Individual at Full Sutton

Investigation into the circumstances surrounding the
murder of a prisoner at HMP Full Sutton, who died on 16
September 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2007
The man who is the subject of this report died on 16 September 2005 at a hospital in
Yorkshire. The man was a prisoner at HMP Full Sutton and had been the subject of
a vicious attack by two other prisoners who had taken him hostage in his cell twelve
days earlier. His arms had been tied up, his head covered with a blanket, and he
had been beaten and strangled before falling unconscious.
He remained a hostage for about an hour before medical staff were able to enter the
cell and administer assistance. The man was taken to hospital and placed on a life
support machine, but did not recover. He was 77 years old and remained in hospital
until his death.
This is a report into the circumstances surrounding the killing.
Due to police enquiries and the subsequent criminal trial, it was necessary to
suspend my investigation pending the completion of court proceedings. My
investigation was reopened once the trial had been concluded with two convictions
for murder. As what happened in the man’s cell has been fully investigated by police
and explored at court, I have dealt in the main with the events leading up to the point
where he was taken hostage. I am satisfied that the prison had no prior warning that
he was vulnerable to attack by the prisoners, and so could not have prevented it.
However, I draw attention to the unsatisfactory state of the prison’s command suite,
a surprising circumstance in one of the country’s high security prisons.
I wish to thank the management and staff of Full Sutton for their support and for
making my investigators welcome. I offer particular thanks to the liaison officers and
administration staff for their invaluable support.
The loss of any family member is distressing, but especially so whilst they are in
custody, vulnerable and die in such horrific circumstances. My investigator and I
offer our sincere condolences to the man’s family and friends.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2007
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CONTENTS
Summary 4
The Investigation Process 6
The Man 8
HMP Full Sutton 9
Key Findings 11
Issues 15
Conclusions 16
Recommendations 17
Annexes 18
3
SUMMARY
On Sunday 4 September 2005, the prison security department at HMP Full Sutton
received a Security Information Report (SIR) to say that a prisoner on F wing was
believed to be bullying two other prisoners on the wing. The information had been
given to an officer by a prisoner. The SIR named two prisoners who had in turn
apparently made it known to other prisoners that they were intending to stab the
alleged bully. The SIR was analysed the same day by intelligence staff, and their
assessment was that officers on F wing should monitor the situation.
Whilst monitoring the movement of the alleged bully and the two prisoners reported
to be planning to carry out the stabbing, F wing officers became aware of another
prisoner who had positioned himself in view of one of the wing internal cameras and
remained close to prison staff. The reason for his doing this was two fold: to make
himself highly visible to prison staff, and to show the other prisoners that he was in
full view of prison staff.
At 5:15pm, the two prisoners who had made it known that they were going to stab an
alleged bully were seen by prison officers to enter the dead man’s cell. This was
followed immediately by a loud commotion. Believing that a fight had broken out in
the cell, officers raised the alarm and went to the cell to see what was occurring.
An officer unlocked the man’s cell door and managed partially to push the door open.
However, the door was immediately kicked shut by one of the prisoners. Further
attempts to unlock the door failed, as the two men had erected a barricade against
the door. Additionally, the door observation window had been covered over thus
preventing the officers from seeing into the cell. One of the officers is a trained
hostage negotiator, and believed at this point that the man had been taken hostage.
At 5:25pm, an officer spoke to the two prisoners [perpetrators] and asked if he could
speak to the man. One of the perpetrators agreed and removed the cover from the
cell door observation panel. The officer could see a figure slumped in a chair, tied
up and covered with a blanket. When he called out to the man, the officer did not
receive a response.
During the hostage negotiations, the duty governor informed the negotiator that the
man had a potentially serious illness. The negotiator told the two hostage­takers
about the condition. At 5:50pm, following further negotiations, one of the
perpetrators passed a home­made knife to the negotiator.
As part of the normal hostage contingency plans, discussions were taking place in
the background with the perpetrators. During the lines of communication,
arrangements were being discussed with those in charge of the situation on how any
eventual surrender plan by the prisoners would operate.
At 6:00pm, a surrender plan was agreed. Fifteen minutes later, the two perpetrators
took the barricade down, and the officers waiting outside were able to unlock and
open the cell door. Both perpetrators co­operated fully with instructions and were
taken to the prison’s segregation unit.
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A principal officer (PO) was the first person to enter the cell after the two perpetrators
had left. He removed the blanket which was still covering the man’s head. He spoke
to him, but did not obtain a response. He was aware that the man was breathing,
albeit with difficulty. He could see his arms were cut and tied behind his back and
blood was coming from his left ear.
A prison nurse also entered the cell and, with the assistance of the PO, moved the
man onto his bed for further examination. Her tests showed that he was
unresponsive but breathing. Two members of the emergency ambulance paramedic
team were waiting just inside the prison and able to be at the cell very quickly. Once
required, they attended F wing and administered oxygen to the man. Their
assessment was that he was breathing but in a critical condition which required an
immediate emergency transfer by ambulance to hospital. The man was taken to
hospital where he was placed onto a life support machine. Sadly, at 1:07am on 16
September 2005, the man died without ever having regained consciousness.
5
THE INVESTIGATION PROCESS
1. On 19 September 2005, one of my assistant ombudsman, and an investigator,
opened the investigation on behalf of the lead investigator, who at the time was
on leave. They met the Governor, prison’s liaison officer, a member of the Full
Sutton Independent Monitoring Board (IMB), and a member of the local branch of
the Prison Officers’ Association, and briefed themon how the investigation would
proceed. After the meetings, they visited F wing and viewed a cell similar to the
man’s as his own cell remained sealed by the police as it was the scene of a
crime.
2. To save unnecessary confusion, notices informing staff and prisoners of my
investigation were not displayed. It was felt that they might cause uncertainty as
between my work and that of the police. However, in a notice to staff and
prisoners, the Governor made everyone aware that my office would be
investigating the death in line with my commission to investigate every death in
custody.
3. The investigators then examined copies of the record of the events, including post
incident Security Information Reports which indicated that one of the perpetrators
involved had admitted injuring the man and hoping that he was dead.
4. On 30 September, the lead investigator took over responsibility for the
investigation and met the Governor and liaison officer at the prison. He received
a briefing from the Governor and visited the area where the man had been taken
hostage.
5. On 5 October, the lead investigator and another of my investigators met the
police officers investigating the death at their incident room. The meeting had
been requested to agree the protocol for how my investigation would proceed
alongside the police investigation. The lead investigator sought the advice of one
of my deputy ombudsman, and she agreed that the investigation would be
suspended until after the completion of the criminal trial. On 1 November, the
investigators returned to the prison to begin cataloguing the documents which the
Governor had made available to them. They completed their work on 2
November and closed the file pending the completion of the trial. Having pleaded
guilty to the charge of murder, the two perpetrators were sentenced to life
imprisonment on 18 December 2006.
6. On 17 October 2005, one of my family liaison officers (FLO), spoke to the man’s
former wife. The FLO explained that my investigation would not proceed until
after the police had concluded their case. (A key purpose of contacting the family
is to allow them the opportunity to raise any concerns that my investigation should
consider.)
7. On 12 January 2007, my lead investigator received confirmation from a detective
superintendent that this office’s investigation could be reopened. On 12
February, the lead investigator returned to Full Sutton and met a member of the
prison’s management, and Security PO, he also met the new Governor.
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8. Following confirmation that my investigation could re­open, the FLO contacted the
man’s former wife once again to ask if she would like to be involved with the
investigation process. On 27 March, she received confirmation that the man’s
former wife would like to be kept involved and to see my report in due course.
She told the FLO that she believed the man was waiting for an operation, that he
was not well and had lost weight. She asked me to consider whether the
healthcare arrangements were adequate, and whether the man was waiting an
unreasonable time for an operation. I have done my best in this report to answer
these questions.
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THE MAN
9. The man was born in Yorkshire, in 1928, coming from a large family that left
Yorkshire soon after his birth.
10. To try and answer the questions raised by his former wife, my FLO wrote to the
prison’s liaison officer. I am grateful for the information in the following
paragraphs which has been supplied by the prison.
11. On 13 July 2005, the man was seen by a doctor and nurse as he had swallowed
a piece of plastic which had snapped away from his dentures. The doctor
examined the man and found that he was showing signs of excessive weight
loss, and asked for an x­ray and blood test to be carried out.
12. Five days later, the man had an x­ray carried out at the prison and the film was
sent to an external radiology department. The result, which was relayed to the
prison on 20 July, showed signs of abdominal aortic aneurism. On 22 July, the
prison doctor discussed the results with a consultant vascular surgeon and he
advised that the man should be referred for a routine abdominal ultrasound
examination. The examination was carried out on 4 August and reported back to
the prison the following day. It confirmed a 4.5 cm diameter aneurism.
13. On 17 August, the consultant wrote to the prison doctor advising that no further
action was required at that stage, and suggested a further scan six months later.
Six days later, the prison doctor wrote to a consultant gastroenterologist raising
his continuing concerns at the man weight loss. He also booked a follow up
scan, but the man had died before it took place.
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HMP FULL SUTTON
14. HMP Full Sutton opened in 1987 and is a modern, purpose built, maximum­
security prison located 11 miles east of York. Its primary function is to hold in
conditions of high security some of the most difficult and dangerous men in the
country.
15. The prison has seven residential units and a segregation unit and a healthcare
centre. E and F wings provide single cell accommodation for up to 48 men per
wing. The design allows staff good observation throughout and is further
enhanced by CCTV coverage of the internal areas. Due to the level of
observation available, E and F wings have been used to accommodate prisoners
who have not coped well on other wings, or who have been difficult to manage.
Additionally the two wings accommodate those prisoners who, as a result of their
notoriety or vulnerability, require greater observation.
16. Each cell has an inundation point, which is a small opening in the door to allow
staff to connect a fire hose to a cell. When the water is turned on, the inundation
point is designed to spray water into the cell. The inundation system prevents
any possible flash back which could otherwise occur if the door of a burning cell
were opened.
Security Information Reports (SIRs)
17. Security Information Reports are used by staff to inform the security department
of any intelligence they believe important. Although information is regularly
passed into the security department, it is not necessarily acted on straightaway.
This is dependent upon the nature and source of the intelligence and its
reliability. (Security information is often passed to staff anonymously.) However,
all the information is analysed and assessed. Once submitted, the SIR is broken
down into three further sections and the assessment and decisions are
commented on by the security manager and duty governor.
Staff Observation Books
18. Observation books are used by any member of staff to pass on information to
other members of staff. Unlike SIRs, observation books are used as a general
information document.
Incident Command
19. Every Prison Service establishment has in place a set of contingency plans for
dealing with specific incidents. As part of the contingency plans, they all have an
area which in the event of a serious incident can be utilised as a command suite.
Command suites vary from prison to prison. They can be anything from an
office which has another primary function to a dedicated suite used solely for
that purpose. Command suites have telephone access, computer facilities and
local contingency plans.
20. During any protracted incident, the Prison Service uses a command structure
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that identifies various areas of responsibility. There are three levels:
Gold: The gold commander is based at Prison Service Headquarters
·
in London. Providing the incident is of such a serious nature to require
the gold command suite to be opened, the gold commander will take
overall charge. The gold commander is assisted by senior police
officers and specialist staff trained to deal with specific incidents.
Silver: Silver commanders are normally a prison governor grade based
·
in the establishment where the incident is taking place. They initially
take charge of an incident, but depending on the seriousness of the
event will make direct contact with the duty gold commander. Silver
commanders liaise directly with the gold commander and also bronze
commanders. As with gold command suites, prison command suites
require sufficient space to accommodate a number of key advisors and
personnel.
Bronze: There can be a number of bronze commanders involved with
·
any one incident and they can be of any grade. They each have
specific tasks to carry out and work directly to the silver commander.
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KEY FINDINGS
21. On Sunday 4 September 2005, prisoners were not required to work and were
instead taking association. (Association periods allow prisoners to interact with
each other and, should they choose to do so, to meet other prisoners in their
cells. Additionally, they can cook food, watch television, play pool or simply
relax.)
22. During the morning, information was given to an officer by a prisoner on F wing
that two prisoners [perpetrators] were being bullied by another on the same
wing. The officer opened an SIR and, after completing his report, passed it to
the security department. The alleged bully was described by the informant as a
black prisoner. The informant told the officer that he [the alleged bully] was
going to be stabbed by the perpetrators. Although a name was not given by the
informant, the officer thought that he knew whom the prisoner was referring to
and wrote a name on the SIR. The SIR, which was later given a unique
reference number by the security department, does not indicate how the officer
came to this conclusion.
23. The security assessment shows no previous links between any of the prisoners
named, but notes that the information given by the informant was usually good.
Staff on F wing were advised to monitor the situation and anti bullying
observations were opened on the prisoner identified by the officer
24. Further information from officers on F wing shows that they had noticed another
prisoner who appeared to be staying in the vicinity of staff and wing cameras.
As this was unusual for the man concerned, it led officers to believe that he may
have known of the perpetrators plans and possibly suspected that he was the
intended target. A further SIR form was raised to the security department telling
them of their suspicions. The SIR shows that the prisoner sitting near to the
cameras was neither the dead man nor the one referred to as the alleged bully in
the earlier SIR.
25. My investigator examined the wing observation book to identify what instructions
had been given to F wing staff following the SIR assessment. Unexpectedly, the
observation book does not show any instruction from the security department to
monitor the situation, or indicate any possible threat to the alleged bully.
26. However, although there was no reference to monitoring the perpetrators in the
observation book, anti bullying observations had commenced. The investigator
was given an explanation by the liaison officer on how security information was
shared. He was told that, after the daily morning meeting with the Governor and
all managers, the manager for F wing was given an action sheet which gave
instructions about observing the two prisoners concerned. It was the
responsibility of the manager to ensure wing staff were made aware of the
security requirements. Although not written into the observation book, I am
satisfied that proper observations were in place.
27. There are only two entries in the observation book for 4 September. One was
made at 7:40pm, and there is a further entry at 10:00pm. The entries suggest
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that the prisoner who had been observed sitting close to wing cameras and
prison staff was possibly the intended target.
28. At approximately 4:55pm, the man collected his evening meal from the servery
situated on the ground floor of F wing. After collecting his meal he returned to
his cell.
29. Approximately 20 minutes later, the perpetrators were seen by officers to enter
the mans cell. The officers were suspicious, as it was unusual behaviour for the
three to be seen together. Officers heard a commotion coming from the cell and
heard the cell door being closed. An officer pressed one of the wing alarm bell
buttons to alert the rest of the prison that there was a problem in the wing and
that assistance was required.
30. An officer went to the man’s cell and after unlocking the door, managed partially
to open the door. However, one of the perpetrators jumped at the door with both
feet forcing it to close and lock, leaving the man inside along with the two
perpetrators. The officer was quickly assisted by other prison staff. At this point,
one of the prison’s trained hostage negotiators decided that the circumstances
were that of a hostage situation.
31. The PO went to F wing to assess the situation for himself. When he arrived he
was told that a prisoner was being held hostage by two others. He gave
instructions to lock all the remaining prisoners, who at that time were still
unlocked, back into their own cells. All prisoners cooperated with the officers
and returned to their cells, allowing prison staff to deal with the situation.
32. At the same time, the duty governor went to the prison command suite. His role
at this point was to act as Silver Commander and take control of the situation
from the command suite. The PO, as the senior uniformed officer on F wing,
assumed the role of Bronze Commander which meant that he worked directly to
the instructions of the deputy governor.
33. When the duty governor arrived at the command suite, which at the time was
also being used as the prison’s intelligence office, he found the office empty as
the staff had left for the day. He told my investigator that he was faced with a
suite with a large number of unrelated intelligence documents covering the
desks. He said the prison’s contingency plans were not readily available and,
after searching for them, he found they had been placed into storage boxes
under a desk and on top of a cabinet. Additionally, he was unable to log into the
command computers as they were not connected to the electrical main system
and the internal batteries did not have sufficient power to operate them.
However, as he is an experienced governor, he knew what he was looking for
and was able to locate the hostage contingency plans reasonably quickly.
Although faced with a chaotic command suite, he quickly contacted Prison
Service Headquarters and briefed the on call Gold Commander about what had
occurred.
34. The Gold Commander took overall control of the situation which meant that,
before any actions were taken at the prison, he would have to give his
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authorisation. He gave instructions to open the gold command suite based in
Prison Service Headquarters and to implement the hostage contingency plans.
35. In the meantime, the hostage negotiator began talking to a perpetrator through
the locked cell door. The negotiator later told police officers dealing with the
case that a perpetrator had said to him, “He’s a fucking nonce … he killed those
people years ago.” The perpetrator also told the negotiator that he had a home
made knife in his possession, adding that the man had been assaulted, bound
and gagged.
36. Shortly before 5:25pm, the same perpetrator asked to speak to his personal
officer. The personal officer spoke to himthrough the locked cell door. The
perpetrators demanded a police negotiator and camera to be at the cell,
although the reason for this remains a mystery.
37. The personal officer asked if he could speak to the man. One of the perpetrators
agreed and he removed the paper that was covering the door observation panel.
When the personal officer looked into the cell he could see a figure slumped in a
chair, tied up and covered with a blanket. The personal officer called out to the
man but did not receive a response from him.
38. The duty governor became aware that the man had a heart condition and
contacted the negotiation teamto inform them. The negotiator told the two
prisoners holding the man about the medical condition, one of whom was heard
to say, “I wanted him dead anyway, he is just a nonce.”
39. At approximately 5:53pm, the personal officer was able to obtain the
perpetrators agreement to end the hostage­taking, but said they wanted a further
15 minutes thinking time before leaving the cell. The information was passed
back to the command suite for a suitable surrender plan to be agreed and set
up.
40. Seven minutes later, a perpetrator passed a home­made knife through the
inundation point to the officer. The knife had been made using a plastic pen,
razor blades having been melted into the plastic.
41. A surrender plan having been agreed with the commanders and the two
prisoners having been told how the plan would work (including in which order the
prisoners would leave), the cell was unlocked at 6:15pm. Both prisoners
cooperated with staff and were escorted to the segregation unit without any
further incident.
42. The PO was the first person to enter the cell. He removed the blanket that was
still covering the man and saw him sitting on a chair. His arms were tied behind
his back, and there were cuts to his arms and blood coming from his left ear.
The man was alive, but unconscious and breathing with difficulty. The nurse
entered the cell immediately after the PO and they both moved the man to the
bed for further examination. Her medical examination concluded that the man
was alive, unresponsive but breathing. She requested immediate medical
assistance.
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43. Two members of the ambulance service, who had been at the prison on stand
by since the hostage­taking was discovered, responded very quickly. Their own
examination showed that the man was in a critical condition and required an
emergency transfer to hospital. He was taken by ambulance to hospital and
placed on a life support machine, but later died without having regained
consciousness.
44. Under normal circumstances, it is the prison’s responsibility to inform next of kin
of a death in custody or of an emergency admission to hospital. Unfortunately,
the next of kin details contained in the man’s prison record were not up to date.
This meant that his next of kin were not immediately contacted and it was some
time before they were told. I understand the prison governor is writing
separately to the next of kin to apologise for their error. Additionally, the
governor is implementing changes to the way next of kin information is recorded
and will be asking all prisoners, on an annual basis, for there details.
45. Due to the serious nature of what had occurred, the Governor made available to
his staff the support of the local and area care teams. That care and support
has continued to be available to staff.
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ISSUES
46. The SIRs reporting that a prisoner was going to be stabbed were dealt with
quickly. They were followed by a full assessment and instructions to staff to
monitor the situation. Although I understand the wing manager was issued with
an action sheet, I would have expected to see an entry in the observation book.
The Governor should satisfy himself that there is an auditable recording
system for communicating security assessment decisions to the
appropriate staff.
47. The duty governor went to the command suite (which also doubled as the
intelligence office) to implement the contingency plans for dealing with a hostage
incident, but the suite was not prepared for an emergency. Desks were covered
with documents and the computer systems were not functioning. The
contingency plans ­ the heart of managing any serious incident ­ were not readily
available and had been packed into storage boxes. I need hardly say that this
was very unsatisfactory, and very surprising in the context of a high security
prison. Fortunately, the duty governor was sufficiently experienced to be able to
open the suite and operate its systems correctly, and no harm was done.
48. Following a review of the incident, the Governor recognised that the location of
the command suite had the potential to hamper significantly the effective
management of a serious situation. He gave instructions to transfer the
command suite to his office. However, I understand that this too is far from
ideal, as it is very limited in terms of desk space and would in protracted
incidents prove somewhat cramped, especially if all members of a serious
incident were in attendance.
The Prison Service High Security Estate should consider whether the
location of the Full Sutton command suite is fit for purpose.
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CONCLUSIONS
49. Although there was some information that the two prisoners who murdered the
man were planning to stab someone, no­one had named him as the potential
victim. It is possible that the man was simply in the wrong place at the wrong
time. He may well have been the subject of an opportunist attack, and was too
old to fight back and protect himself.
50. I am satisfied that the contingency plans worked well, albeit hampered by a
command suite that was not ready for emergency use. I am pleased that the
Governor quickly recognised the problem and has made interim arrangements to
ensure such circumstances do not arise again.
51. I have been pleased to learn that the prison care team and staff welfare were
quickly deployed to offer the necessary support.
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RECOMMENDATIONS
1. The Governor should satisfy himself that there is an auditable recording
system for communicating security assessment decisions to the appropriate
staff.
2. The Prison Service High Security Estate should consider whether the location
of the Full Sutton command suite is fit for purpose.
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ANNEXES
Documents considered during the investigation:
1. Prison record
2. HM Chief Inspector of Prisons Report on Full Sutton
3. Anti Bullying Policy
4. Suicide Prevention Meeting
5. Violence Reduction Meeting
6. Probation Records
7. Life Sentence Plan
8. Parole Board Reviews
9. Discretionary Lifer Panel Reviews
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