Summary
2. Investigation methodology
3. The deceased
4. HM Prison Dorchester
5. Events prior to the prisoner’s death
6. Events following the discovery of the prisoner
7. Consideration of issues arising from the investigation
9. Recommendations
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1. Summary
On 5 December 2003, the prisoner appeared at West Sussex Magistrates’
Court at Worthing charged with a number of offences that had been
committed between 1970 and 1985. The prisoner was committed on bail to
appear at Dorchester Crown Court when required. On 10 June 2005, he was
convicted of those offences and was remanded in custody at Dorchester to
await a pre-sentence report.
The prisoner showed no signs that he was depressed or contemplating
suicide, either at court, or during his journey from court to the prison. Upon
his arrival at Dorchester, he asked to be treated as a vulnerable prisoner
because of the nature of his offences. This request was granted. Ordinarily,
he would have been accommodated straightaway in the vulnerable prisoner
unit in D Wing, but as there were no vacancies there, the prisoner was located
in a single cell in the first-night centre in C Wing. During the next few days, he
did not behave in a manner that suggested he might have been depressed or
contemplating suicide. Staff had no concerns about him. The locum doctor
who saw him the day after his reception did not record details of the
assessment he made of the prisoner’s mental state.
At about 1:35pm on 14 June, the prisoner was found by a member of staff
hanging from the window bars of the same cell in C Wing to which he had
originally been allocated. Attempts to revive him were unsuccessful. He was
pronounced dead at the scene at 2:15pm by a prison doctor.
The investigation found that staff at Dorchester had no indication that the
prisoner might have been feeling suicidal. Prison and paramedic staff made
determined and sustained attempts to revive him but sadly those attempts
were unsuccessful.
I make recommendations regarding:
• medical record keeping.
• improving systems for raising the alarm in a life-threatening situation
• taking statements from staff
• training staff in the use of emergency first aid equipment
• creating a discrete area in which to isolate the body of a deceased
prisoner
• use of radios
• availability of safer cells in the first-night centre
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2. Investigation methodology
The investigation was opened on Friday 17 June 2005, when my colleague
met with the Governor, the chairman of the Independent Monitoring Board
(IMB), the chairman of the local branch of the Prison Officers’ Association and
the establishment’s investigation liaison officer. They were briefed on the
nature and scope of the investigation. On the same day, notices were issued
to staff and to prisoners announcing the investigation and inviting anyone who
wished to contribute to the investigation to make themselves known to my
investigator. No-one came forward.
Thirteen members of staff and one prisoner were interviewed.
An independent clinical review of the management of the prisoner’s health
needs while he was in custody was undertaken by a representative of the
South West Dorset Primary Care Trust (PCT).
One of my family liaison officers spoke to the prisoner’s partner by telephone
to ask her if she wished to raise any concerns relating to the prisoner’s death.
She confirmed that she did not feel any need to meet my investigator but she
was concerned that the prisoner had not been placed on a suicide watch.
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3. The deceased
The prisoner was born in 1940. Little is known of his personal and family
background. During the six years preceding his imprisonment, the prisoner
had been living with his partner.
It is known that the prisoner had accumulated numerous previous convictions
and that, in 1978, he was released from Wormwood Scrubs prison after
serving a 10 year sentence.
The prisoner was unemployed. He was partially sighted and had suffered
from glaucoma. He had no psychiatric history and we have uncovered no
evidence that he had ever tried to harm himself.
He died three days before his 65th birthday.
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4. HM Prison Dorchester
Dorchester is a small Victorian local prison serving Crown and Magistrates’
Courts in Dorset and South Somerset. It is located in the centre of the town.
Although the prison is designed to hold no more than 143 adult and young
male prisoners, it normally holds nearly double that number.
Prisoners are held in four wings, three of which radiate off a central hub. A
and B Wings hold remand and sentenced prisoners. C Wing operates as a
first-night centre and D Wing provides accommodation for those segregated
for the good order of the prison and for vulnerable prisoners.
Healthcare at Dorchester has, since 1 April 2004, been provided by the South
West Dorset Primary Care Trust which works closely with the Dorset and
Somerset Prison Partnership. The healthcare centre provides 24-hour
medical and nursing cover, with inpatient facilities for up to ten prisoners.
Dorchester was last inspected by Her Majesty’s Chief Inspector of Prisons in
April 2004. The report of that inspection included a number of observations
and recommendations about safer custody and healthcare. None are relevant
to this investigation.
The last death in custody at Dorchester was that of a prisoner who was found
hanging in his cell on 2 February 2003. He died in hospital on 13 March 2003.
The report of the investigation into his death contained three
recommendations. None are relevant in this case.
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5. Events prior to the prisoner’s death
On Friday 10 June 2005, the prisoner was convicted at Dorchester Crown
Court of a number of offences he had committed between 1970 and 1985. He
was remanded in custody at Dorchester to await a pre-sentence report. He
was to return to court for sentencing on 1 July.
The prisoner left the court for Dorchester prison at 3:00pm that day. He was
escorted by Reliance Custody Services. He arrived at Dorchester ten minutes
later. The Prisoner Escort Record (PER) showed that, although the prisoner
was considered to be vulnerable because of the nature of his offences, he
was not at risk of suicide or self-harm.
Upon his arrival at Dorchester, the prisoner underwent a first reception health
screen. During this interview, he disclosed to a healthcare officer that he had
recently consulted a doctor about his eyes, had undergone an operation to
remove two cataracts, and had suffered from glaucoma and shoulder pain.
He said that, before he was imprisoned, his GP had prescribed eyedrops,
Ibuprofen, and Lormetazepam, a benzodiazapine drug that is normally
prescribed on a short-term basis for the treatment of anxiety. The health
screen form does not make clear whether the prisoner was still taking any of
this medication when he arrived at Dorchester. He was also concerned that
he experienced skin rashes. He said that he did not drink alcohol or use
drugs, that he had no psychiatric history or mental health problems and had
never tried to harm himself. In answer to the question, “For some people,
coming into prison can be difficult, and a few find it so hard that they may
consider harming themselves. Do you feel like that?” he replied that he did
not.
During the cell share risk assessment that was conducted as part of the
reception procedures, the prisoner said that he had no concerns about
sharing a cell with another prisoner. He also said that he was not a person
who quickly became angry or frustrated. The member of staff who completed
the assessment form noted that there was no evidence of any risks
associated with cell-sharing and that there were no concerns about his risk of
self-harm.
During the reception procedures, the prisoner asked to be treated as a
vulnerable prisoner because of the nature of his offences. His request was
immediately granted. Ordinarily, he would have been allocated to the
vulnerable prisoner unit in D Wing, but, as there were no vacancies there, he
was located in the first-night centre in C Wing. He was placed in a single cell.
Later that day, the prisoner signed a compact that committed the
establishment to the provision of an orderly, purposeful and caring regime,
and that committed himself to behaving in a responsible manner and to taking
part in the regime offered. He also signed an induction sheet to show that he
had been briefed on the establishment’s policy for anti-bullying, race relations,
incentives and earned privileges, drug abuse, visits and unit regime. During
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his induction interview, it was noted that the prisoner showed no signs that
suggested that he might have been at risk of self-harm.
At about midday on Saturday 11 June, the prisoner was seen by a locum
doctor who made brief notes on a proforma that recorded the prisoner’s
general health. Although he did not make an in-depth mental health
assessment, the doctor was able to gauge that there was nothing in the
prisoner’s demeanour to give him cause for concern. He told my investigator
that he thought that the prisoner “looked a bit down”. The doctor was not
surprised at this, given the fact that the prisoner had only been imprisoned the
previous day. The doctor did not make any record of his assessment of the
prisoner’s mental state.
On the same day, the prisoner was interviewed as part of the induction
process. It was noted that he had asked to be kept apart from other prisoners
because of the nature of his offences, and because he was a poor coper. The
prisoner’s designation as a vulnerable prisoner was therefore formally
authorised. He then signed a further compact specific to the regime offered to
vulnerable prisoners. The prisoner was seen during the day by a member of
the Chaplaincy team as part of the induction programme. The Chaplain had
no concerns about the prisoner.
During the weekend, the prisoner spent each day in D Wing mixing with other
vulnerable prisoners. He took exercise, associated freely and took all his
meals. The officers on duty in C and D Wings saw nothing in the prisoner’s
demeanour that suggested that he might have been depressed, preoccupied
or contemplating suicide.
The prisoner made three telephone calls to his partner over the weekend. In
the first call, he referred to a suggestion made to him at court that the offences
of which he had been convicted were such that he was he likely to be given a
long prison sentence. However, at no stage during this or his other telephone
conversations did he allude to any idea or plan to end his life.
On Monday 13 June, the prisoner underwent a needs assessment interview
by a member of Dorchester’s resettlement team. He explained that he had no
difficulties with reading, writing and numeracy, and had no disability other than
partial sight. He said that he required no assistance with regard to housing or
employment or in relation to the abuse of drugs or alcohol. Later that day, the
prisoner was seen by another member of the Chaplaincy team. This Chaplain
had no concerns about him.
On Tuesday 14 June, the prisoner spent the morning in D Wing, on exercise
and association with other vulnerable prisoners. The Governor had arranged
a staff meeting for midday. Lunch was therefore served to prisoners at
11:40am, a little earlier than usual. The prisoner took his meal from the
servery in D Wing and made his way back to his cell in C Wing. At about
11:45am he asked an officer if it would be possible for him to attend an
education class in D Wing that afternoon. The officer promised the prisoner
that he would check to see whether there was a class and that, if so, he would
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arrange for him to attend. The officer then locked the prisoner in his cell and
left for the staff meeting. The unit was not patrolled during the meeting or the
lunch break. That same officer was the last person to see the prisoner alive.
At 1:00pm, another officer commenced his duty as relief reception officer and
was then deployed to C Wing at about 1:30pm. He started to collect used
meal trays from each cell with the help of the wing cleaner. Shortly after
1:30pm, that officer unlocked the door of the cell in which the prisoner was
located and discovered him hanging from the window bars. The prisoner was
suspended by a ligature made from a length of torn bedsheet attached to the
hinge of the window. He was facing towards the cell door. His feet were clear
of the floor. There were no signs of life.
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6. Events following the discovery of the prisoner
The officer, who was not equipped with a radio, ran to the wing office where
he telephoned the Orderly Officer to ask for assistance, leaving the prisoner’s
cell door open. The wing cleaner followed him to the office. The officer then
returned the wing cleaner to his cell and opened the gate leading into the wing
so that staff could enter the wing more quickly. He was absent from the scene
of the incident for approximately 30 seconds while he summoned help.
Meanwhile, on receipt of his call, the Orderly Officer directed a number of staff
who were near his office to go to his assistance. A number of discipline and
healthcare staff arrived about 15 seconds later. Between them, they removed
the ligature from the window and from the prisoner’s neck. They all described
the prisoner as being cyanosed and showing no signs of life.
The investigation found that the local contingency plans do not contain any
reference to the procedures to be followed for calling the emergency services.
However, among those who responded to the incident was the manager in
charge of B Wing. When he arrived, he used his radio to alert the
communications room to the need to call an ambulance. As there are no
facilities in the communications room for dialling 999, the communications
officer shouted through to the gatekeeper who pressed a button on a
dedicated telephone set that connects directly with the 999 facility. The
incident log shows that this was done at 1:35pm.
Meanwhile, more healthcare staff arrived at the prisoner’s cell. They helped
carry the prisoner out of the cell to the landing where he was laid on the floor.
The ligature was removed from the prisoner’s neck and staff checked for signs
of life. It was noted that the prisoner was pale and cyanosed with bruising to
his throat and neck. His tongue was enlarged and protruding. An airway was
inserted and oxygen was administered through an ambubag. Staff maintained
the prisoner’s airway by tilting his head and holding the mask on his face. The
defibrillator available in the healthcare centre was not taken to the prisoner as
no staff trained in its use were on duty. Cardio-pulmonary resuscitation (CPR)
techniques were applied until approximately 1:45pm when a paramedic
arrived.
The paramedic applied a defibrillator which advised not to shock the patient.
CPR was therefore recommenced. A canula was inserted into the prisoner’s
forearm. Between 1:51pm and 1:54pm, adrenalin and atropine were
administered with no effect. CPR techniques were continued until 1:56pm
when all attempts to revive the prisoner were terminated. A prison doctor
pronounced death at 2:15pm.
The police and Coroner’s office were informed of the prisoner’s death. The
establishment’s Police Liaison Officer attended. Scenes of crime officers
searched the prisoner’s cell and took possession of a letter he had written to
his partner that day. This was treated as a suicide note. The police took
photographs of the cell and of the prisoner’s body. These procedures took
approximately two hours to complete. At 4:13pm, the duty undertakers were
asked to remove the body. They left the prison at about 5:30pm. By this time,
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the prisoner had been lying dead on the landing in C Wing for over three
hours. His body was covered with a blanket. During this period, the prisoners
in C Wing were kept locked in their cells, and the incident log-keeper stayed
by the body.
Subsequently, the Senior Lead Nurse for the Dorset and Somerset
Partnership gave managerial counselling and support to the healthcare staff.
The Governor chaired a debrief of all staff involved. All those staff who were
interviewed said that they were given appropriate care and support by the
Governor and the establishment’s care team.
The prisoner’s partner was informed of his death by a member of the
Chaplaincy team from a prison located not far from where she lived.
The prisoner’s partner and her son-in-law visited Dorchester on Wednesday
15 June. They met the Governor and the Chaplain, who showed them the
prisoner’s cell and spent time with them in private. The Governor wrote to the
prisoner’s partner the following day to offer her his condolences and practical
support. The Police Liaison Officer gave her a copy of the letter the prisoner
had left for her. In it, the prisoner wrote that he did not expect to leave prison
and that he could not face a life without his partner.
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7. Consideration of issues arising from the investigation
The following issues arose during the investigation:
• Attempts to revive the prisoner
I draw special attention to the conduct of the prison staff who found the
prisoner hanging, and to those, including the paramedic, who made
determined and sustained attempts to revive him. They did so in very
harrowing circumstances. The conduct of all those involved is worthy of
praise.
• Should the prisoner have been made subject to self-harm monitoring
procedures given the nature of his offences and his age?
The prisoner’s partner was concerned that he was not placed on a suicide
watch because of his age and the nature of his offences.
The investigation found that the prisoner asked to be treated as a vulnerable
prisoner because of the nature of his offences and that this request was
granted immediately. He was therefore located in an area of the prison that
afforded him safety from other prisoners. I consider that this was an
appropriate means of managing the prisoner’s vulnerability from others.
The prisoner was 64 years old when he entered prison on 10 June. He had
not been in prison since 1978. He had been convicted of a number of
offences that were likely to place him in danger from other prisoners. He was
expecting a prison sentence that was likely to keep him apart from his partner
for a long time. These are indicators of a potential risk of self-harm or suicide.
However, the judgement as to whether the prisoner should have been made
subject to any self-harm monitoring procedures needs to draw a balance
between these indicators and the fact that during his time at Dorchester the
prisoner did not display any signs that he was contemplating suicide. I
therefore believe that staff at Dorchester were reasonable in their judgement
that the prisoner did not need to be made subject to self-harm monitoring
procedures.
• Should the prisoner have been allocated a shared cell?
In ordinary circumstances, the decision to grant the prisoner vulnerable
prisoner status would have necessitated his location in D Wing where he
could benefit from a full regime with other vulnerable prisoners. However, on
14 June, no spaces were available in that wing. Consequently, the prisoner
was allocated a cell in the first-night centre in C Wing. As there were no other
vulnerable prisoners located in that wing with whom the prisoner might have
been able to share a cell, he was accommodated in a cell on his own. My
investigator was told that, had the prisoner been assessed as at risk of self-
harm or suicide, he would not have been allocated a single cell.
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In view of the fact that the prisoner was not assessed as a suicide risk, I
accept that the decision to accommodate him on his own was justified.
However, given that prisoners are more at risk in the first few days after their
arrival in prison, I am concerned that a further tragedy could occur at
Dorchester. In order to reduce such a risk, the Governor, with the support of
the Area Manager and Safer Custody Group in Prison Service Headquarters,
should arrange for the conversion of an appropriate number of cells in the first
-night centre into safer (ligature-free) cells as a matter of urgency. These cells
could be used to accommodate those subject to self-harm or suicide
monitoring procedures and those accommodated alone.
• Should the first-night centre be patrolled during meal breaks?
On 14 June, a full staff meeting took place at midday. The midday meal for
prisoners was therefore served earlier than usual. The prisoner was last seen
alive at about 11:45am on that day when he was locked in his cell by an
officer after collecting his lunch meal. The prisoner was found hanging one
and three quarter hours later. The first-night centre in C Wing was not
patrolled during that period. During meal breaks at Dorchester, unless there
are prisoners subject to self-harm monitoring procedures, patrol staff remain
in the vicinity of the centre office where they are able to monitor the cell-call
display board and make regular visits to those assessed as at risk of self-
harm. They can be deployed quickly from the centre to any alarm raised in
the residential area.
The option of ensuring that all units are permanently patrolled by day and by
night in any establishment would have very significant resource implications. I
therefore do not criticise the fact that the first-night centre was not patrolled
during the lunch break on 14 June. That said, the Governor should continue
to be mindful of the heightened risk of suicide presented generally by
prisoners during their first days and weeks in prison.
• Initial assessment of the prisoner’s mental health
The locum doctor who saw the prisoner the day after he arrived at Dorchester
checked his physical health but did not record any details of the assessment
he made of the prisoner’s mental state. The doctor was able to gauge that
there was nothing in the prisoner’s demeanour to give him cause for concern,
although he thought that he “looked a bit down”. The Governor, in conjunction
with the PCT, should ensure that all doctors are aware of the need to make a
proper record of their assessment of the current mental state of all newly
received prisoners, particularly in relation to their risk of self-harm.
• Raising the alarm and arrangements for calling an ambulance
The officer who found the prisoner hanging was not equipped with a radio. He
therefore had to leave the cell for about 30 seconds to telephone for
assistance from the C Wing office. Officers on duty on their own in the first-
night centre ought to be equipped with a radio.
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The investigation found that there is no facility in the communications room at
Dorchester for the communications officer to dial 999. Whenever the
communications officers receive an emergency call over the internal radio
network, they have to ask the gatekeeper in an adjacent area of the gatelodge
to call for an ambulance. It is not necessary for gatekeepers to dial the
emergency number. Instead they merely press a button on a dedicated
telephone set to be connected to the emergency services. This process takes
no more than a second or two to complete. After the prisoner had been found
hanging, a Senior Officer used his radio to alert the communications officer to
the need to call an ambulance. No delay was incurred. The fact that the
communications officer has to rely on the gatekeeper to call the emergency
services was not, therefore, a critical issue in this case.
Local contingency plans do not contain any guidance to staff about the
procedures to be followed for raising the alarm or for calling an ambulance in
the event of a life-threatening situation. This was not a significant factor in the
circumstances described here, but it might be in the future. Local contingency
plans should set out clear instructions to staff about the procedures for raising
the alarm in a life-threatening situation and for calling the emergency services.
• Statements from staff
Not all those staff who were involved in responding to the discovery of the
prisoner submitted statements to the Governor. Most of those staff who were
interviewed seemed to be unaware of any requirement to do so. Statements
should be written as soon as possible after an incident and should describe
the role undertaken by each member of staff. The Governor should clarify
local policy in this area of incident management and should make his policy
clear in the local contingency plans.
• Emergency equipment
A defibrillator is available in the healthcare centre. At the time of the
investigation, only three members of the healthcare team were trained in its
use. Of those, none were on duty on 14 June. There is no evidence to show
that the fact that the prison’s defibrillator was not used in the initial first aid
applied to the prisoner was a critical factor. The investigation has found that
there are plans for further staff to be trained in the use of the defibrillator in
due course. These should be implemented without delay.
• Removal of the prisoner’s body from the prison
The prisoner’s body remained on the landing outside his cell in C Wing
covered by a blanket for about three hours after he was pronounced dead.
The delay in removing his body to the mortuary caused considerable distress
to the members of staff who had to remain in the wing, and to the prisoners
who remained locked in their cells throughout. The investigation found that
the police could not have carried out their forensic tasks more efficiently or
more speedily. The Governor and his staff were unable, in the circumstances,
to arrange the removal of the prisoner’s body, or to establish a discrete area in
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which to isolate his body. However, contingency plans for the management of
any future death in custody should include the acquisition and use of a screen
similar to that used by the police at the scene of a crime.
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8. Recommendations
• The Governor, in conjunction with the PCT, should ensure that all
doctors are aware of the need to make a proper record of their
assessment of the current mental state of all newly received prisoners,
particularly in relation to their risk of self-harm.
• The Governor should review the local contingency plans to ensure that
there are clear instructions to staff for
-raising the alarm in a life-threatening situation.
-calling the emergency services.
-taking statements from staff after a serious incident.
-the acquisition and use of a screen similar to that used by the police at
the scene of a crime.
• The investigation found there are plans for further staff to be trained in
the use of a defibrillator. The Governor should ensure that this training
is implemented without delay.
• The Governor should ensure that all staff patrolling wings are equipped
with a radio.
• In order to reduce the risk of a further death in the first-night centre, the
Governor, with the support of the Area Manager and Safer Custody
Group in Prison Service Headquarters, should arrange for the
conversion of an appropriate number of cells in the first-night centre
into safer (ligature-free) cells as a matter of urgency.
At consultation stage, the Governor asked for the following text to be
inserted:
I have accepted all the recommendations and have taken/will take the
following actions:
• I will work with the PCT to ensure that doctors properly record their
assessment of the current mental state and risk of self harm of all
newly received prisoners.
• We will also provide defibrillator training where it is required.
• Contingency plans have already been reviewed and amended to
provide clear instructions to staff about:
- raising the alarm in a life threatening situation
- calling the emergency services
- taking statements from staff after a serious incident
• We have ordered a tent to protect and screen similar incidents in
future.
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• I have issued a Governor’s Order stating that all patrol staff must carry
a radio.
• I will submit immediately a business case to the new Area Manager to
fund the provision of safer cells for the first night centre.
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