Individual at East Sutton Park

Investigation into the circumstances surrounding the
death of a woman, a resident at
HMP East Sutton Park, in March 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
January 2008
This is the report of an investigation into the death of a woman who died from a drug
overdose in March 2007 at her parents’ home address. The woman had been on
temporary weekend release from HMP East Sutton Park. She was 33 years old and
was serving a two year sentence.
I would like to add my personal condolences to those already expressed to the
woman’s family by one of my Family Liaison Officers.
The investigation was undertaken by two of my colleagues. I also commissioned an
independent clinical review of the management of the woman’s health needs while
she was in custody. This was conducted by the West Kent Primary Care Trust, and I
appreciate their assistance.
I would also like to thank the Governor, Deputy Governor, and staff at East Sutton
Park for their ready help and co-operation during the investigation. The strength of
their commitment to prisoners at East Sutton Park was very evident.
My report includes three recommendations. Additional recommendations have been
made by the clinical reviewer which will be addressed directly to the Primary Care
Trust.
There has been no previous death of a prisoner from East Sutton Park since my
office took on the responsibility of investigating all deaths in custody in April 2004.
This version of my report, published on my website, has been amended to remove
the name of the deceased and the names of staff and prisoners involved in the
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2008
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CONTENTS
Summary 4
The investigation process 5
HMP East Sutton Park 6
HMP Cookham Wood 7
Prison procedures 8
Key findings 11
Issues raised in the investigation 23
Conclusion 25
Recommendations 26
3
SUMMARY
The woman was 33 years old when she died in March 2007 at her parents’ home
whilst released on temporary licence from HMP East Sutton Park.
She had misused illegal drugs from a very young age. She had started drug
treatment several years prior to her imprisonment and had referred herself to several
community agencies to assist her to remain drug free. However, at the time of the
arrest leading to her imprisonment, she had resumed taking drugs once again.
The woman had a number of convictions dating back to October 1997 for theft and
kindred offences. In March 2006, she was charged with possession of a Class A
drug with intent to supply and committed to appear at Crown Court for her case to be
heard. She pleaded guilty to the charges against her, and was later sentenced to
two years imprisonment and received into custody at HMP Bronzefield. In October
2006, the woman transferred to HMP Cookham Wood and then in January 2007 to
the open prison at East Sutton Park.
During her sentence, the woman took a number of steps to address her drug use
including completing a detoxification programme. She engaged well with the support
offered in respect of her physical and mental health. She settled into prison life well
and arrangements were underway for her rehabilitation back into the community.
Leading up to her parole date (March 2007), the woman completed successful
releases from prison on Temporary Licence (ROTL) as part of her resettlement. This
included two day release town visits and one overnight weekend visit to her parents’
home.
On her last ROTL, a week or so before her expected release from prison, the woman
was found dead in bed in her parents’ house. She was due to return to the prison
the next day. Drug paraphernalia was found next to her.
My report makes four recommendations.
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THE INVESTIGATION PROCESS
1. My investigators studied all relevant prison records relating to the woman who
died. These included her main prison and medical records. My investigators
also visited the prison and spoke to the staff who dealt with the woman during
her time there. Three prisoners were also interviewed and provided information
about the woman’s time at East Sutton Park.
2. The South West Kent Primary Care Trust carried out a review of the woman’s
clinical care. I am grateful to them for undertaking the review in a most timely
manner. My investigators discussed aspects of the woman’s treatment, both
with staff at East Sutton Park and with the clinical reviewer.
3. My investigator contacted Her Majesty’s Coroner to inform him of the nature
and scope of my investigation and to request a copy of the Post Mortem report.
Upon completion, my report will be sent to the Coroner to assist in his enquiries
into the woman’s death.
4. One of my Family Liaison Officers contacted the woman’s parents. This was to
give the family the opportunity to raise any issues they would like addressed in
the report. However, the woman’s parents had no issues they wanted to raise
for the purposes of this investigation, and did not want to see the report. They
are aware that they may change their minds at any time.
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HMP EAST SUTTON PARK
5. HMP East Sutton Park first opened as a borstal in 1946. The main building is a
pleasant mansion house overlooking the Weald of Kent. It holds 100 women of
whom ten are young women under the age of 21, and 90 are adults. The
accommodation comprises 21 dormitories of varying sizes. It is a resettlement
establishment, holding women in open conditions preparing them for release
into the community. Prisoners at East Sutton Park are referred to as residents
and I have adopted that term throughout this report.
6. Before arriving at East Sutton Park, all residents are rigorously risk-assessed at
their previous establishment for their suitability for an open resettlement prison.
This includes assessing the risk they present to the public and the risk they
present to themselves.
7. The regime at East Sutton Park includes provision of farms, gardens, catering
and training courses, and physical education. The emphasis is on resettlement
and the prison has good community links, with a number of the residents
working outside each day.
8. Since May 2006, East Sutton Park has been joined in a “cluster” arrangement
with HMP Cookham Wood. Previously, East Sutton Park had been a
standalone establishment with its own Governor and senior management team.
The two establishments were then clustered, and now have one Governor.
Generally, any prisoner who is re-categorised from Cookham Wood (a higher
category prison) will go to East Sutton Park, unless their resettlement plan
includes another open prison. (In July 2007, it was announced that Cookham
Wood was to change its function from a women's prison to a male Young
Offender Institution (15-18 year olds), commissioned by the Youth Justice
Board.)
9. Her Majesty’s Chief Inspector of Prisons, Ms Anne Owers, inspected East
Sutton Park in November 2006 and described it as a very safe prison, with little
bullying and no evidence of self-harm. Most services, including the shop and
food, were good, and healthcare was excellent. Ms Owers also commented
that resettlement was reasonable, with good strategic direction, sound
sentence planning and a wide range of reintegration and family support
services.
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HMP COOKHAM WOOD
10. At the time the woman who is the subject of this report was there, HMP
Cookham Wood was a closed prison for adult women. It was built in the 1970s,
originally for young men, but its use was changed to meet the growing need for
secure female accommodation at the time. As noted, Cookham Wood and
East Sutton Park currently share the same Governor.
11. Accommodation is in single cells, and there is an operational capacity of 185
which includes a juvenile unit for 17 young women. Prisoners are mainly
employed in the workshops (tailoring and contract work), on the gardens, a
painting party and in domestic work such as kitchen and cleaning. Many
women are also offered part-time education which includes improving literacy
and numeracy where needed. There are several offending behaviour groups,
run either by prison staff or probation, as well as support groups (such as the
foreign nationals group) and self-help groups.
12. There is a joint working partnership between Cookham Wood and East Sutton
Park. East Sutton Park taps into the resources at Cookham Wood and
residents frequently attend the site for various activities such as educational
and hairdressing courses.
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PRISON PROCEDURES
Reception
13. On arrival at prison, the paperwork for prisoners is checked before they are
taken off the escort vehicle. Staff check warrants to ensure they have the
correct prisoners in custody, and then set up the necessary records. The
prisoner is taken from the vehicle and booked in by staff on the front reception
desk. Personal and offence details are taken, along with any known or
identified concerns.
14. All prisoners see reception officers and the member of healthcare on duty.
During this process, address and next of kin details are obtained and prisoners
are risk assessed. They are searched, their property is logged, and they are
health screened before being located to a wing.
Mental Health In-Reach teams
15. Mental Health In-Reach teams provide specialist assessment and treatment for
prisoners with mental health problems. Prisons can also offer access to
psychiatrists and counselling services.
Counselling, Advice, Referral, Assessment and Throughcare (CARAT)
16. Everyone coming into prison who is identified as having a drug problem is
assessed, given advice about their misuse, and referred to the specific drug
service they need. CARAT workers can also give basic information about
drugs and their effects, and may offer counselling and group work to prisoners
who want to give up or cut down on their misuse. They can also refer a prisoner
to a drug treatment rehabilitation programme.
Treatment and detoxification programmes
17. Prisons offer treatment programmes (these can include rehabilitation
programmes and therapeutic communities) for prisoners wanting to tackle their
drug problems. The programmes offered vary widely. Some are run entirely by
outside drug workers, some by prison officers, and some by a mixture of both.
Some last a few weeks, others up to 18 months. All local prisons and remand
centres offer a detoxification service for prisoners who want to come off drugs.
The prisoner will be expected to give up misusing while on the programme.
Many programmes are run on Voluntary Testing Units where prisoners are
regularly tested for drugs.
18. The Prisoners Addressing Substance Related Offending course (PASRO) is
one of the programmes provided by the Prison Service. It is a cognitive
behavioural treatment programme which enables people to explore and change
the thinking and behaviour patterns which contribute to their drug misuse and
offending.
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Drug Testing
19. A proportion of prisoners are randomly tested for drugs in every prison every
month. Those tested are selected by computer. In addition, if staff suspect or
receive information that a prisoner is taking drugs, they can be tested on the
grounds of reasonable suspicion.
Release on Licence
20. Prisoners may be released on licence before they have served their full
sentence. Release is automatic for those serving shorter sentences.
Home Detention Curfew (HDC)
21. The Home Detention Curfew (HDC) scheme applies to prisoners who are
serving sentences of between three months and under four years. It allows for
early release subject to a curfew policed by electronic monitoring.
22. Prisoners granted release on HDC will be released between two weeks and
four and a half months before their automatic release date, depending on the
length of sentence. If a prisoner is to be released on HDC they must sign a
licence that tells them the times they will have to remain at their home address
or hostel. On reaching this address, an electronic tag is fitted to the prisoner
and monitoring equipment installed at the address by a private contractor.
Release on Temporary Licence (ROTL)
23. In certain circumstances, prisoners may be granted release on a temporary
licence. This may be on compassionate grounds or to help the prisoner
improve their chances of resettlement. The system of release on temporary
licence (ROTL) is designed to ensure that suitable prisoners are released for
precisely defined and specific activities which cannot be provided in Prison
Service establishments.
24. Residents are only released on temporary licence after they have been
assessed and approved for ROTL by an authorised senior manager and the
probation service. At East Sutton Park, risk assessment boards to consider
ROTL applications are convened regularly and normally consist of the deputy
governor, a senior officer and a member of the probation team.
25. Risk assessments of prisoners eligible for home leave include checking that the
home address is suitable and that released residents are not going to an
environment that is going to put them, or any other person or member of the
community, at risk. This includes ensuring there are no victims of the crime in
the local area. The police are also informed.
26. The two types of ROTL operated at East Sutton Park are Resettlement Day
Release licences (RDR) and Resettlement Overnight Release Licences (ROR).
RDR is for residents to participate in reparative and community service
projects, maintaining family ties, housing, employment, life and work skills,
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training/education courses etc ROR is similar but for a longer period and
enables residents to spend time at their intended release address. It is
considered a key goal for residents reaching the end of their sentences.
Pathways
27. Risk assessments include “pathway levels”. Generally speaking, by virtue of a
resident being at East Sutton Park they are considered safe and trustworthy to
leave the prison unaccompanied. However, each risk assessment contains
distance boundaries that a resident should remain within. If a resident needs to
go further afield, another assessment is carried out that could result in a higher
pathway level being granted. Residents at East Sutton Park can get full-time
work, go to college, and carry out voluntary and community work whilst serving
their sentence.
28. Pathways are used at East Sutton Park to identify which residents are at what
stage on the risk assessment process. The levels are as follows:
Level 1 - No ROTL - have not reached their ROTL dates, are too high a risk to
the public or have not engaged with their sentence plan to enjoy the
privilege of ROTL.
Level 2 - Medical ROTLs only - same as above but are deemed suitably
low risk to the public to allow them to attend medical appointments on
their own.
Level 3 - Have reached RDR eligibility date, have engaged with their
sentence plan and are medium - low risk to the public (town visits
within 15 mile radius).
Level 4 - As above but permitted to go to cleared home address.
Level 5 - As above and have reached their ROR dates.
Listeners
29. Listeners are prisoners trained by the Samaritans to provide confidential and
emotional support to other prisoners. The support offered by Listeners is
confidential. Details of a prisoner’s conversation with a Listener will not be
passed on to prison staff unless the person the Listener is supporting gives
permission.
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KEY FINDINGS
Before the woman’s arrival at East Sutton Park
30. In March 2006, the woman was transferred from court to HMP Bronzefield on
remand following her arrest for possession with intent to supply Class A drugs.
On arrival she was delivered into the prison reception and went through an
interview screening process, which included a First Reception Health Screen.
31. The woman was examined by the nurse and said that she was prescribed
methadone, citalopram (an anti-depressant), prednisolone (for her liver
condition), and inhalers for her asthma. The woman also admitted to taking
heroin, methadone and cocaine all within the previous two days. Due to her 12
years of intravenously injecting heroin, the woman’s body was covered in
scars. The nurse subsequently carried out a drugs test which tested positive
for the aforementioned drugs. However, there were no concerns regarding the
woman’s mental health and she said she had no thoughts of self harm or
suicide.
32. The following day, the woman was examined by the prison doctor. He
recorded that her liver illness had been diagnosed as sarcoidosis in 1995 and
she was currently receiving out-patient treatment at a hospital. She had
suffered from depression for many years. The doctor made a note on her
records that her prescribed medication should continue. As the woman was
currently drug dependent, she was placed on a drug detoxification programme.
33. A week later, the woman was discharged from prison to appear at a later date
in court. She was given a three day supply of her prescribed medication,
including methadone, to take home.
34. In August 2006, the woman was sentenced to two years imprisonment at the
Crown Court. Following sentencing, she was again escorted to HMP
Bronzefield arriving at around 6.30pm that evening. The Prison Escort Record
(PER) Part A form showed the woman’s illnesses as sarcoidosis, asthma, and
depression, and that she was methadone dependent.
35. The woman repeated the prison reception screening process for new prisoners.
As is normal, a cell sharing risk assessment (CSRA) was completed. The
CSRA is intended to provide consistent and continuing risk assessment and
management relating to cell-sharing. The woman was considered a low risk of
harm to others.
36. When she was interviewed by the healthcare nurse, the woman disclosed that
she had seen her own doctor in the last few months for depression and
asthma. She said she was prescribed medication of inhalers, methadone,
risedronate and calchew (calcium supplements), zispin (anti-depressants), and
prednisolone. She had also taken heroin, methadone and benzodiazepines
within the past 24 hours. The woman was concerned about her liver complaint
and felt anxious and agitated. The nurse therefore made a referral for her to
see the prison doctor. As the woman had also been identified as a drug user,
11
she was referred to the detoxification programme.
37. Afterwards, the woman was located on the First Night Wing. She was provided
with her induction programme and the prison regime was explained. The
following morning, she was examined by the doctor who requested her
previous medical history notes from her own GP and hospital consultant. The
doctor prescribed a 40 day methadone detoxification programme which would
end on 20 September. It was a reducing dose from 25mls down to 3mls.
38. Over the next couple of days, the woman’s induction continued with further
assessments and input from the education and offender management units.
She also attended the substance misuse clinic to review her detoxification
programme.
39. On 16 August, the woman saw the doctor and complained of being unable to
sleep properly. She had already been prescribed mirtazapine (for depression)
and now requested trazodone which was prescribed for her. On 29 August,
she was seen by the doctor again. On this occasion she had contracted head
lice and was prescribed medication to deal with the problem. She also asked
for treatment for the multiple scars on her body. There is no evidence on the
woman’s records to show what action was taken on this matter, if any.
40. A nurse triage appointment took place on 13 September to discuss the
woman’s general health. She had been prescribed anti-depressants for six
years, and told the nurse that she was feeling unwell, was crying all the time,
lacked any appetite and had pains in her back. An appointment was made for
her to see the doctor the following day. When the woman saw the doctor she
said she had stopped taking her anti-depressants ten days ago and asked to
go back onto mirtazapine. The doctor examined her and prescribed
mirtazapine of 30mgs to be taken once a day. It was also recorded that the
woman had no thoughts of suicide.
41. On 21 September, the woman was seen again in the substance misuse clinic.
She was examined and found to have high blood pressure and anxiety. She
had finished her methadone detoxification programme. It was recommended
that she should continue on methadone of 5mls for a further week to try and
alleviate her symptoms.
42. The doctor examined the woman again on 25 September. Her blood pressure
was still high and she was referred for an ECG (an electrocardiogram that
records the electrical activity of the heart to check for any damage) and blood
tests. The woman went back to the substance misuse clinic the following day
where her medication plan was changed to reduce her methadone intake by
1ml for ten days. When the reduction reached 2 mls, the methadone treatment
would stop.
43. On 28 September, the woman attended healthcare for blood tests.
Unfortunately the nurse had difficulty trying to locate a vein to take blood
because of the multiple scarring on her arms. The nurse contacted the
hospital, where the woman had provided a sample the previous week, to obtain
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the necessary information.
44. The next day, the woman was seen again by the doctor. The consultant had
written to ask for her to be prescribed prednisolone for her liver condition. The
doctor agreed, and wrote to her consultant requesting more up to date clinical
information about her condition.
45. On 2 October, the doctor reviewed the woman’s medication and continued
prescribing mirtazapine daily. She still had some anxieties, but her mood was
much better and she appeared to be coping well. By the time he saw her again
on 11 October, the doctor had received correspondence from her consultant
who said her liver function had improved. She was still having problems
sleeping and asked to revert to trazodone because mirtazapine was not
working. The change in medication was agreed.
46. The doctor carried out a further review of the woman’s medication on 28
October. Her methadone programme had ended and she was feeling anxious.
The doctor discussed this with her, and explained she was experiencing the
symptoms associated with a detoxification programme and that it would
eventually pass.
47. On the whole, the woman gave staff no cause for concern whilst at Bronzefield.
She was compliant and polite and she continued to manage her physical and
mental health with the support from healthcare staff. In her time at Bronzefield,
she completed her drug detoxification programme and also attended a number
of sessions on relaxation, heroin-awareness and relapse and overdose
prevention. She worked with the CARAT team to try to remain drug free and
the result was that she felt well and positive about her current situation.
The woman’s arrival at HMP Cookham Wood
48. The woman was transferred to Cookham Wood on 27 October. She arrived at
the prison reception around 1.15pm. Details of her physical and mental health
were made available to the reception staff on her arrival. She went through the
interview screening process and induction and was assessed by reception and
healthcare staff. After completing the reception process, the woman was
located on the First Night Wing.
49. Over the next three days, the woman’s prison induction continued. Further
information was provided about the regime, including privileges, medication,
Voluntary Drug Testing (VDT) and meals. A personal officer and a back up
personal officer were assigned. Personal officers have regular one to one
meetings with a prisoner when they can discuss any issues or concerns a
prisoner may have.
50. Due to the woman’s history of drug taking, she was referred to the CARAT
team and had her first meeting with her support worker on 3 November. They
discussed support options to aid her abstinence from drugs. As part of her
sentence planning, it was probable that she would soon be re-categorised to
open conditions and transferred to East Sutton Park. Her support worker
13
believed it was unlikely that she would have enough time to complete a PASRO
course whilst at Cookham Wood. However, he sought advice on this matter, as
well as other possible alternative courses, before making a decision.
51. On 7 November, a probation officer at Cookham Wood interviewed the woman
and discussed her offending behaviour and future plans. There were no issues
regarding accommodation after her release from prison as she intended to live
with her parents. Referrals were made for a PASRO and Access to
Employment course.
52. The woman requested an appointment with the Mental Health In-Reach Team
on 12 November. She also wanted to see the doctor but no appointments were
available. She saw the nurse three days later. The nurse found that the
woman’s blood pressure had decreased from the previous high level when it
was last checked at Bronzefield. She had however contracted a chest
infection, for which she was later prescribed amoxicillin antibiotics. The doctor
also asked for another liver function test.
53. The woman had another meeting with her CARAT support worker on 28
November. He told her that he had received information about the suitability
and relevance of her attending a PASRO course. It was decided that it would
not be appropriate for her to attend the course at this time. As the woman said
she was not keen on attending group therapy work, her support worker agreed
that they should have six structured one-to-one sessions to continue to address
her drug misuse issues.
54. On 5 December, the woman was seen by the nurse in the Mental Health Clinic.
It was agreed that she would be seen weekly for assessments where she
would be encouraged to speak of any fears and concerns about her health.
55. On the morning of 11 December, the woman’s personal officer had a general
chat with her. The woman had already been told she would relocate, in due
course, to open prison conditions and they discussed this. No concerns were
noted by her personal officer following this meeting.
56. One of the reasons the woman was being transferred to open regime
conditions was because of the good progress she had made in addressing her
offending behaviour. It was believed she was ready to move to a resettlement
prison. It had been calculated that she could be released early under the HDC
arrangements from 23 March 2007. The woman was also in a position to be
considered for ROTL from 2 February 2007. However, if for some reason she
was not released early from prison and was required to serve her full term of
sentence, her automatic release date was 3 August 2008.
57. On 13 December, the woman had the first one-to-one session with her CARAT
support worker. The session was very positive and the woman looked forward
to their next meeting, scheduled to take place a week later. When the second
session took place, she was very positive again and discussed her likes and
dislikes of drug use.
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58. Until the woman’s transfer out of Cookham Wood, there was no evidence to
suggest that there were any major concerns about her, or the risks associated
with her drug taking.
The woman’s arrival at HMP East Sutton Park
59. The woman transferred to East Sutton Park on 9 January 2007. She repeated
the reception screening process and was interviewed by reception and
healthcare staff. The woman was interviewed by a Registered General Nurse
(RGN) who conducted a healthcare check and well-woman assessment. The
nurse told my investigators that the woman was a bubbly person who had a 13
year history of using drugs. The woman was very pleased that she had now
managed to remain drug free for over five months. However, she disliked the
way her body looked after many years of injecting.
60. The woman was already on medication when she transferred from Cookham
Wood. This was detailed on her prescription sheet as prednisolone, actinel and
trazodone, all shown as repeat prescription medication. As an open
establishment, most residents of East Sutton Park are allowed to keep their
medication in their possession. The woman therefore signed a compact,
agreeing to look after her medication and not abuse the right. She was
prescribed anti-inflammatory prednisolone, a calcium supplement and an anti-
depressant. She was given a 28 day supply to keep in possession.
61. The woman asked to see the prison Mental Health In-Reach team, and so was
interviewed by the In-Reach team nurse. The nurse’s assessment of the
woman noted that she had misused drugs, had clinical depression from
childhood, had been prescribed trazodone recently to help with sleeping, and
had tried a number of anti-depressants in the past. She felt this should be
reviewed and made a referral for the woman to see a member of the Mental
Health In-Reach team.
62. The woman was allocated a personal officer at East Sutton Park, who carried
out an initial interview with her. The personal officer told my investigators that
she planned to meet the woman fortnightly and, in their initial meeting, she
asked a number of questions to get to know more about her. The woman told
her personal officer that she had a chronic liver disorder, and talked about her
previous drug misuse and her concerns for her elderly parents. Although her
personal officer knew that the woman was not taking any drugs at the time, she
referred her to see a CARAT team worker because of her past history of drug
misuse.
63. The East Sutton Park Estate Manager told my investigators that he met the
woman as part of her induction programme when she first arrived. He gave a
talk to all the new residents about working on the farms and gardens, and
asked for any expressions of interest. The woman immediately expressed a
keenness to work on the farm and was allocated to a work party. The Estate
Manager said the woman was very happy and enjoyed working with the other
residents who worked on the farm and with the young animals. Residents
worked five days a week and planned their own rest days. The Estate
15
Manager would see the woman each day, and would sometimes work
alongside her.
64. The woman was keen to start her rehabilitation back in the community and
made an application for RDR on 12 January 2007. Her request said that she
would like to do voluntary work at a day centre. Her application was to be
considered, risk assessed and checked for the availability of any work.
65. On 13 January, the woman applied for her parents’ home address to be risk-
assessed so that she could stay there on ROTL. The prison probation clerk
wrote back to her on 18 January and said that her request would be assessed
after the woman had met her East Sutton Park probation officer.
66. The woman had her first meeting with an East Sutton Park CARAT worker, on
16 January. At this stage, her CARAT file had not arrived from Cookham Wood
so the CARAT worker spent the time discussing some of the woman’s issues
and getting to know her. The woman told the CARAT worker that she had a
long history of drug usage and also periods of depression. Despite this, she
presented as a bubbly, energetic, level-headed woman who appeared
motivated to remain drug-free and had achieved this now for some several
months. The CARAT worker said the woman was intelligent and aware of the
issues surrounding drug tolerance levels.
67. Whilst at Cookham Wood, the woman had begun an art course which she
wanted to continue. On 18 January, she applied for RDR to attend Cookham
Wood every Tuesday. The application was approved and she was permitted to
leave East Sutton Park at 8.00am and return no later than 5.30pm each
Tuesday.
68. On 21 January, the woman submitted her first ROTL application for ROR. It
was to run for five days between 8 and 12 February. She wanted to visit her
parents - especially her mother, whom she had not seen for over two months.
She also wanted to decorate her room in preparation for her release.
69. On 22 January, the woman met her East Sutton Park probation officer for the
first time. The probation officer had read pre-sentence probation reports and
the information helped when she carried out an initial profile. (This is usually
done within two weeks of the resident arriving at the prison. Thereafter, the
frequency of seeing a prisoner would depend on their needs.)
70. The purpose of the initial profile is to build a picture of the resident, including
any needs relating to housing, drugs or alcohol. As East Sutton Park is an
open prison, the risk of re-offending is continually re-assessed and staff to work
with residents to make plans for their resettlement. The woman was working
towards receiving an early release on HDC, for which she was eligible from 23
March.
71. The East Sutton Park probation officer found the woman pleasant and easy to
converse with. She was very forthcoming in answering questions and relayed
that she really wanted to change. She said her parents and family were
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supportive, and she was also supported by an outside drugs advisor. She had
continued with her one-to-one sessions with the CARAT team. The probation
officer said that the woman’s needs were relatively low when she met her, and
she was progressing very well through her sentence. The East Sutton Park
probation officer faxed a copy of the HDC application form to the woman’s
outside probation officer. Responsibility for the woman later transferred to
another probation officer outside the prison. He subsequently confirmed that
there were no objections to the woman being granted release on HDC licence
at her parents’ address.
72. Despite East Sutton Park and Cookham Wood having a working relationship,
the woman’s CARAT file did not arrive until 23 January, three weeks after she
had transferred. The following day an inmate risk assessment board was held,
attended by a Governor, Senior Officer (SO) and the prison probation clerk.
The woman was initially granted Pathway Level two, the first level which
allowed her to go off site on medical and compassionate grounds.
73. On 27 January, the woman had her fortnightly review with her personal officer.
She said she had settled well into East Sutton Park and was happy with her
room. She had been working in the farm and was enjoying this. As her RDR
had been approved for 3 February, she was looking forward to her first town
visit. There were no concerns raised during this meeting.
74. The following day, under advice from the doctors, the woman submitted a
‘Labour change request’ application for a change of job from the farm work.
She had spoken with the healthcare RGN who had told her that fibres and dust
on the farm were affecting her breathing and it would be better if she worked
indoors. This was a disappointment to the woman as she enjoyed working
outdoors, but she decided that she did not want her health to get any worse.
75. On 29 January, the woman had her second meeting with the East Sutton Park
CARAT worker who agreed that they would complete the in-cell Relapse
Prevention Pack. These were sessions geared towards looking at ways to help
the woman remain drug free and the first was scheduled for 31 January. The
woman said she had settled into East Sutton Park well. She mentioned that
she had requested a change of job from the farm work because of her health
problems.
76. The next day (30 January), the woman was granted ROTL to go to Cookham
Wood for the art class. In regard to her ROR leave, the prison probation clerk
contacted the woman’s outside probation officer and faxed him a copy of the
ROTL application to ask if he had any objections. Subsequently, an inmate risk
assessment board was convened to review the woman’s Pathway Level. She
was then granted Pathway Level three.
77. The woman had her first one-to-one Relapse Prevention session with the
CARAT worker on 31 January. The CARAT worker was keen to ensure that
they started this work before the woman went out on her first period of
resettlement leave. The session went well and covered a number of topics
relating to the taking and misusing of drugs. It looked at the woman’s risk
17
areas and how she was progressing with being drug free. They also discussed
how the woman could deal with any cravings for drugs.
78. The woman attended healthcare on 1 February for a liver function blood test.
The Head of Healthcare was unable to locate a vein to take blood from her,
something that had happened previously. The Head of Healthcare allowed the
woman to locate the blood vessel herself to carry out the procedure.
79. The same day, the woman had an appointment with the Mental Health
Practitioner. The Mental Health Practitioner assessed that the woman was a
low risk of suicide, self harm, harm to others and vulnerability. The woman told
the Mental Health Practitioner that she had thoughts of self harm and suicide
when her mood was low, but this was something she had no intention of acting
on, now or in the future. The woman presented as mentally stable, but talked
about her depressive illness and having low and high moods. She said she
was coping with prison life and was sharing a dormitory with seven other
residents and had not experienced any bullying. She talked about her illness
and medication and that she had been drug and alcohol free since August
2006. The woman said that she had not seen her parents for some time and
was tearful when she spoke about them. An appointment was made for a week
later.
80. Although my investigators found no evidence to support this, it appears the
woman successfully completed her town visit on 3 February. On 6 February,
the prison probation clerk wrote to the woman to say that her outside probation
officer had no objections to her ROTL application. The next ROTL risk
assessment board would convene on Wednesday 7 February and her
application would be considered then. Should the application be approved, the
woman would be granted ROTL for the period Thursday 8 to Monday 12
February. This would mean she would leave East Sutton Park at 9.00am on
the first day and return by 7.00pm at the latest on the end date.
81. On Wednesday 7 February, the woman’s ROTL was approved and she was
granted ROR for 8 to 12 February. She would also be eligible to apply for a
further period of ROR in four weeks time. The woman was subsequently risk
reassessed and now deemed eligible for Pathway Level five. She had
engaged with all the support mechanisms required to address her offending
behaviour, was deemed a low risk to the public, and was generally a low level
of concern.
82. The CARAT worker spoke with the woman just before her first weekend ROTL
and reminded her about using drugs and other risks in the community. The
CARAT worker told my investigators that the woman’s mood was fine, but she
was slightly apprehensive at the thought of going home. Their conversation
included discussions about her parents being elderly and how she would have
to readjust her life to remain drug free. The CARAT worker said she thought
the woman had enough knowledge to be aware of the perils of taking drugs.
The following day, the woman was released for the first time under the
conditions set out in her ROR licence and had a successful weekend.
18
83. Residents returning from a period of ROTL are met at the main prison gate.
Staff can instigate drug and alcohol tests if there is any suspicion that residents
are under the influence of a substance, but this did not apply to the woman.
The officer on duty noted that the woman returned 11 minutes late, explaining
that her father (who drove her back) had got lost and stuck in traffic. She was
given a warning for her lateness. Apart from this, there were no other concerns
and her weekend leave had apparently gone well.
84. The CARAT worker spoke with the woman after she returned from her ROTL.
She gave no concern that she had been tempted to return to misusing drugs.
RDR was granted for her to attend Cookham Wood for the period 13 to 15
February so that she could attend a comedy club course run by the education
department.
85. On 15 February, the woman’s personal officer conducted her fortnightly review.
The woman said that she had enjoyed her leave and spent a lot of time with her
sick mother. She submitted an application to her personal officer to be
considered for voluntary work at one of the community day centres in London
or Maidstone. Her personal officer said she would be informed as soon as
work became available. The woman again raised no concerns and told her
personal officer that she would let her know if there was anything she wanted to
discuss.
86. On 20 February, the woman made her ROTL application for ROR. This was
again for release to her parents’ address, for the period 9 to13 March. The
prison probation clerk faxed it to the woman’s outside probation officer.
87. The woman had her second Relapse Prevention Plan session on 21 February.
Again, it went well and she discussed a number of issues relating to the misuse
of drugs and her resettlement leave. She said she was keeping herself
occupied and was coping with her cravings. Her next session was scheduled
for 28 February.
88. The Mental Health Practitioner had her second session with the woman on 22
February. The woman presented a positive outlook about the future and said
she hoped to get parole very soon. She said that her home visit had gone well.
The Mental Health Practitioner said that she arranged for a psychiatrist to
review the woman, and hoped this would be done before her release.
89. The woman completed her Relapse Prevention pack work on 28 February.
The CARAT worker sent a copy of her pack to a community drugs worker. It
was hoped he would be able to offer one-to-one support regarding substance
misuse issues after her release. The woman had originally referred herself to
the community drugs worker in July 2006. She had wanted advice about
residential rehabilitation services and the funding procedures to get access to
this type of treatment. However, because the woman was later sentenced to
serve a custodial sentence, she took no further action on the matter.
90. On 1 March, an assessment on the woman was carried out by the prison’s In-
Reach psychiatrist. The woman said that the trazodone had helped her sleep
19
pattern but not improved her mood. She was feeling tearful now and asked to
revert back to citalopram, as this had previously helped to stabilise her mood
pattern. She said she had no suicidal thoughts. It was agreed that she would
gradually stop taking trazodone and start citalopram. As the change would
probably not start until around the time the woman was due to be released, the
psychiatrist said he would send a letter to her home doctor.
91. On 3 March, the CARAT worker telephoned the community drugs worker,
asking for information about the services available in the woman’s home area.
The CARAT worker told the community drugs worker that the woman was
doing very well and was committed to abstinence. The woman’s release plan
was sent to the community drugs worker shortly afterwards, and she
telephoned him to arrange to contact each other on her release. The woman
said she felt that further support would be helpful.
92. The woman’s application for release on HDC licence was approved on 5
March. The East Sutton Park probation officer had no problems with
supporting the application. The period in custody had so far been quite
uneventful. The woman had conformed to the prison regime and had by now
completed two successful town visits and one five day home visit at her
parents’ address. She had also attended Cookham Wood to continue with her
art classes and had kept herself active.
93. The woman’s ROR was approved for 9 to 13 March. The CARAT worker said
that she was not aware of this and therefore did not get the opportunity to
speak with the woman before she left the establishment. There is no record of
a fortnightly review between the woman and her personal officer in the period
leading up to when she commenced her ROR. Her personal officer said she
had a brief conversation with the woman the night before she left. The woman
was eager to pack her bags and get ready for her weekend and so the
conversation only lasted a few minutes. The personal officer said the woman
gave no indication that anything was wrong and she raised no concerns.
94. Throughout my investigation, there was ample evidence that staff and residents
had a good relationship with the woman. She was described as an intelligent
woman, polite, well behaved and complying with the prison regime. She was
forthcoming with any concerns she had, including showing a positive attitude to
her health needs. The woman insisted on many occasions that she was aware
of the risks of taking drugs and would not return to drug use. She proved this
on one occasion whilst on ROTL when she refused drugs from an
acquaintance. Her fellow residents also saw her as someone who had
overcome her drug misuse problems and was looking forward to a drug free life
after release in a supportive family network. When she left prison on 9 March
to commence her ROTL, there were no concerns about her well being. As far
as all were concerned, she was happy and had remained drug-free whilst at
East Sutton Park.
Notification of the woman’s death
20
95. The woman was not due back to East Sutton Park until 13 March. On the
evening of 12 March at approximately 4.45pm a Senior Officer (SO) on duty
received a telephone call from Thames Valley Police. The police said that the
woman had been pronounced dead at her ROTL address earlier that day. The
police said at that stage they were treating her death as suspicious, but it was
likely to be drug-related as drug paraphernalia had been found next to her
body.
96. The SO told my investigating officers that she was shocked to hear this news.
She checked the prison computer system for the woman’s details and
telephoned the police to verify the call. The SO was aware that East Sutton
Park did not have a death in custody contingency plan which applied to a death
outside the establishment. However, as with a death in custody on the
premises, the first task was to contact the duty governor. She therefore
telephoned the duty governor at Cookham Wood and faxed the woman’s
details. The duty governor then informed the National Operations Unit and
other parties.
97. The SO began to tell other staff and residents. As teatime was approaching,
she was aware of the difficulties of getting all the staff together. She therefore
carried out one-to-one notification to staff whilst walking through the building.
She emphasised that it was important that they did not discuss it between
themselves so that residents could overhear, as she wanted to avoid
inaccurate information and rumours spreading before she had chance to inform
the residents together.
98. The SO decided to pass on the news of the woman’s death to residents after
they had had their tea when they would all be together. After meal times, staff
have more time to offer support. The SO was herself a member of the care
team and was happy to take on the function. The prison chaplain had also
been notified and was on his way to help support the SO and the residents.
99. Soon after, the duty governor contacted the SO and said that he had managed
to speak with the woman’s parents and arranged for representatives from the
prison to visit them. He told the SO that she should collect the woman’s
personal belongings as soon as possible so that arrangements could be made
for their return to her family.
100. When the chaplain arrived, he joined the SO and two female officers in the
woman’s dormitory, where they spoke with the residents. The SO said she
thought that it would be appropriate to tell these residents first because it was
likely that the impact on them would be greater. When the news was broken,
the residents were clearly concerned and upset. Support was offered and the
SO said that further support was available at any time, should they feel that
they needed it. Despite their sadness, the residents helped the officers collect
the woman’s personal possessions.
101. After spending some time in the woman’s dormitory, the SO went downstairs to
speak to the remaining residents. The chaplain again accompanied her.
Afterwards the SO walked around the dormitories and activity rooms to speak
21
to and offer support to residents and staff who were still shocked at the news.
Arrangements were also made for residents to have access to Listeners should
they wish.
102. The prison’s daily occurrence log book was updated to show that there had
been a death of a resident. The woman’s personal officer, who was on duty at
the time, learnt of her death by overhearing other staff talking about it. On
hearing this information, she quickly found the SO to confirm. The woman’s
personal officer said she was shocked and quite upset on learning of her death.
She was offered support by the SO, and reminded that there was a 24 hour
support phone line available to anyone who wished to speak with someone
outside the establishment.
103. The East Sutton Park Healthcare RGN returned to duty the following day after
being on leave. When she arrived she met another SO in the central office.
The nurse was updated on the activities of the prison and informed of the
woman’s death. The nurse was also shocked, left the office and went to
healthcare. She was disappointed to learn that none of the healthcare staff had
been informed of the woman’s death. This was despite the fact that two
healthcare staff had been at the prison until 6.15pm the previous day. The
healthcare team offered support to one another.
104. The following day, the Governor held a hot debrief meeting to discuss the
circumstances of the woman’s death. No particular issues were raised. The
prison’s Family Liaison Officer and the chaplain visited the woman’s parents to
offer condolences and return her personal belongings. The Family Liaison
Officer explained that support and financial assistance were available for the
woman’s funeral. She provided contact details for the prison so the family could
get in touch at any time if they had any issues they wished to discuss. The
Family Liaison Officer also gave the woman’s parents the money she earned
whilst working at East Sutton Park.
105. The woman’s CARAT worker, who works part-time, was off duty at the time of
the woman’s death. She found out on her return to the office through reading
the daily occurrence book. This upset her and she was offered support from
another colleague.
106. Two weeks after the woman’s death, East Sutton Park held a memorial service.
It was well attended by residents. The woman's parents were invited but chose
not to attend.
Post Mortem
107. The post mortem results confirmed that the woman had a high concentration of
morphine in her blood, together with other substances such as heroin and
alcohol. These substances were taken shortly before her death. There was
also evidence of significant cocaine abuse.
22
ISSUES RAISED IN THE INVESTIGATION
Clinical care received whilst in custody
108. A review of the woman’s medical care was undertaken by South West Kent
Primary Care Trust (PCT). A number of recommendations were made which
will be addressed with the PCT. Those which are relevant to the investigation
are included in this report. The PCT found that the level of care the woman
received was comparable, and in some instances was higher, to that she would
have received in the community.
109. The clinical review confirms that the woman had regular contact and access to
health care and the In-Reach teams in all three prisons in which she served her
sentence. She received prompt and continuous care and support in addressing
her mental health, drug and alcohol issues.
110. The woman continued to attend hospital out-patient appointments and there
was frequent liaison between the hospital consultants and Prison Service
healthcare to manage her health needs. She was involved in decisions about
her care and treatment and was confident about approaching healthcare to
discuss her needs and any medication problems she had.
111. Healthcare staff were aware that the woman had multiple scarring on her body
caused by many years of intravenous drug taking. It was noted that on an
occasion a nurse conducting a blood test experienced difficulty locating a
suitable blood vessel and permitted the woman to take the blood herself. The
clinical review says that it is not best practice to allow a resident with a history
of substance misuse to locate a blood vessel. Alternative arrangements, such
as blood collection sets, should have been available in the healthcare clinic.
The Primary Care Trust should provide alternative equipment to use when
healthcare staff have difficulty taking blood samples.
Communications between Cookham Wood and East Sutton Park
112. For whatever reason, the woman’s CARAT file arrived at East Sutton Park
three weeks after she had transferred there. This is a long period of time,
especially given that the two prisons have joint working arrangements. I am
pleased to say that this delay does not seem to have diminished the level of
care and support offered to the woman. Although I make no formal
recommendation on this matter, the Governor should ensure the timely and
effective transfer of documentation in the event of a prisoner transfer.
Could the woman’s death have been prevented?
113. In the period leading up to the woman’s death, there was no evidence of any
inclination that she might return to drug use. She moved from a closed to an
open prison regime and demonstrated that she had taken steps to address her
offending behaviour and addiction. These included successful completion of
drug abstinence programmes and counselling sessions. Despite her physical
23
health problems, she remained positive in her approach and her goal to be
released early from prison. To this end, with the assistance of her CARAT
worker, she had contacted an external drugs adviser who would be able to offer
her extra advice and support after release.
114. The woman also completed periods of ROTL and demonstrated that she could
be trusted. She left East Sutton Park unescorted on a number of occasions
when no concerns were raised. Her interactions with staff were positive and
staff seemed confident that she would not return to misusing drugs. The
woman did request a change of prescribed medication to assist with her mood.
This was agreed by the doctor psychiatrist, who raised no concerns and noted
she was not suicidal. The woman appeared to be intent on addressing any
problems she encountered.
115. Unlike the first period of weekend ROTL, the woman’s CARAT worker had not
spoken to her before the last period because she was unaware of ROTL being
granted. However she had no concerns about the woman, who was well aware
of all the support mechanisms that were in place and could be offered to her by
the prison.
External factors
116. My investigators are not aware of any reason that might have caused the
woman to take drugs once again. There was no evidence from previous ROTL
periods that she might succumb to temptation. She was also well aware of the
dangers.
Death in custody contingency plan
117. East Sutton Park and Cookham Wood share the same death in custody
contingency plan. As the woman did not die on site, the procedures did not
apply in their entirety. The senior officer on duty said that, having had
experience of using the procedures, she was aware of what was required.
However, I think it might be helpful if the plan was re-visited to ensure it reflects
the circumstances at East Sutton Park and the possibility that a resident may
die on ROTL away from the prison.
The Governor should review the death in custody contingency plan and
include instructions on how to deal with a death outside the prison.
118. Healthcare staff had a good relationship with the woman and it was unfortunate
that they were not immediately informed about her death. Healthcare were not
included in the cascade of information or invited to provide support to residents
or staff.
The Governor should review the death in custody contingency plan to
ensure that staff in all parts of the prison are notified.
24
CONCLUSION
119. The woman seemed to address her drug problems whilst she was in custody.
She received support from many staff and other professionals. She was able
to manage her physical and mental health with the support of prison healthcare
and her hospital consultant.
120. By all accounts, the woman was intelligent and embraced the support offered to
her and adapted well to open prison conditions. She also showed initiative by
referring herself to a community drugs adviser to receive extra support after her
release. She had supportive parents who had offered her a home to live.
121. This investigation has uncovered no reason why the woman resumed taking
drugs on her second weekend ROTL. Indeed, she had less than two weeks
further to serve before her release. She had received kindness and support
from the Prison Service and appeared to have responded well. Sadly,
kindness and support may not be sufficient to overcome many years of
addictive and self-destructive behaviour.
25
RECOMMENDATIONS
The Primary Care Trust should:
1. Provide alternative equipment for occasions when healthcare staff have
difficulty obtaining blood samples.
The Governor should:
2. Review the death in custody plan and include instructions on how to deal with a
death outside the prison.
3. Review the death in custody plan to ensure that staff in all parts of the prison
are notified.
26
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