Individual at Elmley

Investigation into the circumstances surrounding the death of
a man on 8 August 2004 at HMP Elmley
Prisons and Probation Ombudsman for England and Wales
July 2005
This is the report of an investigation into the circumstances surrounding the death of
a man on 8 August at HMP Elmley. The investigation was carried out under the
transitional arrangement for investigating deaths in custody agreed between my
office and the Prison Service, and was conducted by the Head of Security and
Operations, Dover Immigration Removal Centre.
The report deals with the management of the man during his time in the care of staff
at HMP Standford Hill and HMP Elmley, and also the systems, procedures and
staffing matters relevant to the care of prisoners who are potentially vulnerable to
suicide or self-harm. It also examines the circumstances surrounding the decision to
transfer the man from Standford Hill to Elmley.
The Senior Investigation Officer was assisted by the Principal Officer at HMP
Swaleside, and specialist medical input was received from a doctor of the Swale
Primary Care Trust. I am grateful to them all for their work.
Together with the investigation team, I would like to offer my sincere condolences to
the man’s family and partner and would like to thank his parents for their assistance
in providing background information.
I would also like to thank the Governors of Elmley and Standford Hill for making the
necessary arrangements to accommodate the investigation team. Additionally, I am
grateful to the Principal Officer for his assistance with the investigation and the
Senior Officer who acted as the investigation’s Liaison Officer.
I conclude that the man’s death could not have been predicted or, for that reason,
prevented. What was in his mind must forever remain a mystery. I am, however,
concerned by what this investigation has revealed about alcohol and drug abuse at
Standford Hill over the weekend of 7/8 August 2004.
The report makes 12 recommendations for Standford Hill and one for Elmley, and
identifies two examples of good practice.
Stephen Shaw CBE July 2005
Prisons and Probation Ombudsman
2
Contents
Page
Summary 4
HMP Elmley 7
HMP Standford Hill 8
Investigation process 10
Incidents and events leading up to the death of the man 11
Post-incident response 19
Level of compliance with procedures at Standford Hill 22
Level of compliance with procedures at Elmley 24
Findings 25
Conclusions 29
Recommendations 31
Good Practice 33
Glossary of Terms 34
Inquisition 35
3
SUMMARY
1. The man had been in custody for a period of 32 days before his death on 8
August 2004. He had previously served a 28 day sentence for drink driving
in December 1997 at HMP Belmarsh.
2. On 29 July 2004, he was transferred to open conditions at HMP Standford
Hill from HMP Elmley after his initial classification as a convicted prisoner.
3. Whilst in prison, the man had participated in two medical healthcare reception
screens in July and August 2004 – one on initial reception into Elmley and
another on initial reception into Standford Hill. His health screen at Elmley
revealed that he had been treated for depression three weeks before his
sentence but highlighted no cause for concern. He did not inform staff at this
stage of any previous attempt to take his own life and no immediate risks
were perceived.
4. Throughout his time at Standford Hill, the man made many telephone calls to
his partner which generally suggested that he was coping with his sentence.
However, during a number of the calls there were strong suggestions that he
was involved in alcohol and drug misuse. This was later confirmed by
another prisoner, located on the same landing, who admitted to the
investigation team that they were both misusing cocaine and cannabis.
5. At Standford Hill, the man’s healthcare reception screen revealed that he had
informed staff about a previous attempt to overdose. Documentation from
the reception screen states that an attempted overdose took place in January
2004 with written comments stating ‘no problems now’. No immediate risk
was perceived and no further action was taken regarding these comments.
6. The day before his death, he received a visit from his father, partner and
brother. They did not feel that he was at risk but stated that throughout the
visit he talked about how other prisoners were bringing drugs in through
visits.
7. The weekend of 7/8 August 2004 was very hot and there were large groups
of prisoners consuming alcohol and taking drugs, which resulted in a number
of incidents throughout Sunday 8 August 2004.
8. During the evening of Saturday 7 August, the man participated in a party in
one of the cells on his landing. He had a quantity of cannabis and a gram of
cocaine that he and two other prisoners took. It is not known who supplied
him with the drugs.
9. On 8 August at 12.03pm, he telephoned his partner and stated that he was
going to leave the prison and that ‘he had had enough’. It is believed that he
left the prison just after this call. He telephoned his brother and was picked
up by him and a friend who took him to a local caravan site which they knew.
Whilst at the caravan site, his brother persuaded him to return to prison and
4
after a few drinks dropped him off at the back gate leading to the prison
boundary.
10. At approximately 4.55pm, the camera operator noticed the car stop at the
gate and staff were deployed to search the area where they found the man
returning to prison. Although staff smelt alcohol on his breath he was not
slurring or swaying. He informed them that he had absconded that day, but
was persuaded to return by his family. He then became upset and changed
his version of events saying that he left the establishment because he had
been forced to pick-up heroin by another prisoner and that he would get his
throat cut if he did not return with it.
11. The man was taken to reception, where the Orderly Officer interviewed him.
Shortly afterwards, he was asked to show staff where the heroin was hidden.
He was returned to the area but pointed to a different position than that he
had originally identified and refused to answer any questions that were put to
him. Staff could not find any evidence to suggest drugs had been left, and
felt that he was possibly fabricating the story in order to reduce the severity
of the penalty he believed he would receive for leaving the prison.
12. He was again returned to reception while the Orderly Officer organised his
transfer to HMP Elmley. Whilst waiting in reception, he went into the toilet
area and broke out of a window. He was seen running towards HMP
Swaleside and the nearby housing estate.
13. Staff searched the area and eventually found the man hiding in a shed in a
garden. When challenged by staff, he came out of the shed and walked back
to Standford Hill.
14. On arrival at the gate, a number of visitors and prisoners were returning from
town visits. The man started to goad staff and they felt that he was ‘playing
to the crowd’. The Orderly Officer made the decision to transfer him
immediately to Elmley.
15. At approximately 6.55pm, he arrived at HMP Elmley with no documentation
or property. He had become quiet and staff reported that he seemed to have
calmed down.
16. The Orderly Officer at HMP Elmley was concerned that the man had arrived
at the prison without his core record (F2050) or Inmate Medical Record
(IMR), he had a cut to his wrist, and staff had reported that they believed he
had been drinking alcohol. Because the prison was on patrol state and he
needed medical treatment, he was taken straight to Healthcare for treatment
and assessment. Patrol state is the term used by the Prison Service to
describe periods when prisoners are locked in their cells, staffing levels are
at a minimum, and there is at least one officer patrolling the area.
17. After the first steri-strip was placed on his wrist he became very agitated and
refused all treatment. The nurse attempted to undertake a risk assessment
5
of him but he said no to all questions and was using foul and abusive
language.
18. After all attempts to undertake his cell share risk assessment failed, the man
was taken to the Segregation Unit pending his adjudication the following day.
19. After locating him in his cell, the Orderly Officer telephoned the Duty
Governor and relayed his concerns that the man had arrived with no
documentation and seemed to have been under the influence of alcohol.
The Duty Governor then instructed that the man be transferred to the
Healthcare Centre for closer observation throughout the night.
20. At approximately 8.00pm, staff observed the man lying on his bed with a
blanket over his head. He sat up when staff looked through the observation
panel. The Orderly Officer organised a member of staff to get a ‘smokers
pack’ from reception whilst they waited for Healthcare to finish settling
another of their patients. At approximately 8.20pm, staff entered the cell with
the intention of giving him a cigarette before moving him to the Healthcare
Centre.
21. He was found kneeling forward on the floor with his laces tied around his
neck attached to the table. On the wall, by the head of the bed were written
the words "I love you D".
22. Staff attempted to resuscitate him until the ambulance service arrived at the
scene. They were not successful.
23. Contingency Plans were appropriately followed in response to his death.
24. The investigation team could find no evidence to suggest that the man was
being pressurised by other prisoners, other than the one comment he made
on returning to prison. In the short time he was in custody, he had never
suggested to staff or behaved in a way that suggested he was unable to
cope with his sentence or that he wanted to end his life. He was not on an
open F2052SH care plan and had never been on one throughout his
sentence.
25. The toxicology report confirms that he had a quantity of cocaine and alcohol
in his blood on the day he died. The investigation team conclude that this
may have created the mood swings that he displayed throughout the day. It
is also possible that the mixture of drugs and alcohol in his system may have
affected his ability to think through his predicament clearly, and thus resulted
in his tragic death.
26. There are a number of recommendations arising from the man’s death and
the investigation of procedures at Standford Hill and Elmley.
6
HMP ELMLEY
27. HMP Elmley is a large local prison serving the courts of Kent. During
weekend evenings, the prison is in patrol state with prisoners locked in their
cells and reception closed. Staffing levels at this time consist of two Senior
Officers, 11 Officers, two Healthcare workers and four OSGs. The
establishment has 24 hour nursing cover with an in-patient facility.
28. The segregation roll on the evening of the 8 August 2004 was 17. There
were four prisoners under rule 53, six prisoners held under Good Order or
Discipline and seven prisoners held under cellular confinement.
29. The Independent Monitoring Board's (IMB’s) Annual Report for 2003, states
that "the board was satisfied that generally Elmley is a safe environment for
prisoners, staff and visitors. The board was pleased to see improvement in
resettlement work and hope that this continued". The report goes on to say
that, "the segregation unit functions very well and the staff are always co-
operative when dealing with segregation issues".
30. The investigation team informally interviewed the Chairperson of the IMB who
attended the prison on the night of 8 August. She commented that she was
impressed with the level of professionalism shown by staff and the outside
agencies that attended the segregation unit. She also stated that she
believed that, on a daily basis, level of care in the segregation unit was first
class and Elmley was improving all the time.
31. The last HMCIP visit to Elmley was an unannounced follow-up inspection on
12-14 May 2003. In summary, the subsequent report said, "Elmley had
improved considerably from the last inspection with many of the previous
recommendations implemented; relationships between prisoners and staff in
the segregation unit were good and in general, prisoners spent relatively little
time in the unit and segregation was not used excessively".
32. There had been two deaths at Elmley in the previous 12 months: on 2
November 2003 and 16 March 2004.
7
HMP STANDFORD HILL
33. HMP Standford Hill is an open training establishment holding category D
prisoners. Prisoners progress through the system and have the opportunity
of working in the community on a voluntary and paid basis prior to release.
At the weekend, a high number of prisoners are released on temporary
licence for town visits. There is no full-time medical cover. Healthcare is
closed after 5.00pm every day.
34. On Sunday 8 August 2004, the prison unlock roll was 446. There was a total
of 49 discharges through reception that day. With the exception of two
hospital escorts, all prisoners were due to return between 6.30pm and
7.45pm.
35. Staffing levels throughout the day at weekends consisted of three Senior
Officers, 10 Officers and two OSGs. These were in place on the day in
question.
36. The prison boundary consists mostly of small fences and bushes. There are
cameras placed along the main road leading up to the prison but there are
many areas where prisoners can easily breach the boundary without being
seen.
37. Prisoners are issued with their own room key and are not accounted for when
going on or off the accommodation units. At weekends, the regime allows
prisoners freedom of movement throughout the day except for a short time at
roll checks.
38. The prison roll checks at weekends are at 7.45am, 11.40am, 6.00pm and
8.45pm. At these times, prisoners are expected to be in their rooms and
remain inside throughout the roll check.
39. The Investigation team informally interviewed the Chairperson of the IMB.
He stated that the IMB team felt that Standford Hill was a safe place for
prisoners. He commented that he had regularly sat in on prisoner induction
talks given by wing Senior Officers and they gave very clear guidelines on
Bullying, Diversity and Care Issues. A Prisoner Information Booklet
regarding the Anti-Bullying Strategy is given to all prisoners during Induction.
40. Minutes from the Anti-Bullying Committee bi-Monthly meeting do not highlight
a large problem with bullying at Standford Hill. There had been just four
bullying incident forms submitted in both June and July and no investigations
were needed into unexplained injuries to prisoners.
41. On 5 August 2004, Her Majesty’s Inspector of Prisons carried out an
unannounced inspection and reported that “Standford Hill had a good suicide
and anti-bullying system and that staff engaged more readily with prisoners,
including personal officers. The report also said reception and induction
procedures had improved”.
8
42. There have been no deaths at HMP Standford Hill in the last 12 months.
43. The following self-audit results are specific to this investigation:
Percentage Re-audit Percentage
Date Audit
Achieved Date Achieved
14.06.04 68% Discharge Procedures 29.7.04 Compliant
22.12.03 78% Prisoner Induction 12.5.04 Compliant
20.02.04 66% Safer Establishment 1.9.04 Compliant
9
INVESTIGATION PROCESS
44. The team received the terms of reference and began the investigation
process on 19 August 2004 under the Prisons and Probation Ombudsman’s
Standing Commission.
45. In the first instance, the Governor of Elmley, Deputy Governor and Governor
of Standford Hill were consulted. Members of the POA Committee and IMB
were also informed at both Standford Hill and Elmley.
46. The Segregation Unit at Elmley where the man died was visited twice, along
with four visits to B wing at Standford Hill where he was located prior to
transfer back to Elmley.
47. The Detective Inspector handling the enquiry was consulted, along with two
prisoners located at Standford Hill who knew him.
48. All the relevant paperwork relating to his situation, care at Standford Hill and
Elmley and the general operation of both prisons, was examined.
49. A clinical audit was requested by the investigation team after consulting his
IMR. The clinical audit was conducted by the Swale PCT.
50. Additional reports, including the last IMB Annual Report, the relevant HM
Chief Inspector's report, the last Standards Audit report for Elmley and last
Self Audits at Standford Hill, Contingency plans, Security Committee meeting
monthly report, Anti-bullying Policy and Monthly Committee meeting minutes,
and recommendations into the last deaths at Elmley, were examined.
51. The team met once with the man’s parents. Telephone calls between 31 July
and 8 August that he made were listened to. Fourteen staff were
interviewed.
10
INCIDENTS AND EVENTS LEADING UP TO THE DEATH OF THE MAN
52. On arrival at HMP Elmley after sentencing, the man’s Prisoner Escort Record
(PER) and the reception screening and cell share risk assessments
undertaken by reception and healthcare highlighted no cause for concern.
He was recommended a ‘single cell if available due to sleepwalking, talking
and outbursts’. His cell share risk assessment was assessed as medium
because of this, with no immediate risk perceived.
53. The man was seen by the healthcare staff on his arrival at Elmley. His first
reception health screen was undertaken on the day of arrival. He stated that
he had seen a psychiatrist for depression and was previously prescribed
20mg Cipramil. This drug is usually prescribed for depression and panic
attacks. He did not inform staff of the previous attempt to end his life and all
information on the health screen indicated no reason to see a doctor. The
entry in his IMR reads "seen on reception, history of mild depression was on
Cipramil, nil at present, feels okay, no self-harm issues".
54. The initial induction form completed by reception and induction staff with the
man also raised no cause for concern. Again, he was asked if he had a
history of self-harm or if he had thoughts of harming himself and in both
cases stated no. Again no risk was perceived.
55. He was allocated to cell A1/12 on House block 1 which is the induction wing.
He completed a full induction programme with no recorded concerns.
56. On 15 July 2004, the man’s initial categorisation was completed and he was
categorised as a D category prisoner and allocated to Standford Hill. On 29
July, he was transferred to Standford Hill.
57. On arrival at Standford Hill, he was allocated to B wing cell 2-003. His
healthcare screening took place on the same day. This suggests that he
informed the staff that he had taken an overdose in January 2004 with the
entry stating "no problems now". The doctor signed the reception healthcare
screen on 30 July. No further comments were recorded and he was not seen
as at risk.
58. All new prisoners to Standford Hill undertake an induction programme on A
wing. Within this period, the Education, Chaplaincy and Gymnasium staff
saw the man. No concerns were raised at this time and on 3 August he was
allocated work on the gardens.
59. His telephone conversations suggest that he was settling in well to the
regime and the work particularly as the weather was good over the period.
60. A Resettlement Assessment, which took place whilst at Standford Hill,
suggests that he had discussed his previous attempted suicide with staff.
The form states "attempted suicide by taking tablets in July 2003 – over it
now. Did suffer from depression and drank a lot".
11
61. It is usual practice for new prisoners to be informed of their Personal Officer
on arrival onto their designated wing. However, the man’s Personal Officer
was on annual leave over the period of 29 July-8 August, and there was no
designated relief Personal Officer assigned for the landing he was on, due to
a member of staff gaining temporary promotion. During this 11 day period, it
is unlikely that he was interviewed at any length by a member of the wing
staff. However, the Governor said “all prisoners are interviewed by the
Senior Officer responsible for the Induction programme and given the
opportunity to discuss any issues of concern”.
62. The prison has devised a policy “Understanding the Personal Officer
Scheme”, which is an information guide to staff explaining the Personal
Officer work that should be undertaken by staff. Unfortunately, the last
Governor’s Order published was in August 2002, which listed Personal
Officers and their responsible landings. This had numerous gaps in the
staffing list, which resulted in no named Personal Officers in some of the
residential areas. Whilst conducting the investigation the team was pleased
to note that this had been rectified on one of the wings, i.e. B wing.
The Governor should review the Personal Officer scheme to ensure that
all prisoners are allocated a Personal Officer, along with a named relief,
on arrival at HMP Standford Hill.
63. Throughout the man’s time at Standford Hill he made numerous telephone
calls each day to his partner and also one to his brother.
64. Whilst talking to his partner, he came across as coping well and generally
quite happy. In one call he mentions talking to the "vicar about marriage and
divorce" and their future together. In some of his conversations he seems to
suggest that he had been involved in drink and drugs parties whilst at
Standford Hill. In one conversation, shortly after he arrived at Standford Hill,
he said “I'm staying away from everyone from now on”. He also said that “he
was reformed and trying to keep away from it” but, goes on to say "mind you,
there were six sitting in my cell last night and I’m trying to think, how do I get
out of here…”
65. On Thursday 5 August 2004, the man phoned his partner. During this
conversation he states, "everyone’s getting out, it’s hard when I can’t phone
you. If I’ve spoken to you, I’m OK, but if you weren’t there I’d probably upset
everyone and I’d be back over the road by now" (referring to returning to
Elmley). These are the first comments that suggest he might have been
struggling to cope. However, he seemed to quickly get over this and talked
about a newspaper article he had been sent regarding his court case. Some
of his last comments on that day were that he was "staying away from all
druggies and shutting his door".
66. During the weekend of 7 and 8 August, the weather was hot and it is now
known that there were prisoners drinking alcohol and taking drugs in the
grounds of the prison. It is unknown if he had participated in any of the
parties throughout the day on Saturday 7 August. Due to his visit, it is
12
assumed that he only participated in one in the evening. Drinking continued
throughout the wing on the Sunday.
67. On Saturday 7 August the man’s partner, brother and father visited him in the
afternoon. His father stated that throughout the visit his son was pointing out
how other prisoners were getting drugs through visits and that the staff were
not monitoring the visit session.
68. After the visit at 4.15pm, he phoned his partner and thanked her for visiting
and asked her to "come up the next week on her own". He ended the call by
saying that he loved her.
69. At 5.28pm, the man telephoned her again. They talked about him having a
party, he said “it’s just surviving that’s all it is in here”.
70. At 8.06pm, he phoned her yet again and talked about missing her and really
appreciating everything that she had done for him. He went on to say, “you
mean more to me; this is just a bad time”.
71. The man again talked about going to a party in No 10 (cell 10), and said “I’m
going to gate crash them and will be running home to you tonight so if you
get a reverse charge call”. That night he is said by a prisoner to have had a
gram of cocaine and some cannabis that he shared with two other prisoners.
It is unknown where he got the drugs from, but one of the prisoners involved
in the party that night stated that he did not believe that the man was in debt
to anyone for the drugs they were using.
72. On Sunday 8 August at 11.58am, he phoned his partner to say that he had
just got out of bed and that he would give her a ring tonight.
73. At 12.03pm, the man telephoned her again, and said "are you coming up
here today". She replied “No”. He then said "I’ll be leaving here in a bit".
She asked "why?" He said "I’ve had enough now". She asked "when are
you going to phone?” He said, "When do you want me to phone?" She said
"just let me know". He said, "I’ll reverse the charges”. He then asked "where
is my friend - in the caravan?" She confirmed this. He asked her if she loved
him, she said "yes" and he ended the call by saying that he would ring her
later. This is his last recorded call made at Standford Hill.
74. Another prisoner who had been with the man at Elmley, stated that since he
had arrived at Standford Hill he talked most days about absconding and
always seemed to have a lot on his mind. He believed that the man had
mentioned that his brother was staying at a local caravan site and that he had
been in touch with him throughout most of the week and had asked him to
pick him up. Other prisoners suggested that he was smoking cannabis and
taking cocaine on a regular basis. They stated that drugs were quite easy to
get hold of in Standford Hill and they got the impression that he wanted his
brother to bring him in alcohol and pick him up. No other prisoners who the
investigation team talked to thought that he was being pressurised or owed
money to others for drugs.
13
75. On Sunday 8 August, the man was seen at the lunch time roll check by
another prisoner. There were a number of incidents on the man’s wing that
staff had to deal with throughout the day, and it is believed that these were
the result of prisoners drinking alcohol and taking drugs throughout the
weekend.
76. The first incident of the day was at approximately 3.51pm when the Fire
Alarm was raised between rooms 33 to 48. All prisoners on the wing were
evacuated. The Fire Brigade arrived, checked the wing, declared the alarm
false and left the prison at approximately 4.20pm. Staff believed that a
prisoner set the fire alarm off, as a way of calling staff to the area. Whilst the
SO (Oscar 2) was controlling the evacuation of the wing, a prisoner came out
of the wing with a serious cut to his hand. First aid treatment was given and
the prisoner was then issued with a temporary licence and taken by an OSG
to the local hospital for treatment. The prisoner stated that he had slipped
while walking along the landing and cut his hand with a cup he had been
holding. Security information collated later suggests that the cut may have
been the result of a fight over drugs or alcohol.
77. At 4.55pm, a car was seen by the camera operator alongside the LAS Gate
on the boundary of the prison. This is a well-known ‘drop off’ point for drink
and drugs and staff attention was drawn to the cameras as the car stopped.
The camera operator became suspicious when he noticed a man, later
identified as the one who died, get out of the car.
78. A member of staff was directed to the area. At the same time, the OSG was
returning from the local hospital after dropping off the prisoner with the cut to
his hand and was also alerted to the fact that a car had stopped in the ‘drop
off’ area. When the driver of the car saw the OSG pull up behind him, he
drove off. This is now believed to have been the man’s friend and brother
who had persuaded him to return to the prison.
79. At 5.05pm, the man was found by staff near the entrance to the LAS Gate.
He seemed calm at first. When asked if he had anything, he handed over
four new packets of Old Holborn tobacco and a number of letters and
photographs to the staff. He explained that he had planned to abscond but
his family had persuaded him to return to prison.
80. Staff felt that the man was telling the truth due to the fact that he was
returning to prison with his letters and photographs (these are items that
prisoners normally take with them when they plan to abscond). However, he
suddenly became ‘jumpy’ and told the staff that he was under pressure to
bring drugs into the establishment. He was asked if he had any drugs on him
to which he replied no, but pointed to a spot about ten yards away near some
conifers. At this point, he became tearful and continued to say that he was
under pressure to bring drugs into the prison. Staff decided to take him to
the reception area where the Orderly Officer was waiting.
14
81. The SO asked the OSG to sit with the man and give him a cup of tea while
she made arrangements for his transfer back to Elmley and closed
conditions. Throughout the 15 minutes the OSG was with him, he talked
about his family and where he lived. The OSG sensed an underlying
agitation in his voice when he mentioned that he did not want anything to do
with drugs, that there were drugs in the prison and that he wanted to get
away from it. He asked the OSG if he would be returning to Elmley. The
OSG did not confirm this, but believed that the man assumed he would be
returning to closed conditions because he said “well, I’ll be going down the
road”.
82. The man continued to talk about drugs in the establishment and asked "did
the staff know where they were". However, the OSG felt that he was not in a
position to talk to him about security information and therefore told him to tell
the Senior Officer when she returned.
83. The SO then interviewed the man. The SO reported that he stated he had
left the establishment after the fire alarm at 3.51pm. However, another
prisoner believed he left the prison after the roll check, which corresponded
to him phoning his partner for the last time at 12.03pm. The SO did not make
a note of the interview at the time, and only made notes later in the evening
after his death. The investigation team felt that, as a consequence, her
timings could have been wrong.
84. The man described to the SO how he had been sent out to pick-up heroin
from a tree and that if he did not return with it he would get his throat cut.
85. At approximately 6.00pm, the SO and staff took him back to the area where
he told them the drugs were waiting. He pointed to a different place in a
different direction from where he had initially showed staff. After a search of
the area was conducted, no drugs or parcels were found and he then refused
to cooperate and remained silent. Staff came to the conclusion that,
because he had returned with his letters, and could not identify the pick-up
point that he had earlier described, he was fabricating the story.
86. The man told the SO that his friends had picked him up, taken him to the
roundabout and back, and that he had been out of the establishment for half
an hour. Again, this did not correspond with suggestions made by other
prisoners who said that they believed he had intended to abscond as he had
been in touch with his brother regularly, had talked about absconding every
day, and was finding it difficult to settle into his sentence.
87. His parents were able to corroborate his initial statement on the events of
that day by confirming that his brother was doing some work on a caravan at
one of the local caravan sites. The man phoned his friend and asked to be
picked up. His friend then phoned his brother and they picked him up, took
him to the local caravan site, brought him a couple of drinks and persuaded
him to return to prison.
15
88. Because the man had stated that he was in danger if he returned without the
heroin, and as he was a high risk of further abscond as he had already
absconded and returned, the SO made the decision to transfer him back to
Elmley. At this point, he was left in the reception waiting area, locked behind
a gate, whilst the SO made arrangements with Elmley.
89. The holding area within reception has a smaller area which can be partitioned
off by a secure gate where prisoners can be held. Within the gated area
there is a toilet. This is not secure as there is a window with no bars that
leads to the back of the reception building.
90. At approximately 6.10pm, he smashed the toilet window and was seen by
staff running towards Swaleside. An urgent message was put over the radio
net and staff responded to search for him.
91. The Orderly Officer and staff searched the area around the housing estate
located opposite the prison. He was not found, so the SO instructed a
member of staff to go back for the prison van as she felt he might have
started to make his way across the fields that lead to the main road.
92. The SO, two officers and an OSG proceeded along the main road. They
travelled approximately two miles before they satisfied themselves that he
was not crossing the fields.
93. On returning to the prison, the staff split up and continued to search for him.
Whilst the staff were searching around the houses opposite the prison, one of
the residents informed them that they had seen him in one of the gardens.
94. At approximately 6.35pm, the SO and an officer found him hiding in a shed.
He complied with the request to come out of the shed and, although he
looked dishevelled, walked back to the prison with no problems. Staff noticed
that he had cut his arm, which they assumed happened whilst breaking
through the window. He later confirmed this when the nurse at Elmley tried
to treat the wound.
95. On the approach to the prison, there were a number of prisoners and visitors
waiting outside the gate after returning from community visits.
96. Staff state that, when the man saw the other prisoners, he seemed to 'play to
the crowd’ and became quite verbally agitated towards the staff, making
reference to the fact that staff had had to chase him twice that day and that
"he wasn’t very good at getting caught twice". None of the staff involved in
the recapture felt that he was at an elevated risk of self-harm or that he
seemed depressed.
97. Because he had just been recaptured, and there was no secure area to hold
him, and there were numerous prisoners waiting around the gate area to be
processed after returning from community visits, the SO made the decision to
transfer him immediately to HMP Elmley.
16
98. None of the man’s records or property accompanied him and there was no
written handover, F213, PER form or re-categorisation form highlighting the
circumstances of his transfer. He was neither informed verbally nor in writing
of the reason for his transfer.
The Governor should remind staff that the IMR and F2050 must
accompany all prisoners on transfer.
99. A Senior Officer and two staff escorted him to Elmley using the prison van.
Throughout the journey, staff report that he was quiet and said nothing.
100. At 6.57pm, the man arrived at Elmley reception and was met by the Orderly
Officer. He seemed calm and joked that he had given staff the run around
and escaped from them twice. Elmley staff noticed that he had a glazed
expression and smelt of alcohol but was not acting as if he was drunk.
101. Because of the cut to his arm, and the fact that there were no accompanying
records or handover notes, he was immediately taken to Healthcare to be
treated. The Orderly Officer insisted that Standford Hill staff accompanied
him to Healthcare before returning to their own establishment.
102. The on duty Healthcare worker was an agency nurse. He asked the
Standford Hill Senior Officer in charge of the escort for the man’s medical
record. She contacted the Orderly Officer at Standford Hill and passed on
the request. However, neither the IMR nor core record arrived until after his
death. The investigation team later found out that there is no written policy
for gathering core records including the IMR in the event of an ‘out of hours’
transfer, and that staff at Standford Hill feel the system for gaining access to
prisoners’ records and warrants is very time-consuming. In this case, no
effort was immediately made to gather the information for Elmley and later in
the evening another fight between prisoners at Standford Hill further delayed
the record gathering.
103. The agency nurse attempted to dress the man’s cut arm. After the first steri-
strip was placed on the man’s arm, his behaviour changed and he told the
nurse to get away from him and that he didn’t want further treatment. When
the nurse tried to persuade him to continue with the treatment, he became
agitated and said, "do you think I am HIV or something, I have been married
for 13 years".
104. The agency nurse then tried to conduct the reception healthcare risk
assessment, however the man refused to comply. Every time he was asked
a question, he answered using foul and abusive language.
105. The agency nurse felt that the man’s behaviour did not warrant any special
medical care and he was quite safe to go to the Segregation Unit and be
placed in a single cell pending his adjudication for absconding.
106. The man fully complied with a strip-search, but threw his clothes around and
needed to be told to calm down. The only other conversation that he had
17
with staff at Elmley was when he asked if they had a cigarette and told them
he "didn’t want to talk to anyone but wanted to sleep".
107. At approximately 7.30pm, he was taken to the Segregation Unit.
108. After locating the man in the Segregation Unit, the Orderly Officer contacted
the Duty Governor raising his concerns that the man had arrived at the
establishment with no documentation, that he had broken out of reception at
Standford Hill, and that his mood swings suggested he might have been
drinking. The Duty Governor instructed that he be placed in Healthcare for
the night for closer observation.
109. The Orderly Officer informed Healthcare that the man would be transferred to
them overnight. The agency nurse requested clarification from the Duty
Governor on this decision, as he had completed the algorithm which
assesses healthcare concerns as showing no risk.
110. The Duty Governor phoned back to Healthcare in order to confirm his
instruction to locate the man there for the night.
The Duty Governor should be commended for the care shown by him to
the man.
111. At approximately 8.00pm staff checked on the man. He was lying with a
blanket over his head, which prisoners often do to block out the light and
noise. He sat up when the observation panel was opened.
112. As he had previously asked for a cigarette, and none had accompanied him
from Standford Hill, staff went to reception to get a ‘smoker’s pack’ with the
intention of supplying him with a cigarette before his relocation to Healthcare.
113. At approximately 8.20pm, the Orderly Officer and staff entered his cell with
the intention of transferring him to the Healthcare for the night. He was found
kneeling in the cell with a ligature round his neck made from his shoelaces,
which was attached to the table. He was slumped forward on his shins.
18
POST-INCIDENT RESPONSE
114. The Orderly Officer immediately entered the cell and cut the shoelaces with
the ‘fish’ scissors he was carrying. An urgent message for Healthcare to
attend the scene was relayed. The second healthcare worker on duty
attended very quickly and started CPR with the assistance of the Orderly
Officer.
115. Staff recall seeing that, on arrival in the cell, the man’s face was blue and
there was no pulse. The agency nurse was called to attend with the heart
start machine. He was able to attend quickly as the night healthcare staff
had arrived for duty. The agency nurse took over CPR from the Orderly
Officer.
116. On placing the defibrillator on the man, the machine found no rhythm in him
and staff continued CPR until the paramedics arrived.
117. At approximately 8.50pm, the paramedics arrived and continued to attempt to
resuscitate him, but they announced life extinct at 8.52pm.
118. At approximately 10.10pm, the doctor arrived and certified the man was
dead.
119. After the SO had stopped assisting with CPR, he noticed written on the wall
of the cell, close to where the man would have lain, the words "I love you D"
which had been written in what looked like blood.
120. The Duty Governor returned to the prison very quickly. He arrived before the
ambulance crew. The assist Orderly Officer (Oscar 2) had arrived at the
scene with the second healthcare worker and had already started a log of
those entering the man’s cell. The Duty Governor commenced actions as
stated in the contingency plans.
121. After the ambulance crew had declared the man’s life extinct, all staff left the
cell and the area was sealed.
122. The IMB Chair was contacted and attended the Segregation Unit along with
the Chaplain who is also a member of Elmley’s care team. Other prisoners
located in Segregation were cared for and assessed for any heightened risk
of self-harm or suicide. One prisoner who was due to transfer the following
day was admitted to Healthcare for closer observations during the night.
123. During the Chair’s informal interview, she reported how impressed she was
with the respect shown to the man whilst the different agencies were going
about their work.
124. The Duty Governor contacted Standford Hill’s Duty Governor who had also
been called to his establishment and was dealing with an incident. This was
a nasty assault involving two prisoners that resulted in hospital treatment.
19
Security intelligence gathered later revealed that the assault was believed to
be over drugs and alcohol.
125. At approximately 10.00pm, the man’s F2050 (Core record) arrived from
Standford Hill. At approximately 10.35pm, the Police arrived at the prison. At
11.50pm, the Coroner’s representative and SOCO arrived at the scene. At
2.20am, the undertaker took the man from the prison and the cell was
resealed.
126. Incident forms were completed by staff involved and staff interviewed by the
police.
127. The man had named his brother as his next of kin. The Duty Governor
arranged for the Chaplain to represent the prison and inform his brother
personally of the tragic news.
128. At approximately 4.00am, the Chaplain arrived at his brother’s house in
Forest Hill and broke the news of the man’s death. The Chaplain offered
support and to be with the brother when telling the rest of the family, however
this offer was declined.
129. Staff involved in the incident were given a ‘hot’ debrief before leaving the
establishment, and a full debrief took place the following day.
130. On Monday 9 August, the man’s father telephoned the prison and spoke to
the Duty Governor. He was invited to attend the prison; however, this was
declined by the family and a follow-up letter was written by the Governor on
12 August offering condolences and support.
131. His father had to attend at both Standford Hill and Elmley to collect his
personal possessions. The majority of his property was still at Standford Hill.
132. On collecting his property, his father was distressed to find that the man’s
stereo, items of clothing and some money were believed to be missing. One
member of staff cleared his property from his room at Standford Hill.
133. The Head of Security informed the man’s father that he would make enquires
to try to recover his son’s stereo. However, the only evidence the
investigation team could find of an attempt to locate the property was an
entry in the Wing Observation Book, although the Governor later said that
staff were briefed on the importance of recovering the radio. During the
investigation team’s enquiries, his stereo was returned to the team by
another prisoner who claimed he had brought the stereo from him before he
absconded. The team also found that his private cash and earnings had
transferred to HMP Elmley and had not been returned to his family after his
death.
134. On Monday 9 August, a full lock down search of B wing at Standford Hill
found evidence of 11 bottles that were likely to have previously contained
alcohol and a number of weapons. This, along with security intelligence,
20
confirmed that there were a high number of prisoners consuming alcohol
throughout the weekend. A small number of prisoners, suspected of being
involved, were transferred back to Elmley.
135. The toxicology report confirms that the man had traces of alcohol and
cocaine in his blood on the day he died.
21
LEVEL OF COMPLIANCE WITH PROCEDURES AT STANDFORD HILL
136. The investigation team studied three sets of minutes from Security
Committee meetings between the months of May to July. Attendance was
good and statistics showed concerns had been raised over the high number
of drug and alcohol finds throughout each month. However, the minutes did
not contain any evidence to suggest that monthly security objectives had
been set for the establishment.
The Governor should set regular monthly security objectives to address
concerns raised at the monthly Security Committee meetings.
137. The following Self-Audits were examined: Prisoner Induction, Discharge
Procedures and Safer Establishments. All documentation suggested that the
systems were found to be compliant and the audits had no outstanding
action points.
138. The last Standards Audit Unit audit took place in December 2002. All action
points had been completed and this suggested a compliant prison. However,
staff at Standford Hill believed that prisoners transferred out of hours often
went without their IMR, which would have been forwarded later. One
manager at Elmley recalled an incident, only a few weeks after the man’s
death, where a prisoner who had returned from abscond and had reported to
Standford Hill to be told to walk down the road and ‘give himself up’ at Elmley
rather than Standford Hill. The prisoner did as instructed and reported to the
gate at Elmley without any documentation or identification. His
documentation had to be forwarded to Elmley from Standford Hill later.
The Governor should develop a protocol for transferring prisoners out
of hours from open to closed conditions, along with clear guidance.
139. Minutes from the Monthly Suicide Prevention meeting were studied. Out of
the 11 members on the committee, five regularly did not attend. F2052SH
documents that were opened within the month were discussed but there
were no statistics to identify any trends. Between January 2004 and
December 2004 only seven F2052Sh forms were opened, which probably
explains the lack of statistical information available.
The Governor should address the lack of attendance at the Suicide
Prevention and Anti-Bullying meetings. The monitoring of F2052SHs
should be a standard agenda item.
140. The investigation team studied the staff training records of those involved in
the incident and found that there had been a lack of training in Suicide
Prevention. Two out of the three Senior Officers on duty that day had never
received training in suicide prevention and the Orderly Officer had not had
any training since 2001. Out of three of the officers involved in the incident,
one had never received training, one in 1998 and the other in 2000. The only
person who had received training within a reasonable timescale was the
22
OSG driver who last participated in training in May 2002. Staff training was
not part of the agenda for the Suicide Prevention Committee meeting.
The Governor should address Suicide Awareness Training. Suicide
prevention training should be a standard agenda item for the Suicide
Prevention meeting.
141. The Use of Contingency Plan ‘in the event of an Abscond or Recapture’ was
not used by the Orderly Officer when the man returned to Standford Hill, or
after he absconded from the establishment for the second time.
142. The Orderly Officer stated that she had no knowledge of the Contingency
Plans for Standford Hill and her actions were based on experience. On
studying the plan for absconds, the investigation team felt that it gave very
little guidance on actions to be taken and the protocol when sending
prisoners back to closed conditions. The plan does not meet the
requirements set in PSO 1400 and had not been reviewed since 2003.
The Governor should review the procedure for the management of
incidents and ensure that all managers undertake training in incident
management. The Governor should also ensure that the contingency
plans comply with PSO 1400 and that all managers are familiar with the
local contingency plans.
143. Incidents were generally not recorded on an incident log and the only entries
that were made were in a book that the centre officer/controller uses to
account for the roll.
144. The IMB highlighted to the investigation team that they were not informed of
the events of the 8 August 2004 until the following morning. Guidance on
who to inform when an incident occurs was not included in the contingency
plan along with contact with the care team. The procedure for reporting the
incident via the Incident Reporting System was correctly followed.
The Governor should ensure that the Abscond Contingency Plans are
updated to include contacting a member of the IMB and Care Team.
145. A debrief for staff was held the following day. However, there was not a list
of those staff in attendance and the investigation team was unable to confirm
if staff were able to put forward their concerns or suggestions.
146. The contingency plans were not reviewed after the incident.
147. Minutes of the Anti-Bullying meeting were examined for February to August
2004. The meetings seem irregularly attended with only the Chair and
Security PO attending the August meeting. Eight out of the 19 members
attended the June meeting and four attended the February meeting. The
investigation team note that there had been an improvement with the
statistics and in identifying trends over the last couple of meetings since a
different manager had been made responsible for the policy.
23
LEVEL OF COMPLIANCE WITH PROCEDURES AT HMP ELMLEY
148. The investigation team studied the Contingency Plan for Death in Custody
and the Staff Debrief notes. These were found to be compliant with PSO
1400.
149. When the man was found with a ligature around his neck, staff responded
quickly and professionally and all evidence was preserved. The DS informed
the team that she could not fault the systems adopted by staff to preserve the
evidence. The care team fulfilled their role of supporting staff and prisoners
and managers ensured that all prisoners located in the Segregation Unit
were seen directly after the incident. The Duty Governor returned to the
prison quickly and ensured that correct procedures were in place.
150. HMP Elmley has a Suicide Prevention Policy Document, a Suicide and Self-
Harm Prevention Strategy Document, a Know your Job sheet giving staff
guidance on Opening, Monitoring and Closing F2052SHs and an Operational
Order reference the Management of Prisoners ‘at risk’ of suicide and self-
harm. All are comprehensive documents that have been reviewed within the
recommended timescale. The team found that staff were aware of these
documents and had a good understanding of the F2052SH care plan
procedures.
151. The investigation team studied the minutes from the last two Safer Prisons
meetings. Membership included a prison Listener and meetings held bi-
monthly. Points were actioned and, from the minutes, there seemed to be no
major concerns.
152. Training records for staff involved in the incident were studied and it was
found that those involved had been trained in Suicide Prevention in 2001.
The agency nurse had not had any local training. He has a professional
qualification as a Mental Health Nurse.
153. In May 2003, there was an unannounced follow-up Inspection by HMCIP.
Comments from the report suggest that Elmley had put into effect many of
the recommendations that had been raised in their previous visit. These
comments reflect the findings of the investigation team.
154. The investigation team have considered the recommendations from the two
deaths in custody of November 2003 and in March 2004. All
recommendations seem to have been addressed.
155. Minutes of the last two meetings of the IMB were studied along with their
Annual Report for 2003. The minutes raise no major causes for concern and
overall the Board is happy with Elmley’s progress and development.
24
FINDINGS
156. There was no F2052SH opened on the man during his time at Standford Hill
or Elmley. He appeared to be low risk and able to cope with his sentence.
His telephone calls to his partner suggested that he was settling in well at
Standford Hill and often included conversations that suggested he was
looking to the future.
157. His healthcare reception risk assessments undertaken at both Elmley and
Standford Hill were completed within the timescales set. At Elmley, he did
not admit that he had previously attempted to take his own life and was not
highlighted as being at risk. Twice at Standford Hill he talked about a
previous attempt to overdose, which was prior to his previous sentence.
However, he gave two conflicting dates for the attempt. The resettlement
assessment stated he attempted suicide by taking tablets in July 2003, the
Healthcare reception assessment stated overdose in January 2004. Both
assessments did not perceive there to be an immediate risk.
158. The investigation team could not find any evidence to conclude that the man
was being bullied or pressured into bringing drugs back into Standford Hill.
However, the freedom of an open prison seemed to present too much of a
temptation for him. Throughout his time at Standford Hill, he regularly talked
to his friends about absconding from the establishment.
159. His behaviour during his short time in prison did not cause any concern for
staff. His friends in prison seemed very shocked by his death and described
him as a nice guy who regretted his offence and always seemed to have a lot
of things on his mind.
160. The man was at Standford Hill for approximately ten days. He undertook a
period of induction. However, he did not have the opportunity of being
introduced to his Personal Officer due to annual leave and there was no
‘relief’ Personal Officer designated for the landing he was on.
161. The investigation team was unable to locate his wing history sheet, which
suggests that one had not been started.
162. It has been established from his telephone calls that he was involved in a
party in one of the cells on the Friday night. Security intelligence gathered
after the weekend records that another ‘party’ took place outside in the
grounds on the Saturday and continued in the evening on the wing.
Prisoners and staff later reported that the fights and injuries during the
Sunday were the result of prisoners consuming alcohol and possibly selling
drugs.
163. The man’s friends in prison stated that he regularly took cocaine and
cannabis whilst at Standford Hill.
164. He would have remained unlawfully at large had his brother and friend not
persuaded him to return to continue with his sentence.
25
165. Upon returning to Standford Hill the first time, he seemed unsure as to what
would happen to him. The interview undertaken by the Orderly Officer
concentrated on trying to ascertain where drugs were being dropped off and
where they were held in the establishment. At the point that the Orderly
Officer told him he would not be returning to his room, no consideration was
given to explaining to him what would happen to him. He was not informed in
writing as to the reason for his transfer.
166. The Orderly Officer investigated the man’s comments that he was sent out to
collect drugs; however, this was not documented or shared with the Elmley
staff.
167. No consideration was given to the fact that he became upset and might have
been at risk after being caught returning to prison. The fact that he had been
upset earlier was not documented or shared with the Elmley staff.
168. Although on recapture he seemed to have mood swings, staff reported that
they did not feel threatened by him. They felt that he was uncooperative
rather than displaying aggression.
169. The property (quantity of tobacco and letters) that were confiscated from the
man on initial recapture, were not forwarded with him when he was
transferred to Elmley.
170. There was no attempt by the Orderly Officer to gather his official
documentation or his property to accompany him on transfer. During
informal interviews, staff reported that prisoners had transferred without
documentation and IMRs before and this was a regular practice.
171. The man had absconded from Stanford Hill and was facing an adjudication.
Given that Elmley received no other information about him, the decision to
place him in the Segregation Unit cannot be criticised.
In relation to safer custody issues at HMP Standford Hill
172. Between Friday 6 and Sunday 8 August 2004, it seems there were many
prisoners consuming alcohol in Standford Hill. On 8 August, the day the man
died, there were a number of incidents. These included a fire alarm and a
prisoner found with a cut to the hand that required hospital treatment.
Additionally, there was a prisoner who was dehydrated due to the hot
weather and was suspected of consuming alcohol. Security intelligence later
suggested that the cut hand was the result of a fight over drugs. A full lock
down search the following day revealed a number of empty bottles containing
alcohol.
The Governor of Standford Hill should review the events at Standford
Hill over the weekend of 7/8 August 2004.
26
173. There is no secure holding area at Standford Hill that can be used to hold
prisoners who challenge the regime or those who are vulnerable. This has
an impact on the decisions managers make when considering returning
prisoners to closed conditions. The only area that can be segregated from
others is a part of reception, which has a gate but no bars on the toilet
window. This leads directly into the communications room and is in full view
of prisoners who are in reception.
The Governor should consider submitting a bid for funding to facilitate a
secure holding area
174. The Orderly Officer left the prison throughout the evening in order to search
for the man. Throughout this time (approximately 25 minutes) the
establishment did not have an Orderly Officer to respond to any further
incidents and the reduction of staff resulted in no tea time roll taking place.
The Governor should remind Orderly Officers that they should not leave
the prison whilst the prison is unlocked.
175. Because the man had already absconded from the reception holding area,
and there was a large number of prisoners waiting outside reception on
return from town visits, the Orderly Officer felt that it was appropriate for the
man to be immediately transferred to Elmley. The decision to transfer him
without his core record, warrant, PER form, medical record, re-categorisation
form, F213 or adjudication paperwork was not a decision that the team would
expect from a manager with experience who had been placed in charge of
the establishment.
176. No written statements were made by the Orderly Officer on the incidents of
the day. It was only after management were made aware of his death that
evening that they wrote incident notebooks on the events earlier in the day.
177. The man’s cell was sealed until a member of staff was able to clear his
property. At least two members of staff should have carried out this task.
Very few items were recovered from the cell and, when his father collected
the property on 12 August, he reported that a radio and various other items
were missing. The Duty Governor who met with the father stated that he
would attempt to locate the missing property and placed an entry in B wing’s
observation book. Apart from this entry, very little effort was made in
attempting to find the missing property. When the investigation team spoke
to his parents, they were clearly distressed that they had not received all his
property or money and suggested that the prison had deliberately kept it.
The Governor should ensure that at least two members of staff carry
out the cell clearance procedure.
The Governor should ensure that the instructions contained in PSO
2710 “Follow-up to deaths in custody” are followed.
27
178. During an informal interview undertaken by the investigation team with
prisoners who had found the man’s stereo, they suggested that he might
have sold the property to other prisoners prior to leaving the prison. Friends
suggested that it was unlikely that he had any debts through buying drugs as
they believed he had his own supply chain from outside the establishment.
179. No entries were placed in B wing observation book regarding him absconding
or the other incidents that took place on 8 August, until 12 August when an
entry was made and backdated.
28
CONCLUSIONS
180. There was no evidence in the man’s behaviour whilst in prison to suggest
that he was at risk.
181. The investigation team has been unable to establish his level of involvement
in the drug culture at Standford Hill. From the toxicology report and
comments from his friends, we can establish that he consumed alcohol and
took cocaine and cannabis on a regular basis. However, there is no
evidence to suggest that he had been put under pressure to return to
Stanford Hill with heroin. The investigation team feel it is possible that he
may have said he was in personal danger hoping he would be dealt with
more leniently on his return.
182. If there had been a secure room away from other prisoners where the man
could have been located, staff might have been able to take stock of the
situation, monitor and properly interview him, collate the appropriate records
and documentation and collect his personal property before transfer.
183. The Orderly Officer made the right decision to transfer him back to closed
conditions. However, she made no telephone contact with the Duty
Governor to seek his authorisation for the transfer and relied on the radio
operator to carry out the requirements of the contingency plans. She also did
not understand the importance of ensuring documentation and information
was passed on to Elmley.
184. On enquiring into the whereabouts of the man’s property and private cash,
the investigation team found that his money had been transferred to Elmley
on 9 August and had not been collated in order to return it to his parents. A
member of the Senior Management Team should have taken ownership of
this task. One officer instead of the usual two cleared his property from his
cell.
185. The team was unable to ascertain if the man had sold his stereo, but have
concluded that it would have been unlikely that any other prisoner had
gained access to his property after his death. When friends were asked if he
had sold his stereo to repay any debts he had due to buying drugs, they
stated that it was unlikely as they believed he had his own supply chain from
outside the establishment. This has not been corroborated.
186. On commencement of the investigation, Standford Hill management was
unaware of the location of some of the man’s records. Parts had been sent
to Elmley the day after his death and some remained at Standford Hill. This
resulted in an unnecessary delay in the completion of the investigation whilst
the documents were located.
187. It would have greatly assisted the investigation team if a member of
Standford Hill staff had been appointed to gather all the records, paperwork,
possessions and valuables and if these had been kept in one location. A
29
Liaison Officer had been appointed, however he did not meet with the team
throughout their time at Standford Hill.
30
RECOMMENDATIONS
HMP Standford Hill
1. The Governor should review the Personal Officer scheme to ensure that all
prisoners are allocated a Personal Officer, along with a named relief on arrival
at HMP Standford Hill.
2. The Governor should remind staff that the IMR and F2052 must accompany
all prisoners on transfer.
3. The Governor should set regular monthly security objectives to address
concerns raised at the monthly Security Committee meetings.
4. The Governor should develop a protocol for transferring prisoners out of hours
to closed conditions, along with clear guidance.
5. The Governor should address the lack of attendance at the Suicide
Prevention and Anti-Bullying meetings. The monitoring of F2052SHs should
be a standard agenda item at the Suicide Prevention meetings.
6. The Governor should address Suicide Awareness Training. Suicide
Prevention training should be a standard agenda item for the Suicide
Prevention meeting.
7. The Governor should review the procedure for the management of incidents
and ensure that all managers undertake training in incident management.
The Governor should also ensure that the contingency plans comply with
PSO 1400 and that all managers are familiar with the local contingency plans.
8. The Governor should ensure that the Abscond Contingency Plans are
updated to include contacting a member of the IMB and Care Team.
9. The Governor should consider submitting a bid for funding to facilitate a
secure holding area.
10. The Governor should remind Orderly Officers that they should not leave the
prison whilst the prison is unlocked.
10. The Governor should ensure that at least two members of staff carry out the
cell clearance procedure.
11. The Governor should ensure that the instructions contained in PSO 2710
“Follow-up to deaths in custody” are followed.
12. The Governor of Standford Hill should review the events at Standford Hill over
the weekend of 7/8 August 2004.
31
HMP Elmley
1. The Duty Governor should be commended for the care shown by him to
the man.
2. The Orderly Officer should be praised for bringing to the attention of the
Duty Governor the fact that no documentation arrived with the man.
32
GOOD PRACTICE
There is an F2052SH information sheet located at the gate at HMP Elmley which
names those prisoners who are subject to a F2052SH care plan.
The preservation of evidence procedures at HMP Elmley are a further example of
good practice.
33
GLOSSARY OF TERMS
CPR Pertaining to Chest (Heart and Lung) resuscitation
F 2050 Prisoner’s Main Core Record
F2052SH At Risk of Self Harm Record
F213 Injury Report Form
F2169 First Reception Health Screening Form
Gov Governor (Senior Managers) Graded A-F
HMP Her Majesty’s Prison
IMB Independent Monitoring Board
IMR Inmate Medical Record
LIDS Local Inmate Database System (computer)
Offr Officer
PO Principal Officer
POA Prison Officers’ Association
Remand Prisoner held in custody before conviction
SO Senior Officer
Standard Audit Prison Service Internal Audit System
Fish Scissors Scissors that are carried by staff and which are designed to cut
down someone who has attempted to hang themselves
Smokers Pack Quantity of tobacco and papers issued to prisoners on arrival
into reception.
34
INQUISITION
The inquest into the man’s death took place between 19 February and 9
March 2007. The jury found that the man died as a result of 1a suspension
and that he took his own life. At the request of the family solicitor and with the
permission of the coroner, I have included the jury’s verdict, comments and
the Coroners’ Rule 43 report.
The jury were asked to consider a number of questions, which I have listed
along with their answers:
1. During the man’s time in prison up to the day before his death was the
information available to prison staff in relation to any potential risk to his life
dealt with appropriately?
The jury said not, adding that certain procedures were not carried out by
prison staff regarding the healthcare forms.
2. On the day of his death, were any potential risks to his life adequately
appreciated by staff at Standford Hill and Elmley?
Yes
3. Were appropriate steps taken that day regarding his safety by staff at
(a) Standford Hill, (b) Elmley?
(a) No, due to lack of documentation. (b) Yes.
4. Did the staff who had dealings with the man have adequate training (1) and
experience (2) to enable them to identify, assess, communicate and
address any potential risks to his life?
(1) Inadequate training for healthcare staff with regard to prison procedures
and documentation. (2) Yes.
5. Were the actual staffing levels sufficient so as to ensure that the man was
adequately supervised and cared for at (a) Standford Hill, (b) Elmley.
(a) No, due to exceptional circumstances on the day. (b) Staffing levels
appeared inadequate in the Elmley healthcare department.
6. Could any further steps have been taken by prison staff which might have
avoided the man’s death?
Yes, failure to transfer correct documentation and inadequate verbal
communication on handover from Standford Hill to Elmley. More frequent
observations by prison officers in the segregation unit at Elmley may have
avoided the man’s death. And due to the nature of the transfer a prison
governor should have been consulted before the man was transferred from
healthcare to the segregation unit.
35
7. If you consider any of the following matters to be of significance to the
circumstances of the man’s death, please comment on them: (a) whether
or not the man had taken cocaine, either on the day of his death or the day
before; (b) whether or not the man had been threatened; (c) whether or not
the man left the prison to bring drugs in. Please comment on any other
factual matters relating to events on the weekend of the man’s death, if you
consider them to be of significance to the circumstances of his death.
(a) Yes, the man taking cocaine was a contributing factor to his death. (b)
No, due to lack of a secure holding area at Standford Hill, transfer
procedures were not carried out correctly.
A combination of cocaine and alcohol was of significance to the
circumstances of the man’s death
On 13 March 2007 the Coroner wrote to the Director General of the Prison
Service under the terms of Rule 43. The report included the jury verdict and
questionnaire. Additionally, the Coroner made the following five points:
1. The national First Reception Health Screen form F2169 (in use as at July
2004) provides for a mandatory referral by a healthcare worker for a mental
health assessment if the answer to question 8,9 or 10 is positive (past
mental health treatment or medication or self harm). Guidance could be
considered to assist healthcare workers on the correct procedure where
they assess that there is no current concern regarding the prisoner’s
mental health.
2. Guidance could be considered to supplement PSO 1700 to assist nurses
and doctors in how to complete the Segregation Unit Safety Algorithm
where the prisoner does not co-operate at the interview.
3. A protocol could be considered between HMP Standford Hill and Elmley
covering the circumstances, if any, in which it is permissible to transfer a
prisoner without his Inmate Medical Record (IMR) and a requirement in any
such circumstances for escort staff to hand over specified information
(written and/or verbal).
4. The provision of a facility could be considered for the temporary detention
at HMP Standford Hill in a secure location for a prisoner awaiting transfer
while his IMR is collected because out of hours a healthcare worker has to
be brought in to arrange this.
5. It could be considered whether there is a link between the consumption of
alcohol and an enhanced risk of self harm.
The Coroner ended his letter adding that he would copy the letter to Her Majesty’s
Chief Inspector of Prisons and asked for it to be distributed to local management.
36