Individual at Exeter

Investigation into the circumstances surrounding the
death of a man who died at
HMP Exeter in September 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
February 2008
The man aged 27 years, was found hanging in his cell at HMP Exeter in
September 2007. He had been in custody for less than three weeks. He had
used his bed sheet as a ligature attached to his cell window frame. Staff upon
discovering him responded immediately to cut the man down, laid him on the
floor and attempted resuscitation. Sadly, he had died and was pronounced
dead in his cell.
I would like to add my sincere condolences to those already expressed by
staff and prisoners at Exeter to the man’s family and friends for their loss.
The man was a convicted prisoner who had been released on a Probation
Licence in December 2006. He breached the conditions of his licence and
absconded in February 2007. He was subsequently arrested on suspicion of
murder and was recalled on 23 August to HMP Exeter for breach of his
licence. He did not give staff or other prisoners any cause for concern. His
death was a shock to all who knew him.
One of my investigators conducted the investigation. The local Primary Care
Trust conducted a clinical review into the man’s care and treatment whilst at
Exeter. I would like to thank the Governor of Exeter and his staff for their help
and active co-operation during this investigation. I am also grateful to the
police for their assistance.
The man’s father has been in contact and visited Exeter. He has also been in
contact with one of my Family Liaison Officers from an early stage. A key part
of the investigation was to ensure the man’s father had the opportunity to
raise his concerns.
The death of the man was the fourth apparent self inflicted death at Exeter
since I became responsible for investigating all deaths in prisons in April
2004. I am satisfied that he did not share with staff, prisoners, friends or
family outside prison any indication that he intended to take his own life.
Stephen Shaw CBE
Prisons and Probation Ombudsman February
2008
2
CONTENTS
Introduction
Summary
Investigation process
Background
HMP Exeter
Suicide and self harm monitoring
Previous deaths in custody
Listeners/Samaritans
HM Chief Inspector of Prisons’ Inspection
Approved Premises
Key Findings
Events prior to 11 September 2007
Events of 11 September 2007
Post Mortem
Contact with the man’s family
Staff and prisoner welfare
Issues considered in the investigation
The discovery of the man hanging
Clinical care
Family concerns
The man’s cell
Bullying
Care and welfare of staff and prisoners
Conclusions
Recommendation
3
SUMMARY
On 14 December 2006, the man was released on a nine month Probation
Licence from HMP Lowdham Grange, which was due to expire on 29
September 2007. He had spent six and a half years in prison. A condition of
his licence was to reside in a designated hostel in London and comply with
the hostel rules. He breached the hostel rules by failing to adhere to an
11.00pm curfew on 22 January 2007.
The man telephoned the hostel the following day and was informed that his
licence had been breached. He said that he would probably hand himself in
but he would need to sort things out first. He was arrested nearly seven
months later in August, in Exeter, on suspicion of a murder that had occurred
in the city days previously. He was released on police bail pending further
enquiries, and taken to Exeter prison on 23 August 2007, for breaching his
probation licence.
The man went through the prison’s reception process and during the
completion of his cell sharing risk assessment he presented as high risk of
assaulting another prisoner. The first night centre prisoner profile form was
completed. The man expected to be in prison, he said that he had previously
served four periods of custody and had never committed an act of self harm
or felt at risk of self harm. He denied misusing drugs or alcohol, but said he
used cannabis recreationally.
The man was located at his request alone in a single cell C4:20. He received
visitors and made telephone calls and was able to communicate with a
girlfriend by shouting to her as she stood on the road outside the prison wall
directly below his cell. During the morning roll check at 6.00am on 10
September, the man was found hanging from a ligature made from a bed
sheet attached to his neck and tied around the window bars. Staff acted
quickly to cut him down and commence resuscitation. Sadly he was prounced
dead in his cell.
A post mortem examination concluded the man had died as a result of
hanging. There was no evidence to suggest third party involvement. He had
given no outward indication to staff or fellow prisoners that he intended to take
his life.
Found in the man’s cell at the time of his death was a local newspaper
covering the murder investigation for which he was on bail. Next to it was a
hand written document listing the offences he had been convicted of, and the
resulting sentences, and his age at the time of his release.
4
THE INVESTIGATION PROCESS
1. The investigation was formally opened at HMP Exeter on 14
September 2007 by my investigator. The Governor and his staff
produced the man’s core record and a number of other documents
for examination. My investigator met with members of the
Chaplaincy, Prison Officers’ Association (POA) and Independent
Monitoring Board (IMB).
2. Notices were issued to staff and prisoners informing them of the
investigation and inviting anyone with relevant information to make
themself known to the investigator. My investigator was given
unrestricted access to the prison, staff, prisoners, and
documentation relating to the man. He was also able to speak with
the local police in relation to issues of common interest.
3. Prison officers, members of health care staff and prisoners were
formally interviewed and those interviews were tape recorded. The
interviews have been transcribed and interviewees invited to sign
and return them. Although not all transcripts have been returned
signed, they are attached as annexes to this report. My investigator
wrote to the man’s criminal solicitor and three people that visited the
man whilst at Exeter, inviting them to get in touch if they have
information that may assist the investigation. To date only one of
the man’s friends has contacted my investigator.
4. The local Primary Care Trust conducted a clinical review of the
man’s care and treatment by reviewing his Inmate Medical Record
and a report by his general practitioner. Reference was also made
to the prisoner’s core record. A panel review of his medical care
was conducted on 4 December 2007.
5. CCTV footage of C wing was obtained but sadly the camera
equipment was not functioning properly and images of C4 wing
could not be properly captured.
6. A Family Liaison Officer from my office contacted and visited the
man’s father with my investigator. The man’s father said he had
visited the prison after his son’s death, the staff were extremely
friendly and helpful towards him. He was able to speak to other
prisoners and they told him that his son was happy on the night he
died.
7. The man’s father did not believe his son could end his own life. He
said his son was not under stress as he was due to transfer prisons.
He had proposed to his girlfriend and she had accepted. On the
night he died he had been speaking to her out of the window of his
cell. The man had asked her to thank his father, for sending a
postal order. He said his son hated prison. He believes he must
have been innocent of the alleged murder charge because if he
5
were guilty he would have fled to Cyprus where he would have
been safe from arrest.
8. The man’s father knew that his son wrote him a letter which was not
actually posted before he died. The police have the letter and he
did not see it, until my investigator arranged for him to receive a
copy. The content did not give him cause for concern.
9. My investigator told the man’s father that he visited the prison within
three days of his son’s death. He saw the cell were his son had
died and interviewed three prisoners who knew him.
10. The man’s father pointed out that his son was tall yet he was found
hanging from a low window approximately 1m high. He had doubts
that this was possible. He also told us that his son hated pain so
would not inflict any on himself. He understood that he would
possibly never know what really happened that night, and was
concerned that his son was not checked between 10.00pm and
6.00am.
11. The man’s father suggested that had the prison staff read his son’s
outgoing correspondence they might have noticed he was upset or
worried. It was explained that prisons randomly read some mail,
unless they have concerns about a particular prisoner. On arrival at
Exeter his son had told the staff he was not depressed and they
had no reason to be concerned about him. In the man’s letters he
wrote about his relationship with a girl who had not written back to
him.
12. The man’s father told the investigators that his son had access to a
mobile phone when he was in custody previously. He alleged that
the phone was given to him by a prison officer for a charge. He
said if the staff were prepared to do this, they may have been
responsible for his son’s death.
13. My investigator wrote to HM Coroner to inform her of the nature and
scope of my investigation and to request a copy of the post mortem
report. Upon completion, this report will be sent to the Coroner to
assist her enquiries into the man’s death.
6
BACKGROUND
HMP Exeter
14. The prison is located within the City of Exeter and was built around
1850. It currently has four accommodation units with a healthcare
facility in support. The Certified Normal Accommodation is 314 and
the Operational Capacity 533. The prison holds both adult male
remand and convicted prisoners committed to custody from
Cornwall, Devon and Southwest Somerset.
Suicide and self harm monitoring
15. As in all prisons, Assessment, Care in Custody and Teamwork
(ACCT) has been introduced at Exeter to monitor and support
prisoners assessed to be at risk of suicide or self harm. (The
previous system was known as the F2052SH procedure.) Once
placed on ACCT, the prisoner is observed at pre-determined
intervals according to the perceived level of risk.
16. Each prisoner is assessed within 24 hours and then reviewed at
intervals decided on an individual basis. The ACCT guidance says
that, to be effective, the review should involve the key people who
know the person at risk or are involved in their care. The key
questions for each review are listed as:
• have the problems that caused the ACCT plan to be
opened now been resolved?
• if not, what needs to be done to resolve them?
• have any further problems arisen that are now causing
distress and more risk?
• if so, what action can be taken to address these?
• is the person at risk now in contact with friends, family or
other support?
• does the person at risk now have something in their lives
that they feel good about?
• if not, how can this be improved?
17. Over time, the reviews should also consider other factors such as:
• distress – has anything changed to make the person at
risk more or less desperate?
• resources – has anything changed that makes the person
at risk now feel more or less alone?
• previous suicidal behaviour – has anything changed that
makes suicide more familiar or more acceptable to the
person at risk?
7
• suicide intention or plan – has anything changed to show
that the person at risk is more or less prepared to kill
themselves?
• pattern of self harm – is self harm becoming more or less
frequent?
18. Amongst other things, the ACCT guidance states that prisoners
should be cared for in a safe environment and it is for the Case
Review team to decide the most appropriate place to locate an
individual prisoner. The man was not identified as a prisoner at risk
of self harm and was therefore not subject to self harm monitoring.
There was no requirement for staff to check on him after the last roll
check of the day just before 10.00pm until the morning roll check at
6.00am.
Listeners/Samaritans
19. As part of the community approach to suicide prevention, Exeter
offers a Listeners service. Listeners are prisoners who are trained
by the Samaritans to listen to and befriend prisoners who are in
crisis. The service offered by the Listeners is completely
confidential. All prisoners are advised of the existence and
availability of the Listeners and Samaritans.
20. Prisoners at Exeter also have the opportunity to contact the
Samaritans through letters, visits and telephone calls. Details of
how to contact the Samaritans are displayed alongside all prisoner
telephones. There is no evidence that the man made contact with
the Samaritans or Listeners.
Previous deaths in custody in Exeter
21. There have been three previous apparently self inflicted deaths and
one of natural causes since I became responsible for investigating
all deaths in prisons in April 2004.
HM Chief Inspector of Prisons’ Inspection
22. The HM Chief Inspector of Prisons conducted an inspection of
Exeter in December 2004. She found Exeter to be a largely safe
prison and she had few concerns about bullying or intimidation,
even though it held young adults alongside adult prisoners.
23. The HM Chief Inspector of Prisons found almost all newly received
prisoners, including those recalled because they had breached their
licence, spent their first three days in the first night centre (FNC).
Their immediate and longer-term needs were assessed by specially
trained prison staff and voluntary sector workers as part of a two-
day induction programme, which also provided information about
the prison routine and facilities.
8
24. The prisons’ policy of protecting people from being bullied and
challenging bullies, was widely advertised and supported by a clear,
published strategy. A senior officer coordinated anti bullying issues.
Prisoners including young adults told the inspectors that there was
little bullying and only four prisoners were registered as bullies at
the time of their visit. They faced appropriate levels of observation
and sanction and, in the case of persistent bullies, education.
25. The inspectors found that there were comprehensive arrangements
to minimise the risk of self-harm or suicide. Assistance for
distressed prisoners was extensively advertised, the clear strategy
document was widely understood and adhered to. There was a full
time co-ordinator who was a member of the safety custody
committee and there was assistance from the Samaritans and
trained listeners. The safer custody committee met monthly and
was well attended by senior managers and a range of people from
within the prison and the wider community. Monitoring of distressed
prisoners was of a good standard, except at night when they found
examples of cursory recording.
Approved Premises
26. Approved Premises provide supervised accommodation for
offenders under the supervision of the Probation Service. They
provide a greater degree of supervision for offenders than is
possible in other forms of housing.
27. Approved Premises were formerly known as bail hostels. Most
approved premises are owned and managed by the National
Probation Service for England and Wales. A small number are run
by voluntary sector providers but all are required to work to the
same operating standards. Residents follow a structured regime,
which includes overnight curfew. There is 24 hour supervision at
the Approved premises by trained staff.
28. Approved Premises accommodate offenders who have committed a
very wide range of crimes. Approved Premises hold a range of
offenders on bail and on licence.1
1 Licence is the term to describe the agreed conditions and restrictions with which a released
prisoner must comply when they are first returning to the community at the end of the
custodial element of their sentence.
9
KEY FINDINGS
29. In 2000, the man was sentenced to 96 months imprisonment for
serious offences. On 14 December 2006, he was released from
custody on a Probation Licence. The licence expiry date was 29
September 2007. A condition of his release was that he must
permanently reside at Probation Approved Premises and abide by
an 11.00pm curfew.
30. The man initially presented well whilst at the Approved Premises.
He was proactive in finding himself employment and worked for four
weeks until 20 February 2007. He told his supervising probation
officer that he lost his employment when he disclosed he had a
criminal record. His supervising probation officer said that the man
was always polite and co-operative and reacted positively even
when he was denied an overnight pass. On 21 February, he failed
to return to the approved premises.
31. Two days later on 23 February, the man telephoned the Approved
Premises and was informed his Probation Licence had been
revoked. He said that he would probably hand himself in but would
need to sort a few things out. His details were circulated on the
Police National Computer because he had breached his licence.
32. The man remained at large until August when he was arrested and
interviewed regarding a murder in Exeter earlier in the month. After
arrest and interview, he was bailed by the police pending further
enquiries and taken under prison escort to Exeter prison at 2.25pm
on 23 August, for breach of his licence. He was bailed to return to
Exeter Police Station on 3 October.
33. Upon his arrival the man went through the reception process. He
was interviewed by a member of the healthcare staff who
completed the First Reception Health Screen. It was noted that he
had been in custody before having been recalled from licence. The
man said he had seen a doctor recently for a chest infection. He
was concerned regarding a green discharge from his nose. He said
that he was a social drinker and had not abused drugs recently.
34. In relation to his mental health the man said that he had not
received treatment from a psychiatrist outside prison. He had never
been to a psychiatric hospital, or been allocated a psychiatric nurse.
He said he had received antidepressants in 1996, but had never
tried to harm himself and had no current thoughts of self harm. His
previous prison medical records were not requested until after his
death.
35. The man was deemed fit for all prison work, physical education and
gym work. A Cell Sharing Risk Assessment (CSRA) was
completed and he said he had a history of assaulting previous cell
10
mates and would harm cell mates. A first night centre prisoner
profile form was completed, in which the man said he did not feel at
risk of self harm but had been treated for depression in the past.
He was allowed a television set and given access to telephones.
36. The Anglican and co-ordinating Chaplain at Exeter told my
investigator that the man was seen by the duty Chaplain upon his
arrival at Exeter on 24 August. The duty Chaplain noted that the
man was on licence recall and had registered his religion as Church
of England. The man had no further recorded contact with the
chaplaincy department.
37. The man spent his first night in Exeter on the first night centre in cell
B3-5. The following day he was moved to cell C4:20 which is
situated at the end of the top floor of C wing overlooking St David’s
railway station Exeter. It is not unusual for prisoners on C wing
overlooking the station to communicate with people outside the
prison by shouting through their windows. It is known that the man
used to shout to a girlfriend from his cell whilst she stood on the
road outside, and that he received visits from his friends and made
telephone calls.
38. Another prisoner returned to the prison from court on 24 August.
Up until that time he had been in cell C4.20. On returning to his cell
he discovered it had been occupied by the man. Officers opened
the cell door to allow the prisoner to collect his belongings. The
prisoner said that the man was pleasant to him and he collected his
belongings and left. Subsequently they spoke and discussed the
view from cell C4.20. The prisoner worked on the food servery and
saw the man regularly as he collected his meals.
39. A physical education instructor at Exeter recalled meeting the man
twice. The first time was when the man went through an induction
process to join the gym. The instructor recalled that they talked at
that meeting about Cyprus. He said that the man seemed quite
affable. A couple of days later on 10 September, the man played
football in the gym. The instructor saw nothing in the man’s
demeanour that gave him cause for concern.
40. An officer recalled that on the morning of Tuesday 10 September,
the man was unlocked for breakfast. During the morning he went to
exercise classes for an hour before returning to his cell. The officer
spoke to him regarding an inter-prison phone call with a female
prisoner at Eastwood Park. The officer said he would speak with
his senior officer who would let the man know if the phone call could
take place. The officer was aware that the man was being
transferred to HMP Channings Wood on Thursday so was trying to
organise the call for Tuesday evening’s association. That afternoon
the man attended the gym and after his return went out of his cell to
wash. The officer recalled locking prisoners into their cells at
11
6.00pm. As he approached the man’s cell he came out and asked
if he could get something. The officer allowed him to do this and he
returned to his cell. The officer locked him in the cell and the man
gave him thumbs up sign and said ‘cheers’.
41. An Operational Support Grade (OSG) was working nights on the
evening of 10 September, when at 10.00pm he physically checked
all the prisoners on C wing by looking through the door observation
panel. The OSG recalled that the man was alive and on his bed in
cell C4.20. They did not speak to one another.
42. At 5.55am, a second OSG answered a cell bell on C4 wing. He
then started his morning roll check. He opened the cell flap of cell
C4.20 and put the cell light on. He could clearly see the man
hanging from the cell bars of his window with a ligature made from
his bed sheet attached to his neck. The man was in a seated
position on the floor. Using his prison radio the second OSG called
for assistance and gave his location. He attempted to open his
sealed pouch containing a cell key to be used in emergencies, but
could not break the seal. A third OSG and another officer arrived
next and opened the cell door. The officer released the man by
cutting the ligature with his anti ligature knife, and placed him face
up on the floor. He believed that the man had died as his body was
very cold and stiff. The third OSG also said that the man had his
eyes open and was very stiff. As the nurse had arrived the third
OSG waited outside the cell for the ambulance crew to arrive. The
Night Orderly Officer arrived with a nurse. En route he confirmed
with prison control, using his radio that an ambulance had been
called. Once he was satisfied that the situation was under control,
he resumed his normal duties.
43. The OSG heard a call over his prison service radio for urgent
assistance and medical assistance to C4 landing. He went to C4
landing and to cell C4.20 where he saw the man lying on the floor
on his back with the officer, and two OSG’s in attendance. The
man appeared to the OSG to be stiff. The nurse attended and the
OSG continued with his duties.
44. The nurse was on night duty during the night, providing healthcare
cover for the prison and using radio call sign hotel one. He
received a radio call at 5.55am asking him to urgently attend C-4
landing. He collected the emergency medical bag and arrived at
cell 4.20 at 6.00am. He saw the man lying on the floor of the cell,
face up. He saw a ligature mark on his neck and checked for a
pulse and signs of breathing but found neither. The nurse called for
a defibrillator and immediately started the resuscitation procedure
continuing for at least two minutes until the ambulance crew arrived
and took over. The nurse noticed the man’s limbs were stiff and his
face was pale. The ambulance staff examined him and could find
no signs of life, and noted he had rigor mortis. The man’s life was
12
pronounced extinct at 6.12am. His cell was sealed pending the
arrival of the police, who seized exhibits and photographed the cell.
45. Found in the man’s cell at the time of his death was a local
newspaper concerning the murder investigation for which he was
on bail. Next to it was a hand written document listing the offences
he had been convicted of, the resulting sentences and estimated
age at the time of his eventual release.
46. After the man’s death, the Chaplain offered care and support to
prisoners in nearby cells. The prisoners she spoke to were
completely surprised that the man had died. He gave them no
indication that he intended to harm himself, and they described him
as a pleasant individual who kept himself to himself. The prisoner
who had previously occupied the man’s cell was also shocked to
hear of his death.
47. The Chaplain held a memorial service for the man the following day
which was attended by prisoners and staff. She subsequently met
with the man’s friend, his father and family friends at the prison.
48. The man’s friend said she was a girlfriend of his and had visited him
in prison the week before he died when he had proposed to her.
He knew he was being transferred to Channing’s Wood and was
looking forward to the move. The man’s friend and her sister had
spoken to the man by shouting up to his cell from the road outside
the prison the evening before he died. She said the man had
seemed in good spirits and did not seem unhappy. She was aware
that he was on bail for a serious offence and had seen his lawyer.
She too was shocked to learn of the man’s death.
Post Mortem
49. A post mortem examination on the man was conducted by a Home
Office Pathologist on 11 September 2007, at hospital. The post
mortem found no evidence of significant injuries beyond those
consistent with hanging. There was nothing to indicate that he had
been forcibly restrained or involved in a struggle. It was the
pathologists opinion that the cause of death was asphyxia caused
by hanging.
Contact with family
50. The man’s friend had been nominated as his next of kin. She was
notified of his death as soon as practicable by the Governor. The
man’s father was subsequently notified. The man’s father praised
the contact he had from the prison after his son had died and the
support he received from the prison family liaison officer. He visited
the prison with other family members and spoke to the Governor, a
member of the chaplaincy and prisoners who knew his son.
13
ISSUES
The discovery of the man hanging
51. Staff acted promptly when they found the man hanging. The nurse
arrived promptly and commenced resuscitation, continuing until the
arrival of the ambulance staff who pronounced his death. The
prison contingency plans worked well allowing for the speedy entry
to the prison by the ambulance crew.
Clinical care
52. The Primary Care Trust clinical review of the man’s treatment was
aware that he had spent a period of previous custody until 14
December 2006 at HMP Lowdham Grange, Nottinghamshire. His
previous Inmate Medical Record was not available at the time of
reception, nor had it been requested until after his death. I do not
believe this to be a contributing fact in his death. However,
healthcare staff should be reminded that previous medical records
should be sought to ensure continuity of care.
The Head of Healthcare should ensure that previous medical
records are sought to ensure continuity of care.
53. The man’s reception screening reported little of any significance to
contribute to his eventual death. He did not report any alcohol or
substance misuse. He had only seen a doctor in recent months
because of a chest infection. He had previously been prescribed
anti-depressants in 1996.
54. The man had not presented to healthcare staff since his routine
reception screening consultation. There were no other causes for
concern. He did not display any noticeable risk factor warranting
intervention to healthcare or discipline staff. All the relevant policies
and procedures for healthcare screening were complied with.
Family concerns
55. The man’s father suggested to my family liaison officer and
investigator that staff might have been responsible for his son’s
death. The post mortem examination showed only injuries
consistent with hanging. The police and my investigator are
satisfied that no third party was involved.
The man’s cell
56. On my investigators initial visit to Exeter he visited the cell that the
man had occupied (C4:20). He found that it was reasonably
spacious and was situated on the top floor of the wing at an end of
the landing. It contained a bed, toilet, a television and reading and
14
writing materials. A copy of the local newspaper was in the cell with
details of the murder that the man was suspected of, together with a
hand written tariff of likely earliest dates of release.
57. There was broken Perspex covering the cell window which is
designed to keep the cell warmer. Apparently prisoners break the
Perspex to allow them to communicate with persons outside the
prison walls. It is known that the Perspex covering was broken prior
to the man occupying the cell. Although the man used the window
frame as a ligature point the cell contained many potential other
ligature points.
Bullying
58. My investigator has interviewed members of staff, prisoners a
member of healthcare and a chaplain. He has found no evidence to
suggest that the man was either being bullied or a bully.
CCTV
59. My investigator was supplied with a CD Rom which was supposed
to provide CCTV coverage of C wing on 10/11 September 2007.
However, on viewing the CD, there are no images of C4 landing.
Staff and paramedics can be seen entering C2 wing which lead
them to C4 wing at around 6.00am. The security staff at Exeter
have been aware that the CCTV system has not been operating as
well as it should. I am informed that Exeter did not have a
maintenance contract for the CCTV equipment suppliers and there
was no system for monitoring its effectiveness.
The Governor should ensure that the CCTV system is regularly
maintained and working effectively.
Care and welfare for staff and prisoners
60. Staff and prisoners felt generally well supported and staff involved
in the finding of the man completed incident statements prior to
going off duty. However, staff said they had not been involved in a
‘hot ‘debrief’ to learn immediate lessons from the death.
The Governor should ensure that where staff are involved in
critical incidents attend a ‘hot debrief’ as soon as practicable.
15
CONCLUSION
61. The man was described as a decent, well-behaved prisoner who,
although was only at Exeter for a short time, was known by staff.
He had been arrested on suspicion of murder and bailed. However,
as he had breached his release on licence conditions, he was
returned to custody, and expected a further term of imprisonment.
That said, it is clear that his death came as a complete surprise to
those who had dealings with him. Outwardly, he gave those who
knew him including his father, girlfriend, fellow prisoners and staff
no indication of the distress that he must have been suffering.
62. When the man was discovered hanging, staff commenced
resuscitation promptly and ensured the unhindered entry and
access to the prison by the ambulance staff. I do not believe that
through the man’s general demeanour his final actions could have
been predicted by staff at Exeter.
16
RECOMMENDATIONS
The Head of Healthcare should ensure that previous medical
records are sought to ensure continuity of care.
The Governor should ensure that the CCTV system is regularly
maintained and working effectively.
The Governor should ensure that where staff are involved in
critical incidents attend a ‘hot debrief’ as soon as practicable.
GOOD PRACTICE
I have been most impressed by the prison’s response to finding the
man hanging and then to his death. The prisoner and staff who first
found him responded quickly and efficiently to the emergency. The
family liaison was sensitively handled.
17