Individual at Durham

Investigation into the death of
a man
at HMP Durham in October 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2006
This is the report of an investigation into the circumstances surrounding the death on
21 October 2004 of a man at HMP Durham. The man was found hanged in his cell.
He was 34 years old.
The investigation was conducted under the terms of the transitional arrangements
agreed between my office and the Prison Service, which ran from 1 April 2004 to 30
November 2004. The bulk of the investigative work was conducted on my behalf by
a senior manager (the senior investigator – SIO) at HMP Manchester. The SIO was
assisted by a Principal Officer from HMP Wakefield. A clinical review was carried
out by the Carestream Prison Lead from Northumberland NHS Trust. An
investigator from my office liaised with the SIO during this investigation. I am
grateful to all members of the team for their work.
One of my Family Liaison Officers accompanied by my investigator visited the man’s
mother. I know they offered their sympathy and condolences. I would like to take
this opportunity to add my own condolences to the man’s mother, to his other family
members and to his friends.
I should also record here my thanks to the former Governor of Durham and his staff
for the help the investigators received during the investigation. All staff co-operated
fully and readily with the inquiry. I regret the delay in bringing this report to
completion.
At the time of his death the man had only been in Durham for three days. He was a
remand prisoner charged with murder having handed himself into police custody with
a confession that he had murdered his girlfriend. The man had spent many years in
prison custody and he told staff at Durham those years would stand him in good
stead for whatever sentence would result from his latest offence. He denied any
thoughts of self-harm or suicide and gave no indication to anyone of having any such
thoughts.
I have made five recommendations. Two concern admission procedures in the case
of prisoners charged with murder, one concerns documentation, one relates to
contact with bereaved families, and one relates to staff training.
Stephen Shaw CBE March 2006
Prisons and Probation Ombudsman
2
I
SUMMARY............................................................................................................4
SENIOR INVESTIGATING OFFICER'S REPORT................................................6
INVESTIGATION PROCESS................................................................................6
HMP DURHAM .....................................................................................................8
THE MAN..............................................................................................................9
BACKGROUND ..................................................................................................10
EVENTS LEADING UP TO THE MAN'S DEATH:
17 TO 19 OCTOBER 2004.............................................................................11
20 OCTOBER 2004........................................................................................12
21 OCTOBER 2004........................................................................................13
THE DISCOVERY OF THE MAN'S DEATH........................................................15
AFTER THE MAN'S DEATH...............................................................................16
LEVEL OF COMPLIANCE WITH AUTHORISED PROCEDURES......................17
CONCLUSIONS FROM CLINICAL REVIEW......................................................18
FINDINGS AND CONCLUSIONS.......................................................................19
RECOMMENDATIONS.......................................................................................21
3
SUMMARY
On 17 October 2004, the man approached two police officers and told them that he
had murdered his girlfriend. The man remained in police custody until 19 October
when he was remanded by the court into custody at HMP Durham. The Prisoner
Escort Record Form (PER) that accompanied him into Durham had been ticked by the
escort staff to record concerns about him, such as drugs and alcohol issues, but it was
not recorded that he was perceived to be at risk of self-harm or suicide.
On arrival in reception at Durham, the man’s healthcare screening was undertaken by
the Registered Mental Nurse (RMN) who had over 20 years experience in psychiatric
medicine. The RMN said the man had been very co-operative, coming across as a
person who was used to prisons and prison life. There was nothing about his mental
health state to give cause for concern. The RMN was aware of the nature of the
man’s charges, so he contacted the Charge Nurse in healthcare to find out whether it
was still the practice to admit to healthcare those charged with murder (this had once
been the practice at Durham in accordance with previous healthcare standards). The
Charge Nurse told the RMN that, provided he had no concerns about the man’s
mental health state, there was no need to admit to healthcare. The RMN offered the
man the option to go to healthcare, but he declined saying that he had spent many
years in prison and was quite happy to be located in a normal wing.
An officer saw the man in reception and gave him a smokers’ pack. The man was
offered a PIN Number, to enable him to use the telephone, but he declined the offer.
After this, the man was located into a shared cell in C Wing, the identified first night
induction unit.
Following his location, the man was seen by one of the prison’s GPs. The man
declined the medication available for drug detoxification, but accepted a continued
prescription of dihydrocodeine for pain relief for a hand injury.
During 20 October, the man underwent stage 1 of Durham’s induction process,
seeing a range of staff including a principal officer (PO) for a reception board. A
CARATs (drug advice service) worker tried to speak with the man but he declined
the offer. The man saw a Community Psychiatric Nurse (CPN) in substance misuse
as result of his referral for detoxification medication, but again refused the
detoxification medication available. The man had wanted methadone, but as he was
not on an existing prescription for that medication he was told that he could only
have lofexidine (Britlofex) or symptomatic pain relief which he refused. The CPN in
substance misuse observed the man to be in mild drug withdrawal, but displaying no
major symptoms.
At about 1.45pm on the afternoon of 21 October, the man’s cell-mate was taken to a
social visit, leaving the man alone in their cell. All the cells on C3 landing were
unlocked at around 2pm to allow for ‘downtime’ (out of cell) activities. After around 30
to 40 minutes, all the prisoners on C3 landing were locked back into their cells. The
cell-mate was still on his social visit so the man was again locked alone in his cell.
At about 3.30pm, the first Officer unlocked the man’s cell for him to go to the treatment
room for his medication. The man was lying face down on the bottom bunk. A
4
ligature, made from a television power cord, was tied around his neck and attached to
the underside of the top bunk. The first Officer summoned assistance and was joined
by the second Officer. Other staff also responded to the alarm call and arrived quickly.
The first and second Officers supported the man’s body and a Senior Officer untied
the ligature from the underside of the top bunk. The man was placed on his back on
the floor and the second Officer cut the ligature from around the man’s neck. The Staff
Nurse and another nurse commenced attempts at resuscitation and they were joined
by two other nurses who brought an oxygen cylinder, a defibrillator and other first aid
equipment. Examination of the man revealed that he had no vital signs, his pupils
were fixed and dilated, and he had no palpable carotid or radial pulses.
Staff commenced cardio-pulmonary resuscitation (CPR) and continued until
ambulance paramedics arrived at around 3.50pm, when they took over the attempts to
resuscitate the man. Unfortunately, their efforts proved unsuccessful and the man was
pronounced dead at 4pm by one of Durham’s doctors.
When my staff visited the man’s mother she said that she knew her son would take his
life. She said that her son and his girlfriend shared a volatile relationship, but he had
never hit her and once he had killed her he would not have been able to live with that
fact. The man’s mother said that she had thought about telephoning Durham to tell
the staff about her fears.
The man did not leave a suicide letter so we can never be certain about his motives.
However, whatever his reasons and at whatever point he made the decision to take
his life, the man gave no indication either to staff or to his cell-mate that that he had
any such thoughts. It could even be argued that he took particular care to present
himself as a person with no undue worries about being back in prison and about facing
what inevitably would have been a lengthy sentence.
The clinical review, has pointed out a number of risk factors in the man’s case.
These included his refusal of a PIN number, the fact that he was charged with
murder, and the fact that he was going through detoxification. With these risk factors
in mind, the clinical reviewer has suggested that admission to healthcare and/or the
opening of an F2052SH would have been safer options.
5
SENIOR INVESTIGATING OFFICERS REPORT
INTRODUCTION
On the instructions of the Prisons and Probation Ombudsman, an investigation has
been carried out into the tragic death of the man, a prisoner at HMP Durham.
The Senior Investigating Officer was a senior manager D HMP Manchester, assisted
by a Principal Officer from HMP Wakefield.
The investigation team would like to offer their sincere condolences to the family and
friends of the man for their tragic loss.
The investigating team would like to thank the Governor and staff of HMP Durham for
their co-operation and assistance during the course of the investigation.
Particular thanks go to the invaluable assistance of the investigation liaison
officers.
INVESTIGATION PROCESS
The investigation involved a period of 22 days between 22 November 2004 and 14
December 2004 conducting interviews and collating all documentation and then a
further period completing the reports. This investigation was spread over a longer
period than was envisaged, due in part to the resources issue mentioned above along
with sickness and operational duty absences on the part of the SIO for which I offer
my apologies.
Durham appointed two staff to act as liaison officers. Durham provided all the
necessary documentation. All personnel co-operated fully.
Durham had made contact with the man’s mother. The Deputy Governor also
contacted the man’s mother and offered her the opportunity to visit the prison to meet
with staff and prisoners who knew her son. Staff from the Ombudsman’s office visited
the man’s mother to offer her and her family the opportunity to contribute to the
investigation if they so wished.
The Governor published a local notice to staff, and a separate notice to prisoners,
announcing the investigation and offering them the opportunity of contributing to the
investigation.
The Investigation Team met the Deputy Governor, and later, the local Prison Officers
Association branch chairman, to inform them of the investigation. The chairman of
the Independent Monitoring Board (IMB) was informed and offered the opportunity of
contributing to the enquiry. A copy of the report from the IMB Member who attended
the incident was submitted to the investigation team.
6
During the course of our initial inquiries we visited the cell in which the man died as
well as visiting other areas of the prison with which the man had had contact. We
reviewed all documentation and established a chronology of events.
All members of staff identified for interview were offered the opportunity of being
accompanied by a work colleague or trade union official at interview. Terms of
Reference were handed to all interviewees and all were given a transcript of their
interview. A total of 20 people were interviewed, including the man’s cell-mate who
had since been transferred to HMP Acklington.
Given that the man was in Durham for only a very short period of time we invited as
wide a range of staff and prisoners as possible who had contact with him to
contribute.
A doctor from Northumberland NHS Care Trust carried out a clinical review into the
man’s care and treatment.
A comprehensive report was received from Northumbria Police covering the arrest,
circumstances of the offence and a record of events concerning the man’s time in
police custody.
7
HMP DURHAM
HMP Durham is a large Victorian local prison. Durham holds all types and categories
of male prisoners. The certified normal accommodation figure is 568, with an
operational capacity of 785. Durham has operated close to its capacity for a number
of years. On the day of Mr The man’s death, Durham’s prisoner population was 647.
An average of 40 prisoners are discharged to, and received from, court each day.
Durham has seven adult wings (three of which were closed at the time of Mr The
man’s death). The prison has a gymnasium, a 20-bed health care unit and a small
segregation unit. The prison provides educational classes, including basic skills,
offending behaviour programmes, physical education and seven workshops.
The last Standards and Security Audit carried out at Durham in November 2002
included an examination of the suicide and self-harm procedures and rated them as
‘acceptable’.
A full unannounced inspection by Her Majesty’s Inspector of Prisons for England and
Wales in August 2003 found that reception, suicide and self-harm and anti-bullying
work were all carried out to a high standard. Durham was found to be providing a
fundamentally safe and decent environment. It was noted that, in a pattern all too
common in an overcrowded prison system, Durham was able to offer too little by way
of purposeful activity, although it was found to be delivering what it could, consistently
and humanely, reflecting the commitment and professionalism of staff at all levels –
relationships between staff and prisoners were reported as being consistently good.
There had been five previous self-inflicted deaths at Durham in 12 months preceding
the man’s dearth – three were male prisoners and two were female (until recently
Durham was a mixed prison). Action Plans arising from the investigations into these
deaths were examined by the investigation team.
The investigation team’s over-all impression is of a busy and purposeful atmosphere
with little negativity and with good staff prisoner relationships.
8
THE MAN
The man was born in February 1970 and was the youngest of six children – three
boys and three girls. His next-of-kin was his mother who lives in Hexham in
Northumberland.
The man’s record of offending was substantial and over the years his offending
became more serious, influenced heavily by his drug misuse. He had five previous
periods of custody as a juvenile and young offender between 1983 and 1993. He
also had a number of custodial sentences as an adult offender between 1994 and
2002. The offences included burglary and theft, assault, escaping from lawful
custody, offences of both actual and grievous bodily harm and wounding with intent.
The man was released from HMP Liverpool in 2002, having served a six year
sentence for robbery and breach of a licence condition.
9
BACKGROUND
The man’s mother said her son had been in and out of prison for 17 years and she
considered him to have become institutionalised. She said that, whenever he went
into prison or was transferred to a new prison, he would always telephone her to tell
her of his new prison address and she would send him some money.
The man’s mother said her son had used drugs for many years. His preferred
method of withdrawal from substances was to do so without using prescribed
detoxification medication or support.
The man’s mother said that her son had been with his girlfriend for two years. It was
a volatile relationship, although her son had never actually hit his girlfriend. The
man’s mother understood that her son’s girlfriend had relationships with other men
while in the relationship with her son and she would taunt him about this.
The man’s mother said that her son had never previously harmed himself. However,
once he had killed his girlfriend she thought he would not have been able to live with
himself and so the man’s mother knew he would take his life.
The man’s mother told the staff from the Ombudsman’s office when they visited that
up to that point in time, 6 December 2004, she had received from HMP Durham
neither a letter of condolence, nor any offer of help with funeral expenses. These
matters were subsequently followed up with Durham and rectified.
10
EVENTS LEADING TO THE MAN’S DEATH:
17 to 19 OCTOBER 2004
On the early evening of 17 October 2004, the man approached a stationary police car
and informed the two officers in the car that he had killed his girlfriend. He was taken
into police custody while his story was checked. The man remained in police custody
until midday on 19 October when he was remanded into custody at HMP Durham by
the local magistrates’ court, charged with murder. The Prisoner Escort Record (PER)
form that accompanied the man to Durham recorded a number of risks, such as drugs
and alcohol issues, but no perceived risk of suicide/self-harm.
A Senior Officer (SO) interviewed the man in reception at Durham. The Reception
SO said that the man was fairly subdued and quiet. However, he was well versed in
prison life and he gave the Reception SO no cause for concern.
The RMN saw the man for his health care assessment. The RMN is an experienced
psychiatric nurse with many years’ experience of working in prisons. The RMN said
that the man had been very co-operative during the health screening process, giving
the impression that he had been in prison a few times and was experienced in prison
ways. The man gave no indication that he might have been contemplating self-harm.
However, because he was charged with murder, The RMN contacted the Charge
Nurse in healthcare to ask whether it was still the policy to admit into healthcare
prisoners charged with that offence. The Charge Nurse advised the RMN that it was
no longer the practice to routinely admit into health care those charged with murder,
unless the prisoner requested admission or there were other indicators that he or she
might be suicidal or mentally ill. Following this conversation, the RMN asked the man
if he wished to be admitted to healthcare, but he declined saying that he had done 17
years in prison and was perfectly happy to be in a normal prison wing.
Part of the screening process is about use of drugs. The man said that he used drugs
such as heroin, amphetamines and cocaine and he reported that he was ‘rattling’
(suffering the effects of drug withdrawal). As a consequence, the RMN ticked the
relevant boxes on the health screening form for the man to be referred to the doctor
and the drug detoxification team.
In the case of those charged with murder, a referral should have been made for the
man to be referred to a CPN (community psychiatric nurse). The RMN said that he
could not recall whether he made such a referral, however there was nothing about
the man’s mental health state to have warranted an urgent referral. The RMN made a
note in the man’s medical record that he had denied any thoughts of suicide or self-
harm, but the RMN did not record that the man had declined an offer of admission to
healthcare.
Another prisoner who was received into Durham at the same time as the man spoke
with him while they were in reception. The man told this prisoner why he was in
prison. The prisoner told the investigation team that he overheard reception staff
asking the man whether he wanted to be placed in the healthcare unit, but again the
man declined, saying he was alright. The prisoner was later located into the cell
adjoining the man’s cell.
11
The man was seen by an officer who explained to him the first night routines in the
induction unit. The man accepted a smokers’ pack and toiletries, but declined the
offer of a PIN number (new prisoners are offered a PIN number to enable them to use
the telephone). This officer said at interview that the man kept asking how long it
would be before he would go to the wing from reception. Nothing had occurred to
give this officer cause to feel concern about the man; it was not especially unusual for
prisoners to decline a PIN number.
At around 3.40pm, the man was located into a shared cell in C wing (the first night
induction unit). Following his arrival in C wing the man was seen by a prison GP for a
drug detoxification assessment and because the man wanted pain relief for his right
hand which he had broken some weeks earlier. The GP said at interview that the
man declined the medication offered to him for detoxification but accepted a
prescription of five days of dihydrocodeine for pain relief for his hand injury.
20 OCTOBER 2004
During the morning of 20 October, the man attended the first stage of the induction
programme which all newly arrived prisoners are required to undertake. During this
stage he was seen by a range of people to assess his needs and to give him
information about processes and procedures at Durham.
In discussion with a PO and an SO the man said that he had family support and
expected to receive visits. He again declined drug detoxification support. The PO
said at interview that the man was pleasant and seemed in good spirits.
Due to the fact that the man was a potential life sentence prisoner, he was seen the
Lifer Manager who was accompanied by another officer. The man said that he
expected a life sentence, but also said that he had been in prison so many times that
a further prison sentence was of little consequence to him. He felt that his many
previous years in prison custody would stand him in good stead and, whatever
sentence was coming to him, he would get through it. The Lifer Manager recorded
that there was no indication of suicidal ideation and that no additional support was
identified as being required at that time. The man was aware of the support network
available to him should circumstances change. When the Lifer Manager explained
about the support available from Samaritans and prisoner Listeners (prisoners trained
by the Samaritans), the man smiled and said that would not be necessary.
The officer who was present when the man saw the Lifer Manager said that he had
known the man a long time. He described the man as a person who never showed
emotion, a man who seemed not to want to talk to prison officers and who did not
have much interaction with other prisoners either. The man was not a person who he
would have suspected as likely to commit self-harm.
Following an automatic referral for detoxification assessment made during the man’s
reception screening, he was seen on 20 October by a CPN in substance misuse. The
CPN in substance misuse was accompanied by an officer whose role is to monitor
12
prisoners going through drug detoxification. The man said that he used heroin on a
daily basis and was also being prescribed dihydrocodeine and diazepam by his GP.
He reported that he was suffering mild withdrawal symptoms. The man’s GP practice
was subsequently contacted by telephone and it was found that he was not in fact
receiving any prescribed medication. The man requested methadone, but the CPN in
substance misuse told him that methadone was only prescribed for people who had
an existing prescription for that drug. The man was therefore offered lofexidine or
symptomatic relief, but the man refused, stating that he would prefer to ‘do his rattle
on his own’ rather than use lofexidine.
The CARATs (drug advice service) worker also attempted to interview the man during
the morning of 20 October. At interview with the investigation team she recalled that
when she went to the waiting room to collect the man she found him lying on the
bench. She told him who she was and asked him to come with her for interview. The
man said that he did not want to see her. He said he knew she was a CARATs
worker and said that he did not want help from that service. The CARATs worker
explained that for reasons of confidentiality she would like to speak to him on a one-
to-one basis rather than in a public area; but he still declined to go with her. She
informed him what CARATs was about and that if he would like a referral to the team
at a later date he would only need to put in an application. The CARATs worker
described the man’s demeanour as arrogant, but said there was nothing about him to
cause her any concern.
The Chaplain said that he went to see the man in the waiting room but found that he
had gone back to his cell. The Chaplain went to the man’s cell and explained that he
had to see him to check on his religious registration, which had been recorded as
Muslim. The man replied that that was correct and the Chaplain asked him if he was
aware of the arrangements for Ramadan, to which the man replied that he was. The
Chaplain told the investigation team that the man had initially been curt, but he had
then calmed down.
21 OCTOBER 2004
During the morning of 21 October, the man attended the second stage of the
induction programme with an induction officer. At interview, the induction Officer
explained that in this session prisoners are taken through domestic matters: the
arrangements for visits, mail, property, meal-times and choosing meals. Prisoners
are also informed about policies and services such as race relations, anti-bullying,
Samaritans and suicide awareness. The induction Officer could not recall the man
and could not recall whether she saw him on a one-to-one basis or whether he was
one of a group.
At around 1.45pm, the man’s cell mate, was taken by the first Officer from the cell to
go on a social visit. When he left the cell, the cell-mate recalled that the man was
lying on his back on his bed. The first Officer relocked the cell door.
At about 2pm, cells were unlocked for ‘downtime’, to allow prisoners have showers, to
make telephone calls and associate with other prisoners. The prisoner who met the
13
man in reception said that he had not seen very much of the man following their
arrival. However, when cells were unlocked for downtime at about 2pm on 21
October, the man’s door was open, so the prisoner went into the cell and asked the
man if he was coming out. The man was lying face down on his bed and did not
speak. The prisoner thought that the man might have been asleep and so he left the
cell.
The PO who had seen the man on 20 October for a reception board was also on duty
in C wing on 21 October. The PO believed that she saw the man out on the wing
during downtime, although she could not recall having any conversation with him.
The first Officer returned to C wing at just before 3pm, by which time downtime had
finished and prisoners had been locked back into their cells.
14
THE DISCOVERY OF THE MAN’S DEATH
The first Officer was unlocking cells on C3 landing for prisoners to receive medication.
The first Officer recalled glancing at his watch as he unlocked the man’s cell. The
time was 3.30pm. The man was lying face down on the bottom bunk and as the first
Officer stepped further into the cell he saw a ligature, an electrical flex, around the
man’s neck and attached to the underside of the upper bunk. The first Officer
immediately shouted for assistance. The first Officer said the second Officer arrived
within seconds and between them they supported the man’s body while an SO and
another officer released the ligature from the upper bunk. The officers lowered the
man’s body to the floor and the second Officer cut the ligature from around his neck
using a pair of scissors that had been handed to him.
The Staff Nurse had heard an officer shouting for assistance and, at the point that he
reached the man’s cell, he saw officers supporting the man’s body and other officers
trying to release the ligature from the wire mesh of the upper bunk. The Staff Nurse
attempted to untie the end of the ligature that was around the man’s neck, but he was
unable to untie the knot. Instead, the ligature was cut away with scissors.
As soon as the man was lowered to the floor, the Staff Nurse began to assess him.
The man was unresponsive to painful stimuli, he was not breathing, his heart had
stopped, his pupils were fixed and dilated and he was cyanosed (cyanosis is the
turning blue of bodily extremities following death). The Staff Nurse began mouth to
mouth breathing while another nurse started chest compressions. Other nurses
arrived from healthcare with the emergency response kit. The Staff Nurse and another
nurse continued with CPR (cardio-pulmonary resuscitation) until the ambulance
paramedics arrived at 3.50pm to take over. The paramedics were unable to
resuscitate the man and the duty doctor pronounced the man dead at 4pm.
The attempts at resuscitation in the man’s case were particularly traumatic and
the Staff Nurse’s efforts are worthy of commendation.
15
AFTER THE MAN’S DEATH
The duty governor arranged with the police for them to visit the man’s mother to inform
her of her son’s death. Once the police had confirmed that the man’s mother had
been informed, the duty governor telephoned her to offer condolences on behalf of
Durham and to give her contact telephone number as a liaison point.
The duty governor also arranged for the man’s brother, who was in custody at HMP
Liverpool, to be informed.
When the man’s mother was visited by PPO staff on 6 December 2004, she said that
Durham had not sent her a letter of condolence nor had she been offered assistance
with her son’s funeral expenses. The PPO took up these matters with Durham,
following which a letter of condolence was sent and financial assistance given.
16
LEVEL OF COMPLIANCE WITH AUTHORISED PROCEDURES
The man was not the subject of F2052SH procedures at the time of his death.
Nevertheless, all procedures for dealing with at risk prisoners were checked and found
to be in accordance with laid down national guidelines.
The local policy documents for the care of prisoners at risk of self-harm and the
protocol for the operation of the Listener scheme were comprehensive. However, the
policy has not been signed by the Governor and Area Manager as required under PSO
2700.
As part of programmed Prison Service audit arrangements, the Standards Audit Unit
conducted an audit in November 2002. Durham’s prevention of suicide and self-harm
procedures were rated as acceptable.
The minutes of Durham’s prevention of self-harm and suicide committee for the
preceding six months were examined. The committee was found to have been
active, for example, by carrying out checks on F2052SH documentation. The
meetings were well attended by a multi-disciplinary team including prisoner Listeners
and representatives from the Samaritans.
Staff suicide awareness training records were examined and the available
documentary evidence indicated many staff were out of date for suicide and self-harm
awareness training. Durham’s local suicide prevention policy requires staff to be
trained at least once every three years. We have made a recommendation on this
matter.
Self-harm response kits are available in every wing office, prominently displayed and
appropriately sealed with contents lists attached.
17
CONCLUSIONS FROM CLINICAL REVIEW
There are a number of significant features in this case:
1. The man was accused of murder.
2. The record indicates that his previous sentence was life1.
3. He had no fixed abode.
4. He refused to take a telephone PIN card.
5. He was detoxifying from significant amounts of heroin and
benzodiazepine.
6. He denied feelings of self harm to everyone he whom he spoke.
A murder charge is recognised as a risk factor for suicide and if, as the record
indicates, he previously had a life sentence, he would know that he faced a long future
in prison.
The lack of any fixed abode and the wish not to contact family represents another risk
factor, but was not referred to in the clinical record. It would be helpful in future to
ensure that information of this kind, elucidated by non-clinical staff, is recorded in the
clinical record and mentioned to clinical staff.
The man was detoxifying relatively rapidly. Rapid detoxification has been linked with
deaths in young men.
In my view, there were sufficient risk factors present to sound alarm bells, despite the
repeated denial of feelings of self harm. In hindsight, his admission to healthcare
and/or the opening of an F2052SH with subsequent mental health review would have
represented a safer option.
Having noted that, making these judgments in the short time frame available in a busy
local prison reception can be notoriously difficult and I do not believe that anyone
behaved negligently.
1 this is not correct
18
FINDINGS AND CONCLUSIONS
The man gave himself into police custody on 17 October 2004, confessing that he had
killed his girlfriend. He remained in police custody until midday on 19 October, when
he was remanded into Durham. The PER form passed to Durham from the police
indicated that the man was not perceived to be at risk of suicide or self-harm.
During his reception interview, the man said that he had family support and expected
to receive visits. However, he refused a PIN number which would have enabled him to
use the telephone.
The RMN, a psychiatric nurse with over 20 years’ experience, carried out the man’s
health care screening interview. The RMN was aware of the man’s charges and took
those into account when making his assessment.
There is no agreed local policy available to nurses in reception regarding guidance on
the issue of admission to healthcare of prisoners charged with murder, so the RMN
appropriately contacted the Charge Nurse. The RMN was advised that that there was
no need to automatically admit the man into healthcare, but should admit him if he
wished to be admitted or if the RMN thought there was a need for admission. The
RMN asked the man about being admitted to healthcare, but he declined. Additionally,
there was nothing about the man’s demeanour to give the RMN cause for concern.
Another prisoner recalled hearing the man decline the invitation to go to healthcare.
The RMN made no note in the man’s records, however, that he had been offered and
had declined admission to healthcare.
The man was not referred to a CPN for a psychiatric assessment, as was required by
the criteria set out in Durham’s First Reception Health Screening Form: the relevant
criterion in the man’s case being that he was charged with murder.
The man reported that he used heroin on a daily basis and that he was taking
prescribed Benzodiazepines. Following a referral to the detoxification team, the man
was seen by a CPN in substance abuse on 20 October. However, the man declined
the detoxification medication offered to him saying that he would ‘do his rattle on his
own’ without lofexidine.
The man was seen and spoken to by many staff during his three days in Durham,
during his initial reception and then in connection with his induction programme. On
no occasion did the man display any signs to suggest he was at risk of self-harm or
suicide. He had many opportunities to voice any concerns he might have had for his
wellbeing, but he did not do so.
The man had been allocated a shared cell in the first night/induction Unit. His cell-
mate said that the man did not speak much but he did say that he had murdered his
girlfriend. At about 1.45pm on 21 October, the cell-mate was taken from their cell to
go on a social visit and the cell-door was relocked leaving the man alone.
A prisoner who met the man in reception on 19 October was located in the cell next
door to the man’s. The prisoner recalled the landing being unlocked for downtime at
around 2pm on 21 October. He popped his head round the door on his way past the
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man’s cell and asked if he was coming out but the man did not answer. He was lying
face down on his bed and the prisoner left him alone. The prisoner said that the
landing was locked away about 40 minutes later when downtime ended.
When the man’s cell-door was relocked after downtime, he was still alone as his cell-
mate had not returned from his social visit. At about 3.30pm, the man’s door was
unlocked for him to get his medication. The man was discovered to be hanging by a
ligature made from a television power cord that he had attached to the underside of
the upper bunk. Staff responded quickly and professionally in trying to revive the man
and paramedics were at the scene within 20 minutes. Unfortunately, the efforts made
to resuscitate the man proved unsuccessful. No suicide note was found in his cell.
The clinical reviewer has pointed out a number of risk factors surrounding the
man’s circumstances: one was his refusal of a PIN number, another was the fact
that he was detoxifying from drugs and had elected to do so without the
medication offered to him. A further risk factor was his offence – not only an
offence of murder, but his victim was a loved one. The clinical reviewer
concluded that in hindsight, the safer option would have been to admit the man
to healthcare and/or to open an F2052SH with a subsequent mental health
review. While I can understand the clinical reviewers sentiments, I also note that
the man was offered a place in healthcare by the RMN; an offer which the man
declined to take. Moreover, in his brief time in Durham the man gave no
indication that he was in distress. When asked about thoughts of self-harm or
suicide, he said that he had no such thoughts and he also said that his many
years spent in prison would stand him in good stead for whatever sentence
would be coming to him for his latest offence.
After the police had visited the man’s mother to break the news of her son’s
death, the duty governor telephoned her on behalf of the prison. During their
conversation, the man’s mother said that she had known her son would kill
himself and she had thought about telephoning the prison to inform them of this.
The man’s mother said the same to the PPO staff when they visited her on 6
December 2004. Since the man’s death, the Prison Service has issued guidance
further to Prison Service Order 2710 which advises that the preferred choice for
breaking the news of a death in custody is for the family visit to be made by
prison staff.
The duty governor had further contact with the man’s mother and other members of
the extended family over the following days. Durham’s death in custody contingency
plan states that a letter of condolence offering sympathy from the Governing
Governor should be sent to the family within three days of a death. The letter of
condolence sent to the man’s mother by Durham’s Deputy Governor was dated 8
December 2004. This was seven weeks after the man’s death and only after the PPO
had reminded Durham of its omission. Similarly, it was only when reminded by the
PPO that Durham offered the man’s mother assistance with funeral expenses.
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RECOMMENDATIONS
We make the following recommendation:
HEALTH
1. The PCT and Head of Healthcare should review Durham’s healthcare admission
procedures for those charged with murder, and ensure they are available in reception
for those undertaking health screening of prisoners received into the prison.
Prison Service Response: Recommendation accepted. All new receptions are
seen by healthcare staff in reception. A full medical screening is undertaken to
ascertain the needs of the individual. This is done in conjunction with Cell
Sharing Risk Assessment Form. The decision where to locate is then made.
2. The PCT and Head of Healthcare should develop a clinical audit system for the
audit of First Reception Health Screening to ensure compliance with local and national
policies and procedures.
Prison Service Response: Recommendation accepted. An audit of First
Reception Health Screening will take place on a monthly basis with 10% of
screenings being audited.
3. The Governor and PCT should ensure that all sections of the First Reception
Health Screening Assessment are completed fully on all occasions, with sufficient
documentary evidence of decisions taken and any significant clinical issues noted in
the prisoner’s medical record.
Prison Service Response: Recommendation accepted. As per
recommendation, this is now carried out as a matter of routine upon arrival of
new receptions.
OPERATIONAL
4. The Governor should ensure that letters of condolences are sent to the next-of-
kin within three days, as required by Durham’s contingency plans. The Governor
should also ensure the latest Prison Service guidance is followed in connection with
the offer to bereaved families of payment of funeral expenses.
Prison Service Response: Recommendation accepted. This task is now
carried out by the Safer Custody Team, in liaison with the Governor. This is in
conjunction with PSO 2700 and local contingency plans.
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5, The Governor should consider a rolling training programme for refresher training for
staff in suicide and self-harm awareness, in accordance with Durham’s own local
policy on this issue.
Prison Service Response: Recommendation accepted. A full staff refresher
training programme is in progress, with all staff to be retrained by April 2006.
This is to coincide with the implementation of ACCT (which is to replace the
F2052SH system for monitoring prisoners judged at risk of self-harm).
RECOMMENDATIONS ON STAFF PERFORMANCE
6. The caring and dedicated attitude displayed by the Staff Nurse in attempting to
resuscitate the man is particularly worthy of recognition by the Governor.
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