Individual at Everthorpe

Investigation into the circumstances surrounding the
death of a man at HMP Everthorpe
in October 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
August 2007
This is the report of an investigation into the death of a man at HMP Everthorpe in
October 2006. He was discovered hanging in his cell, suspended by a bed sheet
tied to a light fitting. His death has been investigated by Humberside Police who are
satisfied that no one else was involved.
I offer my sincere condolences to the man’s family and friends for their loss. I hope
that this report answers their questions, but recognise that it may not alleviate their
distress or lessen their grief. They describe him as a cheerful and happy person
despite his incarceration.
The man was born in 1984, and was 22 when he died. He had been in prison on this
occasion since May 2004. In June 2002, he had received a custodial sentence for
two violent offences. He was released on licence in March 2004, and was
supervised by the Probation Service. However, in May 2004, the man was arrested
by the police for his alleged involvement in another violent offence. Due to the
serious nature of the allegation, the Home Office revoked his licence and recalled
him to prison to serve the outstanding part of his custodial sentence. The court
dealing with the new offence also remanded him into custody.
In March 2005, the man appeared at Sheffield Crown Court and received a sentence
of five years and six months’ imprisonment. He was initially held at HMP Doncaster.
He was transferred to Everthorpe on 1 September 2005, and remained there until his
death 13 months later. The man was a popular prisoner amongst his peers and
staff.
I would like to express my thanks to the Governor of Everthorpe, his staff, the
chaplaincy, and the Independent Monitoring Board (IMB), for their help and active
cooperation throughout my investigation. I am grateful too to, East Riding of
Yorkshire PCT, for her assistance. I also wish to thank Humberside Police who have
willingly shared their information. In conducting this investigation, I have also been
assisted by the findings from a report by HM Chief Inspector of Prisons, following the
unannounced Inspection of Everthorpe on 25 and 26 April 2006.
The death of the man was the first apparently self inflicted death to have occurred at
Everthorpe since I took responsibility for the investigation of all deaths in prison in
April 2004. In the man’s case, he had shared with no one (either staff or
prisoner) anything that might have indicated that he was at risk of suicide or self-
harm. His mother does not believe he intended to take his own life. However, some
possible indications of self-harm were not picked up by the prison, and a record that
he had cut his wrist on a previous sentence seems to have been missed.
The Governor will wish to consider a number of important issues that have emerged
from this investigation. The possible abuse of subutex (a growing problem in many
prisons) is one of them. Indeed, my report contains a number of criticisms and
makes ten recommendations. That said, and in sad circumstances, this is a report
that also contains much that reflects well upon Everthorpe and the Prison Service as
a whole.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2007
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SUMMARY
The man was found hanging in his single cell at Everthorpe at around midnight on
21/22 October 2006. He was 22 years old and had been at Everthorpe since 1
September 2005.
In March 2005, the man had appeared at Sheffield Crown Court and received a
sentence of five years and six months’ imprisonment. It was not his first time in
custody, and he had told staff at HMP Doncaster that on a previous sentence he had
self-harmed by cutting his wrist.
Following his sentencing in March 2005, the man was initially held at HMP
Doncaster. On 1 August 2005, he was told that his father had died of a heart attack.
the man was taken to healthcare who documented that he was very shaken and in
shock. The man denied feeling suicidal or wanting to harm himself.
He was transferred to Everthorpe on 1 September 2005, and remained there until his
death 13 months later. The man was a popular prisoner amongst his peers and staff
and gave absolutely no indication that he might have been at risk. It is known that
the man was unhappy about the terms of his late father’s will, but this was not seen
as a possible cause of self-harm.
The fact that the man was unwilling to be treated for a number of injuries was also
not identified as a possible indicator of self-harm.
On Saturday 21 October 2006, the man apparently seemed his normal self, if a little
more subdued and quiet than usual. His close friends put this down to the fact that
they had received visits and the man had not. At around midnight, an Operational
Support Grade (OSG) officer went to the man’s cell to ask him to turn his music
down as it was playing unusually loudly. On looking through the cell flap, he saw the
man with a green t-shirt over his head and suspended by a bed sheet attached to the
light fitting. The OSG summoned assistance on his radio, entered the cell and cut
the man down. Staff tried for some time to resuscitate the man but to no avail. A
doctor arrived at 00:25am on Sunday 22 October and pronounced that the man had
died.
The man’s mother has no concerns about the man’s treatment whilst at Everthorpe.
She is full of praise for the staff and prisoners whom she met at the prison. She
does not believe that the man intended to take his life.
I also have nothing but praise for the response of staff after the man was found
hanging. They acted promptly and professionally and I am satisfied that everything
possible was done to try and save the man’s life. Systems for allowing the doctor
and ambulance access to the prison worked well.
I also commend staff and prisoners for the way they have assisted the man’s mother.
The man’s mother was particularly grateful for the sensitive way the Governor, his
staff and prisoners have engaged with her since her son’s death. She was
especially touched by the kindness shown by all at one of two services conducted in
the man’s memory.
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The staff/prisoner interaction at Everthorpe was some of the best that my
investigators have witnessed. Perhaps for that reason, the death of the man had
affected everyone that my investigators met. The local branch of the Prison Officers’
Association, the chaplaincy, and many staff and prisoners have asked for their
condolences to be passed on to the man’s mother.
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THE INVESTIGATION PROCESS
1. This investigation was formally opened at Everthorpe on 25 October 2006 by
investigators from my office, three days after the man’s death. The Governor
and his staff produced the man’s core record and a number of other
documents for examination. Notices were issued to staff and prisoners telling
them of the investigation and inviting anyone with relevant information to
make themselves’ known to the investigation team. My investigators were
given unrestricted access to the prison and its staff, and to all documentation
relating to the man. My investigators spoke to a member of the Independent
Monitoring Board (IMB) and the chaplaincy. They also spoke to Humberside
Police in relation to issues of common interest. My investigators were given a
tour of the prison and wing where the man died, and spoke to prisoners who
knew him well.
2. My investigators also obtained the man’s clinical records, and a copy was
sent to East Yorkshire Primary Care Trust so that an independent review of
the care he received in Everthorpe could be undertaken. The review was
completed by, East Riding of Yorkshire PCT.
3. Tape recorded interviews were conducted with prisoners and staff who had
significant contact with the man, and transcripts of these are included as
annexes to this report. All those interviewed have been asked to sign the
transcript and indicate any corrections.
4. My investigators have also had access to the reports of inspections conducted
by Her Majesty’s Chief Inspector of Prisons.
5. My Investigator, and Family Liaison Officer from my office, met the man’s
mother, and outlined the details of the investigation to date.
6. The man’s mother said that her son telephoned her most weeks, and she
described the conversations in the latter months as akin to talking to a
supportive friend. She described a change that took place following the man’s
father’s death, and the mugging of a close friend. He started to look back on
his life and not to like things from his past. He became more thoughtful and
his behaviour changed for the better. For example, he would phone her to
thank her for sending him money. The man’s mother said at first his plans for
his future were unrealistic and unlikely, but more lately they had become more
and more realistic. He was hopeful about his future, which is why her son’s
death had come as such a shock to her. The man’s mother is sure that her
son did not mean to take his life.
7. The man’s mother has three theories about why the man ended his life, none
of which was intentional. These are:
• he may have been acting out something he had seen on the internet to
get a buzz and it went wrong (although as he had no access to the
internet he may have heard this from someone);
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• he wrote rap music and he may have been acting out the lyrics to be
able to write about the experience more vividly – she wondered if he
was writing lyrics about suicide – the Police have taken a folder with his
rap music lyrics in;
• he had taken some mind altering drugs.
8. The man’s mother said that her son was not depressed. She is aware that he
was found with a t-shirt over his head. Her son did not like physical pain and
she does not think he would inflict this on himself.
9. The man’s mother has been impressed with the caring and respectful
atmosphere at the prison. She visited and attended a memorial service for
the man, and was able to meet staff and prisoners. The Governor gave the
man’s mother his mobile telephone number for her to contact him if she
wanted.
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HMP EVERTHORPE
10. Everthorpe is a category C training prison which first opened in 1958 as a
borstal. It was converted to its present role in 1991 and now holds convicted
adult male prisoners. In 2005, Everthorpe underwent a significant expansion
programme that provided two new wings and 220 new prison places. It now
has six wings and an operational capacity of 689 prisoners.
11. Her Majesty’s Chief Inspector of Prisons conducted an unannounced
inspection at Everthorpe on 25 and 26 April 2006. She concluded that
Everthorpe provided a safe environment for prisoners, and one that was
responsive to the individual needs of those identified as being at risk of self-
harm and suicide.
12. As Prisons and Probation Ombudsman, I assumed responsibility for
investigating deaths in prisons in April 2004. the man is the only prisoner to
have died at Everthorpe since I took on this role.
13. My investigators found that the staff/ prisoner interaction at Everthorpe was
extremely positive, with staff having a good knowledge of prisoners as
individuals.
14. In common with other prisons, Everthorpe runs a personal officer scheme.
Prisoners are allocated two officers on their wing to act as a first point of
contact in all matters. My investigators found that the personal officer scheme
at Everthorpe was well run, with officers having a good knowledge of those
prisoners in their charge.
15. The healthcare facilities at Everthorpe are linked to the East Riding of
Yorkshire Primary Care Trust (PCT). (On October 1 2006, the East Riding of
Yorkshire PCT was formed from a merger of the Yorkshire Wolds & Coast
PCT and the East Yorkshire PCT.) Everthorpe does not run a 24-hour
healthcare facility. Outside normal healthcare hours, arrangements are made
for local doctors to attend if needed or in emergencies ambulances are
summoned.
16. Each officer and operational support grade (OSG) performing night duty is
issued with a sealed key pouch to be opened only in emergencies and a fish
knife (a specially designed knife shaped like a fish) to assist in cutting
ligatures. OSGs would normally have little direct contact with prisoners.
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KEY FINDINGS
17. In June 2002, the man received a custodial sentence for two violent offences.
He was released on licence in March 2004 and was supervised by the
Probation Service. In May 2004, the man was arrested by the police for his
alleged involvement in another violent offence. Due to the serious nature of
the allegation against him, the Home Office revoked his licence and recalled
him to prison to serve the outstanding part of his sentence. The court dealing
with the new offence also remanded him into custody.
18. The man was remanded in May 2004 to HMP Doncaster, where he completed
a healthcare questionnaire and eczema was noted as a current health
problem. The man’s recent drug use was documented as heroin and crack
cocaine, although the man’s mother informs us that this was not true and was
made up by her son, possibly to get on the detoxification programme. He was
offered detoxification, and creams for his eczema were prescribed. The man
showed no signs of mental illness or clinical depression, and no ideas of self
harm/suicide were recorded.
19. On 27 November 2004, a further remand health questionnaire was completed.
He said that he had used cannabis two days earlier, but he showed no signs
of mental illness, clinical depression or ideas of self-harm. In respect of the
man’s previous history of self harm, it was noted that he had cut his wrist five
years earlier, and had been on a self harm watch. The man’s mother pointed
out to my investigators that, had the man cut his wrists five years earlier, she
would have been informed. As she was not she believes the information
recorded on the questionnaire is incorrect. She added that she thought the
only time her son was on a watch for self-harm was when he was held in
police custody prior to his first time in prison.
20. In March 2005, the man appeared at Sheffield Crown Court and received a
sentence of five years and six months imprisonment. The length of sentence
took into account the fact that he was on licence from prison when he
committed the offence in May 2004, and for which he received an additional
150 days. Following his sentence, a Mental Health Questionnaire was carried
out when he got back to Doncaster. No mental health issues were identified.
21. On 1 August, the man was told that his father had died of a heart attack that
morning. He was taken to healthcare, where it was documented that the man
was very shaken and in shock. He denied feeling suicidal or wanting to harm
himself. The man was prescribed a sleeping pill for three consecutive nights.
On 10 August, he was given a 14 day course of sleeping pills to help him
sleep.
22. On 1 September 2005, as part of his sentence planning, the man was
transferred to Everthorpe where a healthcare reception questionnaire was
completed. The questionnaire identified that the man had a history of drug
misuse (cannabis) and it was recorded that he drank 40 units of alcohol a
week. The man’s mother told my investigators that she thought her son
exaggerated the amount of alcohol he consumed to the person carrying out
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the assessment. Mental health problems and self harm suicide sections of
the questionnaire were not completed. The man asked to see the Medical
Officer (MO) for a review of his medication.
23. On 8 September 2005, the man was seen by the MO who prescribed cream
for eczema, and noted his recent bereavement. On 20 January 2006, the
man was prescribed dicolfenac for dental pain. On 17 March, he was seen on
the wing by the MO. The man was not well, with possible flu symptoms
documented. He was prescribed antibiotics and paracetamol, and seen
regularly by healthcare over a four day period until his condition improved.
24. On 17 April 2006, a security information report was submitted that indicated
that the man appeared to be under the influence of alcohol. On 26 April, he
was seen on the wing by healthcare and said he had fainted the previous day.
His blood pressure was within the normal range, and two scratches and
bruising were noted behind his left ear. The man said he had been lying on
his bed and got up quickly. He was seen the following day by the MO who
noted a small bruise behind his ear.
25. On 3 July, prison intelligence suggested that the man and another prisoner
were bringing in drugs (subutex – a medication used as a heroin substitute)
from visits. On 27 July, the man was seen with a cut to his hand but he was
unwilling for healthcare to look at it. On 30 August, he was seen by
healthcare with acne on his chest and back and was prescribed erythromycin
cream.
26. One of two personal officers that the man could go to if he had any problems.
recalled starting work on the wing in July when the man was an enhanced
prisoner with wing cleaner duties, and that he had problems getting out of bed
in the morning. The officer gave him two written warnings for his behaviour.
The first was on 6 September when he was not behind his door for evening
lock up. The second was a week later on 13 September when he was not
ready in time to go to the workshop.
27. The other of the man’s personal officers, said that the man did not want to talk
to staff very often. He had a lot of close friends on the wing and he described
him as a bit of a ‘jack the lad’. The man found it difficult to get up in the
morning, and when he was out of his cell he was one of the last to return. A
security information report was submitted in September recorded that the man
was found to be playing poker during his time in a workshop.
28. A prisoner at Everthorpe knew the man from Sheffield. He met him again at
Everthorpe whilst serving a sentence, and was aware that the man’s father
had died. He described the man as a larger than life character, always
laughing and smiling, a decent lad, and a pleasure to know. The prisoner said
that, although they were on different wings, they had worked together in a
computer aided design workshop for several weeks.
29. On the morning of Friday 20 October, the man recalls being in the workshop
as usual, and the man was sitting with another prisoner. They were laughing
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and doing hip hop and ‘beatbox’. He described the man as being pretty
upbeat and wished everybody attending the class could be as happy as he
was. Prisoners and staff liked the man, and he said the man had the utmost
respect for everyone. He said that the man did not attend class on the Friday
afternoon before he died.
30. A teacher employed at Everthorpe, who teaches computer information and
technology said, the man had been in his class of 12 for seven weeks prior to
his death. The teacher recalled that, when the man first attended his class,
he was quite open about the fact that he was not really interested in
computers. He was not a hard working prisoner and, although the teacher
tried hard to engage with him, the man was not interested and told him that he
would never want a career in computers. However, he was keen to work if
the teacher gave him something to type, and his real interests were sport,
fitness, and health and diet. The teacher tried to facilitate a relevant course.
The man had asked the teacher to help him draft a letter to a solicitor over his
concerns over his late father’s estate.
31. The teacher described the man as a prisoner who always had a smile on his
face, cheerful and one who got on with everybody. On the Friday morning
before the man’s death, the teacher said that whilst in class the man was
laughing and joking as usual. He thought he was the last person to arrive in
his class, but that was not unusual.
Saturday 21 October 2006
32. Another prisoner at Everthorpe, said during interview that he had met the man
for the first time when he arrived at the prison 14 months previously. He said
that the man looked out for him and asked him if he wanted anything. The
prisoner told my investigators that he knew the man smoked cannabis “now
and again” but he did not believe he took anything else. He described the
man as kind and said they became good friends. The man had a dream of
becoming a famous rapper and was good at card tricks.
33. The prisoner said that the day of the man’s death was just a normal day.
They got up, had a shower, got dressed and went to each others’ cells, drank
tea, smoked, listened to music, got bored, played pool, table football, and had
fun by winding the staff up and talking rubbish to them. The man made a
number of telephone calls during the afternoon.
34. The prisoner had a visit that afternoon and, when he returned, he said that the
man looked really down in comparison to how he had been in the morning.
The prisoner asked what was wrong, and the man said he had been trying to
telephone some of his people but could not get through. The prisoner told
him that it was not a big problem and that he should not feel down. He also
said that, if the man had problems, he kept them to himself.
35. When all the prisoners were told return to their cells for the evening, the man
was in the prisoner’s cell. On reflection, the prisoner felt that the man wanted
to say something to him that afternoon, but did not. The prisoner told my
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investigators that he did not think the man smoked cannabis or took any other
illegal drugs.
36. Another prisoner met the man when he first went to Everthorpe, and they
used to relax, exercise, play pool and table football together every day. He
described the man as bubbly, a ‘jack the lad’ (a phrase, as noted above, also
used by a member of staff), who was liked by everybody. On Saturday 21
October, they were both on the exercise yard as neither had any visitors. The
prisoner thought the man looked depressed that afternoon, and asked him
what the matter was to which he replied that he was alright.
37. The man’s mother was aware that her son had tried to call her at
approximately 2.55pm on 21 October, but she was out with her dog. He then
called a friend who said that he seemed fine, was talking about the future and
about getting out of prison. He had asked for details about an intensive
driving course. After this call, he told his prison friends that “all of my friends
are moving away”. His friends say his mood dipped, but he later seemed
okay.
38. A further prisoner at Everthorpe said he had known the man well for four
months, having met him in prison. He said the man befriended him as soon
as arrived at Everthorpe, and he had a close friendship with him. He said that
they all looked out for one another. They played table football every day and
were laughing all the time. The man used to smoke cannabis, and that he
had previously taken subutex which had been smuggled into the prison. He
described the man as a really funny guy, who would make people laugh and
kept everything positive. He had the ability to cheer up prisoners, and was
always telling them to stop getting stressed.
39. The prisoner recalled that everything was alright in the morning of 21 October,
and he played table football with the man. They then went for a shower, and
in the afternoon played more table football until he went off for a family visit.
When they returned from their visit, the prisoner said that the man looked a bit
down so they asked what the matter was. The man replied that nothing was
the matter. The prisoner said the man smoked cannabis in his cell, and they
had another game of football before going to their respective cells at 5.30pm.
40. A prisoner at Everthorpe, who lived opposite the man on D wing and knew
him for six weeks before the man’s death, said their relationship was strong,
and they were both interested in music and rapping. The prisoner said that
the man was also very good at card tricks. They attended the information
technology workshop together. The prisoner said the man’s mood was fine.
He was aware that the man had previously taken illicit subutex.
41. On the evening of 21 October, the man and another prisoner played table
tennis. The prisoner who lived opposite the man said that he was the last
person to speak to the man before they were locked in their respective cells
for the night. The man came into his cell and looked through his CD
collection, before an officer arrived to lock the cell. The prisoner lent the man
two CDs.
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42. An Operational Support Grade (OSG) started his night shift at Everthorpe at
8:20pm on 21 October. He received a briefing about matters of interest from
the officer going off duty. He was told that another prisoner was on a self
harm watch (i.e. subject to special self-harm support and monitoring), and had
to be observed twice during the night.
43. The OSG was responsible for looking after approximately 200 prisoners on C
and D wings. He walked around the wings checking all the cell doors were
locked and the fabric of the building was intact, and dealt with prisoners who
rang their cell bells. At 9:30pm, he commenced pegging (this means that he
used an electronic wand to record his movements at predetermined pegging
points).
44. The prisoner who lived in the cell next to the man’s, said he had known him
since his arrival at Everthorpe. They exchanged cigarettes on occasions.
The prisoner described the man as a polite and outgoing young lad, who
generally had a smile on his face and was always laughing.
45. At about 11.00pm, the prisoner said that he was watching television and
heard what he describes as rap music playing loudly from the man’s cell.
After approximately 15 minutes, he realised that the same track was playing
repeatedly and thought that the man was jotting down the words and then
rapping. He waited until 11.45am and then banged on their adjoining wall, but
still the track kept playing. The prisoner was reluctant to ring his cell bell to
draw the noise to the attention of the prison staff, but thought something might
be wrong with the man. As he went to ring his cell bell, he heard a member of
staff open the man’s cell flap and swear. He heard the member of staff use
his radio to summon assistance.
46. Just before midnight, the OSG pegged on the third floor landing of C wing.
He heard loud music, and made his way to cell C:24 where the music was
coming from. The OSG opened the observation panel and saw the man
hanging from the light fitting with a ligature made from a bed sheet. A green t-
shirt covered the man’s head. His feet were not touching the floor, and the
cell chair was behind him.
47. The OSG immediately used his radio to inform Oscar 1 (the code designating
the Senior Officer in charge of the prison) what he had found and his location.
He then broke the seal on his key pouch, went into the cell, removed his
ligature knife from its pouch and climbed on the cell bed. The OSG held the
man around his body and cut the ligature between the light fitting and the
man’s neck. As the man fell, the OSG held onto him and placed him on the
bed. As he did this, the man’s head hit the wall.
48. Although the OSG has had no first aid training, he thought that the man was
dead. He turned the music off in the cell. He immediately went back onto the
landing and called the Senior Officer and other officers. Officers started
resuscitation efforts, giving mouth to mouth resuscitation and chest
compressions.
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The Governor should consider whether all staff who work with prisoners
when the healthcare centre is closed should be qualified to administer
first aid.
49. On the night of 21 October, the officer in charge call sign Oscar 1 arrived for
work at 8.00pm and ensured that all the prisoners, staff, radios and keys were
accounted for. Oscar 1 knew the man well and said that he was quite jovial,
had a good sense of humour, and always gave the impression that he would
never be the first to work and the last one away. At around midnight, Oscar 1
received an urgent call over the radio network, telling him that there was an
attempted suicide on D wing. Oscar 1 immediately went to the wing and
arrived with other who had the radio call signs Oscar 2 and Oscar 3
respectively.
50. As they entered the wing, Oscar 1 remembered hearing loud music being
played. The OSG, who was on landing two, signalled to them. Oscar 1
cannot remember what the OSG said, but recalled that he looked shocked.
Oscar 1 went into cell D2:26 and saw the man lying on the bed with his face
covered with what he described as a hood. He was lying face up, and Oscar
1 asked Oscar 2 and 3 to attempt resuscitation.
51. Oscar 1 radioed the control room to ask for an ambulance and doctor, and
then left the cell to implement the prison contingency plans and ensure that
the doctor and ambulance could enter the establishment as quickly as
possible. The control room log records that Oscar 1 requested the ambulance
at 00.04am, and the call was made a minute later. The duty manager was
informed two minutes later at 00.07am, and the doctor at 00.10am.
52. Oscar 2 started the night shift at Everthorpe at 8.30pm on Saturday 21
October. At around midnight, he heard a radio call saying that there was an
attempted suicide on D Wing. He arrived on D wing with Oscar 1 in less then
a minute of receiving the call. They were directed to cell D2:26 by the OSG.
As they entered the cell, Oscar 2 saw the man lying on the bed. Oscar 1
checked his pulse, but could not find one.
53. Oscar 2 left the cell to collect the resuscitation mask and equipment from the
wing office, and then returned to the cell. He removed the green prison t-shirt
that was covering the man’s face. He began to administer mouth to mouth
resuscitation and chest compressions, at a cycle of two breaths and 15 chest
compressions, continuing until a doctor arrived. Oscar 3 and the OSG
remained whilst Oscar 2 continued attempting to resuscitate The man.
54. The prison doctor arrived at 00.25am as Oscar 2 was performing
resuscitation. The doctor pronounced the man’s death at 00.25am.
55. The cell was sealed for subsequent examination and retrieval of exhibits by
the police. The police arrived at 1.30am, and remained until 4.24am. The
funeral directors arrived at 3.45am and departed at the same time as the
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police. A hot de brief of the staff involved in the discovery and resuscitation of
the man was held after the funeral directors had left the prison.
56. The news of the man’s death was broken to his mother by the police.
57. An impromptu memorial service for the man was held in the chapel later that
morning (Sunday 22 October), attended by prisoners and staff. The teacher
was asked to purchase a remembrance card for the prisoners in his
workshop, and spoke at the memorial service.
58. After the man’s death, prison staff listened to the telephone calls that the man
had made in October. They were of the opinion that there was nothing of
significance that could have given anyone any indication that he intended to
take his life.
59. When a prisoner was asked if the man had given him any indication that he
was upset about anything, he said that the man alluded to a dispute over his
late father’s estate. However, during the week prior to his death, the man was
happy. The prisoner had not seen the man take drugs in prison, although he
was told that he had. The prisoner said that he cried when he was told of the
man’s death. He subsequently went to a second memorial service in the
chapel which was attended by the man’s mother, staff and prisoners from
different wings. He organised a sympathy card and got everybody in the
workshop to sign it. He briefly spoke to the man’s mother at the service, and
described the service as nice. The prisoner felt well supported by staff and
other prisoners.
60. Another prisoner heard of the man’s death the following morning as he was
unlocked. He was shocked as the man had given him no indication
whatsoever that he intended to take his life.
61. One of the man’s personal officers was told of the man’s death when he
arrived for work on the Sunday morning. He says that he was absolutely
gutted, as there was no indication the day before and he could not understand
it. He said that normally prisoners would tell officers if they had concerns
about fellow prisoners and this did not happen
62. The prisoner in the cell next to the man’s said he was completely shocked.
He could not recall anything different about The man’s demeanour, apart from
playing his music loudly on the Saturday before his death.
63. During the morning of 22 October, a prisoner saw the activity around the
man’s cell. He knew that someone had died, and was shocked to hear it was
the man. The prisoner said he knew that the man ad taken illicit drugs and
alcohol whilst at Everthorpe.
64. The prisoner who lived opposite the man’s cell was told of the man’s death
during the morning of 22 October. He said he felt completely empty. He said
he cried for an hour as he could not believe that it had happened and he
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expected the man to walk through his cell door. He wrote some lyrics and
attached them to the man’s cell door as a mark of respect for his friend.
65. The prisoner who lived opposite told my investigators that the track that was
playing when the man was discovered in his cell was from Mobb Deep’s
album ‘The Infamous’ (1995). I note that one track is entitled Cradle to the
Grave, but can otherwise identify no special significance in the lyrics. It is not
known which particular track was actually playing when the man was found.
66. The teacher was not at work during the weekend the man died, and was told
of the man’s death when he returned on the Monday. He too was shocked
when he heard the news and could not believe it. He said that the man
seemed fine when he last saw him on Friday morning, and had given no
indication that anything was any different.
67. The man’s mother was shocked to learn of her son’s death, and does not
believe that he intended to take his life. She has been in contact with the
prison and attended a memorial service in memory of the man’s life which
was attended by the Governor, his staff and prisoners. The man’s mother has
described the support she received from Everthorpe as fantastic. The
Governor and the prison’s family liaison officer met the man’s mother
personally and facilitated her visit to the prison. The Governor gave the man’s
mother his direct telephone numbers and the prison offered to contribute to
the man’s funeral costs.
15
POST MORTEM
.
68. A post mortem examination on the man took place at Hull Public Mortuary on.
The toxicology results were:
Ethanol 5mg/100ml
Paracetamol Not detected
Salicylate Not detected
Opiates Not detected
Benzodiazepines Not detected
Barbiturates Not detected
Cannabinoids Not detected
Methadone Not detected
Cocaine metabolites Not detected
Phenethylamine Not detected
Morphine Not detected
Contents: A negative toxicological screen.
The post mortem concluded:
1. That the man’s body was that of a well nourished young man with no
natural disease that would have contributed or caused death.
2. The pathological findings are those of hanging, in keeping with the given
circumstances.
3. The pattern of ligature mark is indicative of self infliction.
He gave the cause of the man’s death as hanging.
16
ISSUES CONSIDERED IN THE INVESTIGATION
Clinical care
69. The clinical review has found that the history and assessment of the man’s
injury on 26 April 2006, and his refusal to have treatment on 27 July for
another injury, should have indicated to staff that the injuries were of a serious
nature. A report of injury to inmate form was not completed by either the
prison officers or healthcare staff, and as a consequence a referral to the
Safer Custody Team was not made. Although the man refused treatment on
27 July 2006, no questioning as to the history of the injury or a further follow
up to see if the man had changed his mind regarding receiving treatment was
made.
The Governor should increase the awareness of all prison staff
regarding the signs and symptoms of suspicious injury and the process
to follow when one is suspected.
70. The clinical reviewer recognised that, if a member of the general public were
to refuse treatment, it would not be followed up as a matter of course.
However, in the prison setting, due to the fact that the exact nature of the
injury and an assessment of the extent of the injury had not been made, it
should be deemed good practice to follow up prisoners who refuse treatment.
The Head of Healthcare should remind healthcare staff of the need to
improve the clinical assessment and documentation of injuries.
71. Upon the man’s arrival at Everthorpe, the healthcare questionnaire indicates
that the man was not asked about previous mental health problems and self
harm/suicide attempts. The fact that the man had recently suffered
bereavement was also not documented. It would appear that no review was
undertaken of his notes from Doncaster, where a previous self harm attempt
was documented along with details of his recent bereavement.
72. Had these facts been identified by healthcare staff upon transfer, the man
would have been offered a referral for a mental health assessment. It is noted
that the member of staff completing the healthcare questionnaire was a newly
employed member of staff who did not have previous experience of working in
a prison healthcare setting.
The Head of Healthcare should review their process for undertaking the
initial healthcare assessment to ensure a review of previous records is
also undertaken.
The Head of Healthcare should review the induction process for newly
appointed staff to include a period of preceptorship and a documented
process for indicating clinical competence.
73. The prison may wish to give consideration to the support it offers prisoners
who are recently bereaved either immediately prior to coming into prison or
17
during their sentence. It would appear from a review of the records that
limited support was offered to the man following the death of his father.
The Governor should review the service offered to prisoners in respect
of support given following a recent bereavement.
Records and record keeping
74. The findings from the clinical review would indicate that, although all entries in
the records were in chronological order and signed, the general standard of
records and record keeping could be improved as noted by the following:
• the prescribed drugs on the Prescription and Administration record
chart dated 12 July 2006 and the accompanying instructions for use
were for the most part illegible;
• some of the entries in the notes were illegible;
• most entries did not document that a full assessment had been
undertaken;
• alterations to entries had not been signed or dated;
• the time that the entry had been made was not documented in the
majority of the cases.
The Head of Healthcare should undertake a clinical audit of patient
records based upon the National Medical Council (NMC) Standards for
record keeping in ‘Just for the Record’.
Antibiotic prescribing
75. From the date of the man’s admission to prison in May 2004 until his death 29
months later in October 2006, the man was prescribed antibiotics on five
occasions. It is acknowledged that the clinical assessment may have
indicated the need for antibiotics, however it is suggested that a review of
antibiotic prescribing and guidance regarding appropriate prescribing is issued
to prison healthcare to ensure that they are or continue to be prescribed
appropriately.
The Head of Healthcare should review the prescribing of antibiotics in
prison healthcare and promote the use of the recently approved
antibiotic prescribing guidelines.
Good practice
76. The clinical reviewer has commented that the man’s requests to see the
doctor were generally acted upon within what would appear to be a
reasonable timescale. The reviewer has also said that, when the man was ill
with ‘flu like symptoms’, his illness was managed in a caring and patient
18
centred manner. Finally, the man’s death was immediately reported to the
PCT so that an immediate review of the man’s healthcare could be
undertaken.
77. The clinical reviewer concluded that the care the man received was equitable
with that of the wider community. The reviewer also recognised that
healthcare staff are already undertaking specific actions in relation to the
recommendations she has made.
The personal officer scheme
78. The personal officer scheme at Everthorpe works very well with the assigned
personal officers having a good rapport with, and knowledge of, their allocated
prisoners. The staff/prisoner relationships were some of the best and most
professional that my investigators have witnessed.
Access to drugs in prison
79. From the interviews my investigators conducted with both prisoners and staff,
it would seem that both illicit drugs and illicitly brewed alcohol are available to
prisoners. Everthorpe is scarcely unique in this regard, and I understand the
Governor is working hard to stem the supply through drug reduction strategies
and the detection of offenders. However, I am particularly concerned about
the abuse of subutex, a substance not routinely screened under the Prison
Service’s mandatory drugs testing programme. Given the circumstances
giving rise to this report, this may not be the most appropriate place to make a
formal recommendation to the Prison Service in respect of testing for illicit use
of subutex. However, the Governor may wish to draw my concerns to the
attention of his area manager.
Resuscitation
80. The response of prison staff to finding a medical emergency is rarely
acknowledged in public. I am pleased to use my reports to remedy that
unfairness. As I have detailed earlier, the reaction of the night staff on duty
when the man was found was first rate.
The staff should be commended by the Governor for the way they dealt
with the discovery of the man’s body.
81. I note that Oscar 2 administered mouth to mouth resuscitation and chest
compressions at a cycle of two breaths and 15 chest compressions. I intend
no personal criticism of Oscar 2 who, like his colleagues, responded with
great care and professionalism to the emergency he faced. I am also doubtful
if it made any practical difference to the outcome. However a ratio of two
breaths to 15 compressions is not in line with the current guidelines of 30
chest compressions to two rescue breaths.
The Governor should remind staff of the recommended guidelines for
resuscitation.
19
Support to staff and prisoners
82. Staff and prisoners felt well supported after the man’s death. Those involved
that night attended a hot debrief and were offered support from the prison
care and welfare team. Prisoners felt generally well supported by the staff,
the chaplaincy and other prisoners. Two memorial services were held at the
prison, the first on the morning of the man’s death and the other some days
later which was attended by his mother, staff and prisoners.
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CONCLUSION
83. The man gave no indication to anyone that he intended to take his life. He
was a popular prisoner amongst other prisoners and with staff.
84. His mother had three theories about the circumstances leading to his death:
• The man might have been acting out something he had seen on the
internet to get a buzz and it went wrong.
• The man wrote rap music and might have been acting out the lyrics to
be able to write about the experience more vividly.
• The man had taken mind altering drugs.
85. My investigation has found no evidence to verify any of these theories. I have
found no evidence that the man had seen anything on the internet whilst at
Everthorpe. Second, while it is known that the man wrote rap lyrics and
listened to rap music, and his lyrics folder has been seized by the police as
part of their investigation, it is not known what song was playing when he died
and I can find no special significance in the lyrics of the album ‘The Infamous’
by Mobb Deep. Third, there is no evidence from the toxicology results that
the man was suffering the effects of mind altering drugs.
86. On the other hand, my investigation has found some evidence of the man’s
likely previous self-harming behaviour. That said, I am unable to surmise
what was going through his mind at the time of his death. His loss shocked
everyone who knew him.
21
RECOMMENDATIONS
1. The Governor should consider whether all staff who work with prisoners
when the healthcare centre is closed should be qualified to administer first
aid.
2. The Governor should increase the awareness of all prison staff regarding
the signs and symptoms of suspicious injury and the process to follow
when one is suspected.
3. The Head of Healthcare should remind healthcare staff of the need to
improve the clinical assessment and documentation of injuries.
4. The Head of Healthcare should review their process for undertaking the
initial healthcare assessment to ensure a review of previous records is
also undertaken.
5. The Head of Healthcare should review the induction process for newly
appointed staff to include a period of preceptorship and a documented
process for indicating clinical competence.
6. The Governor should review the service offered to prisoners in respect of
support given following a recent bereavement.
7. The Head of Healthcare should undertake a clinical audit of patient
records based upon the National Medical Council (NMC) Standards for
record keeping in ‘Just for the Record’.
8. The Head of Healthcare should review the prescribing of antibiotics in
prison healthcare and promote the use of the recently approved antibiotic
prescribing guidelines.
9. The staff should be commended by the Governor for the way they dealt
with the discovery of the man’s body.
10. The Governor should remind staff of the recommended guidelines for
resuscitation.
Everthorpe has accepted these recommendations and drawn up an action plan
to implement them by the end of 2007.
The man’s inquest was concluded at Hull Coroners Court on 17 April 2007 and
the jury concluded that the man’s death was an accident.
22