Individual at Forest Bank

The circumstances surrounding the death of a man after
his release from HM Prison/ YOI Forest Bank on 11 May 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
October 2005
Contents
Part One: 1. Introduction
2. Summary
3. Investigation methodology
4. The deceased
5. HM Prison/ YOI Forest Bank
6. Events prior to the man’s release from prison on 11 May
2005
7. Events on 11 May 2005
8. Consideration of issues arising from the investigation
9. Recommendations
Annexes: A Report of a Clinical Review by Salford Primary Care Trust
Part Two: Supporting documents
This is the report of an investigation into the circumstances surrounding the
death of a former male prisoner in Bolton, Lancashire. He was found dead in a
block of flats at about 10:30pm on 11 May 2005. Earlier that day, he had been
released from Forest Bank prison near Manchester on completion of a six month
sentence.
A post mortem examination carried out on 13 May 2005 concluded that the man
died from a heroin overdose.
My terms of reference for the investigation of fatal incidents allow me to use my
discretion in determining whether to investigate the death of a prisoner that
occurs after his release from prison. As the man died within approximately 15
hours of release I considered that it was appropriate for his death to be
investigated by my office.
The investigation was conducted on my behalf by my colleague.
I also commissioned an independent clinical review of the management of the
man’s heath needs while he was in custody at Forest Bank. This was conducted
by a representative of the Salford Primary Care Trust.
I am grateful to the PCT for their work. I would also like to thank the Director and
staff of Forest Bank for their help and co-operation during the investigation.
This published version of the report does not include any of the original annexes,
which were extensive.
Emma Bradley October 2005
Deputy Prisons and Probation Ombudsman
2. Summary
The man was born on 1 January 1974, in Bolton. He came from a stable family
background but became involved in criminal activity from the age of ten. He left
his family home at the age of 17, when he began to lead an unstable existence
that revolved around the use of illicit drugs. He became a heroin addict and
repeatedly committed acquisitive crimes to pay for the drugs he used. He had
been sent to prison on several occasions.
On 11 February 2005, the man was sentenced to six months imprisonment at
Bolton Magistrates’ Court. He spent the whole of this period of custody at HMP
Forest Bank, an establishment run by the private sector. During his sentence, he
remained drug free but refused help in relation to his previous drugs misuse,
including interventions that were offered by the CARATS team (Counselling,
Assessment, Referral, Advice and Throughcare).
The man was released from Forest Bank on the morning of 11 May 2005. At
10:30 pm that day, he was found dead in a block of flats in Bolton. He died of a
heroin overdose. He was 31 years old.
The investigation found that the man was offered appropriate help and support in
relation to drugs misuse and resettlement planning while in Forest Bank.
I make one recommendation.
3. Investigation methodology
The investigation was opened on 16 May 2005, when my investigator met with
the Head of Operations and the Director at Forest Bank and toured the
establishment with a senior manager. The following day, my investigator met
with the Head of Operations, a member of the establishment’s Independent
Monitoring Board (IMB) and, separately, a representative of the Prison Service
Union, to brief them on the nature and scope of the investigation. Notices were
issued to staff and to prisoners announcing the investigation and inviting anyone
with information relating directly to the man’s death or to the manner in which he
had been treated whilst in custody at Forest Bank to make themselves known to
my investigator.
An independent clinical review of the management of the man’s health needs
whilst at Forest Bank was undertaken by a representative of the Salford Primary
Care Trust.
Informal discussions were held with nine members of staff at Forest Bank.
4. The deceased
The man was born on 1 January 1974 in Bolton. He had a stable family
background, disrupted only by his very early involvement in criminal activity from
the age of ten years. His subsequent formal convictions from the age of 14
impacted on his progress at school and impeded his employment prospects. He
left the family home at the age of 17 and began to lead an unstable existence
that revolved around repeated periods of custody and moving between various
dwellings occupied by drug users. He was addicted to various drugs, including
heroin. The man’s drug addiction appeared to be the source of his criminal
career: he committed numerous acquisitive crimes in order to finance his
addiction. He became isolated from his family and seemed to have no direction
in his life. On each occasion he was released from prison he was homeless, and
returned to live with other drug addicts.
The man’s most recent sentence of six months imprisonment was given by
Bolton Magistrates on 11 February 2005. He spent the whole of this period of
custody at Forest Bank prison. Staff there described him as pleasant and well
behaved. He was keen to work during his sentence and was employed for a
while in an upholstery workshop.
5. HM Prison Forest Bank
Forest Bank is a local prison in Greater Manchester and is operated by United
Kingdom Detention Services (UKDS) in the private sector of the Prison Service.
At the time of the investigation it could hold up to 1040 remanded, convicted and
sentenced adult male prisoners and young offenders. It serves Magistrates and
Crown Courts in the Greater Manchester area.
The establishment comprises six house blocks each with identical two-storey
wings radiating from a central hub. Each wing is designed to hold up to 65
normally, or, if overcrowded, 85. Work is provided in a variety of industrial
workshops, courses, education classes, catering, and other types of employment
such as cleaning, gardening and orderlies, for approximately 800 prisoners.
There is a detoxification facility that provides accommodation for up to 86
prisoners. Of the total accommodation available in the unit, 16 beds are retained
for those who require the closest supervision. Healthcare staff work in support of
three key workers assigned to the unit.
A CARATs service (Counselling, Assessment, Referral, Advice and
Throughcare) is also provided. The CARATs team comprises four Prison
Custody Officers (PCOs) who are paid by UKDS and who operate as initial
assessors. They are supported by seven key workers who are funded by the
North Trafford Substance Misuse Unit. The salaries of the key workers and the
team leader are refunded by the Office of Contracted Prisons via the Controller of
Forest Bank.
The healthcare centre provides 24-hour medical and nursing cover and inpatient
facilities for up to 25 prisoners. Healthcare staff are employees of UKDS.
Forest Bank has been open since January 2000. In June 2002, it underwent its
only visit to date by Her Majesty’s Chief Inspector of Prisons. The main
recommendations of the report of that inspection were that:
• the prison should have a resettlement strategy and action plan
• there should be an increase in purposeful activity for all prisoners
• there should be an overall safer custody strategy, linking reception and
induction, detoxification, anti-bullying and health issues in order to deal with
all elements of potential vulnerability
• detoxification procedures should be in accordance with the relevant Prison
Service Order
• all prisoners held in the healthcare unit should have care plans
Each of these recommendations has subsequently been implemented.
6. Events prior to the man ’s release from prison on 11 May 2005
On 11 February 2005, The man was sentenced to six months imprisonment for
theft.
Upon his arrival at Forest Bank that day, the man underwent a reception health
screen. He told staff that he used £20 of heroin on a daily basis, that he was not
taking any prescribed medication for any reason and that he was not concerned
about any aspect of his mental or physical health. He did not wish to see a
doctor. He had been in prison at Forest Bank before and seemed to be able to
cope with another sentence. He was allocated to the establishment’s induction
wing where he was to stay for four days. He declined intervention from the
CARATs team (Counselling, Assessment, Referral and Throughcare Service).
On 14 February, the man was moved from the induction wing to C2 wing. This is
a unit designated as a drug-free environment holding prisoners who volunteer to
be regularly tested for drugs. The man remained in this unit until his release. In
March 2005, the man took two voluntary drug tests, the results of which were
negative. He did not undertake any offending behaviour courses. He did not
receive any visits. At no stage did the man come to the attention of the medical
or nursing staff.
On 18 February, the man underwent a custody needs assessment interview in
the education department. During the interview, he repeated that he was a
heroin user and stated that he had in the past requested help regarding his drug
misuse. However, when asked whether he would like to attend a drug
awareness course, the man replied that he did not. He also stated that he did
not need support in custody or on release to stop offending or in general terms.
He said that there were no medical issues that were likely to affect his release
plans, and that he did not need help with any health issues before release. He
did not want to attend a healthy living course. He said that he had no financial
pressures. He said that he had no contact with family members and no home to
go to on release. Although he did not want any help to find employment, the man
did ask for help to find somewhere to live.
On 25 February the man began work in the upholstery workshop where he
remained in full time employment for most of the remainder of his sentence.
My investigator was told that all prisoners at Forest Bank are given a
resettlement course eight weeks in advance of their release date. The course
comprises two elements: induction and pre - release. The man attended the
induction phase of this course, but refused to attend the pre - release phase.
During the induction phase, the man asked for help in relation to his housing
needs. It was later decided, with his consent, that, upon his release from prison,
he should return to his former address. My investigator was also told that, had
the man attended the pre - release phase of the course, he would have had an
opportunity to benefit from drug misuse counselling. The course comprises a
number of modules including a harm reduction and overdose prevention module
that examines:
• high risk situations
• safe methods of using drugs
• effects on tolerance of reduced use/abstinence
• basic cardiopulmonary resuscitation techniques should prisoners
encounter someone who has overdosed
• prevention of accidental over dosage
Prisoners are also offered a booklet entitled “Overdose-protect and survive”.
On 10 May, the man was assessed by a nurse as being medically fit for release
from prison.
7. Events on 11 May 2005
At 8:30am on 11 May, the man was released. He was reminded that his
sentence expiry date would fall on 9 August 2005, and that until that date he was
liable to be returned to custody if convicted of any further imprisonable offence.
His discharge certificate shows that the man took with him £137. 55, made up of
a discharge grant and a subsistence allowance. His discharge address was
recorded as that at which he had been living prior to his imprisonment.
Nothing further is known about the man’s movements until he was found at
approximately 10:30pm that day, slumped in the hallway of a flat in Bolton, by a
person who was an occupant of the flat and an associate of the man’s. The
address is approximately two miles from the man’s discharge address. The
person who found him called an ambulance. When they arrived at the scene at
approximately 10:55pm, the paramedic crew confirmed that the man was dead.
They suspected that he had taken an overdose of drugs. However, they found
no drug taking equipment at the scene nor any evidence of needle marks on the
man’s body. The police officer who attended the scene straightaway confirmed
that there were no suspicious circumstances. The police informed the Coroner
and the man’s listed next of kin, his aunty. The aunty later informed the man’s
mother. The man’s body was removed from the scene to the local mortuary later
that night.
A post mortem examination indicated that the man died from a heroin overdose.
8. Consideration of issues arising from the investigation
The following issues arose during the investigation:
Support for abstaining from drug misuse while in custody
• Given that the man died from a heroin overdose on the day he was released
from prison, was enough done while he was at Forest Bank to support him in
abstaining from drug misuse during his time in custody?
Upon his arrival at Forest Bank, the man underwent a reception health screen
during which he admitted that he had been using heroin to the value of £20 per
day. He did not wish to see a doctor about his drugs misuse. He refused a
Hepatitis B vaccination, a drug awareness course and the CARATs service.
In her clinical review of the management of the man’s health needs, the
representative of Salford PCT comments that the reception screening offered to
him was sufficient and properly handled. I agree.
The man volunteered for the drug free programme. He apparently remained free
of drugs until he was released from prison.
Resettlement planning
• Were the man’s resettlement needs identified and was he given adequate
help and support in preparing for release?
The induction phase of the resettlement course that the man attended eight
weeks prior to his release date included an assessment of his housing needs.
The man asked for support in this respect. It was later decided, with his consent,
that he should return to his former address. The man refused all other support.
He refused to attend the pre - release phase of the course that offered him an
opportunity to benefit from drug misuse counselling. By this time, the man had
apparently remained drug free for the whole of the time he had been in prison
and had consistently expressed no interest in any support with regard to drugs
misuse in custody or after release.
I consider that, in the circumstances, the man’s resettlement planning was
carried out satisfactorily.
9. Recommendation
Medical records
The Director of Forest Bank should ensure that whenever prisoners decline or
refuse to see a doctor, an accurate record is made in the prison medical file.
Annex A
Salford
Primary Care Trust
Report of the Clinical Review
of the management of the health needs of a man while he was a prisoner
at HMP/YOI Forest Bank
Salford Primary Care Trust
Introduction
The aim of this investigation is to provide an independent review of the medical
and nursing care of a man whilst in custody at HMP Forest Bank, in particular
with reference to his drug addiction.
Methodology
In order to examine relevant health issues and assess clinical case, Salford
Primary Care Trust serious untoward incident policy was followed. On 1st June
2005, the Associate Medical Director and Head of Operations carried out
informal interviews with key medical staff at the prison, including, the nurses,
drug team and doctor, and reviewed the Inpatient Medical Records available.
Based on this evidence this report has been written.
Background
The man had previously been a prisoner at Forest Bank and was re-admitted to
Forest Bank on the 11th February 2005. He joined the drug free programme, was
released 3-months later on the 11th May 2005, and died 14 hours after release.
Medical History
Upon arrival at the prison he undertook reception screening and was found to
have no physical or mental health problems. He admitted to a £20 daily drug
habit, one month before admission, and he was offered Hep B vaccination but
refused.
The man signed up for the drug free programme with CARAT and 2 urine
samples were tested on the 8th and 13th March 2005. However no drug
screening was carried out upon admittance as he had refused to see the doctor
on the 12th February 2005 and for the remainder of his stay.
Key Findings
The reception screening offered to the man was sufficient and properly handled.
The support offered by staff for his substance misuse during his stay was
appropriate, and the patient benefited from the drug free programme. However,
he refused to see the doctor throughout his stay. There were no suicide or self-
harm indicators present and the man was not prescribed methadone whilst in
prison. On his release he was not classified as a drug user and therefore
according to prison policy and procedure no letters were issued to the GP.
Both the reception medical and the release medical procedures were completed
with the man but documentation was missing and recording keeping was
minimal.
As the man had lowered his tolerances to heroin whilst in Forest Bank, it was felt
by staff that using the same amount of heroin or pure heroin after his release
might have led to an overdose and death. The toxicology report has not yet been
received.
Recommendations & Good Practice
As the CARAT programme is beneficial to prisoners and the contract was
terminated, it is recommended that an alternative programme be established.
(Prisons and Probation Ombudsman’s comment:- After the investigation was
completed, my investigator was told that the CARATs programme continues to
be delivered at Forest Bank, but by a different provider.)
Documentation and record keeping could be improved with written entries when
prisoners refuse to see medical staff and compilation of all previous health
records belonging to prisoners.
Summary
As a result of this clinical review Salford Primary Care Trust find that the medical
and nursing care of the man whilst in custody at Forest bank was adequate and
appropriate.