Individual at Glen Parva

Investigation into the circumstances surrounding the death of
a man on 18 August 2005 whilst a prisoner
at HMYOI & RC Glen Parva
Report by the Prisons and Probation Ombudsman for
England and Wales
April 2006
This is the report of an investigation into the death of a man at the Leicester
Royal Infirmary on 18 August 2005, whilst a prisoner at HMYOI & RC Glen
Parva. He was on remand awaiting trial at the time of his death. He was found
hanging in his cell and died a few days short of his 20th birthday.
I wish to offer my sincere condolences to the man’s family for their loss.
This investigation was conducted by one of my senior Investigators. I would like
to extend my thanks to the Governor, and his staff at Glen Parva for their help
and co-operation during this investigation.
A clinical review was undertaken by the South Leicestershire Primary Care Trust
into the medical care that the man received. I am grateful to the doctor for his
report.
Although this report contains some indications as to the man’s mood in the
period running up to his death, his intentions can only be guessed at. Although
he had asked to speak with a prisoner Listener (a prisoner trained by the
Samaritans to offer support to others) just a few hours before he died, there was
little to suggest that he was in immediate danger of suicide or self-harm. Indeed,
in his behaviour and attitude, there was little to mark him out from many of the
young men at Glen Parva and in other young offender institutions.
I make four recommendations as the result of this investigation. Other
recommendations are contained within the clinical review.
This version of the report has been amended to remove the name of the man
who died and those of the staff and prisoners involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2006
Contents
Summary
Investigation methodology
The man
HMYOI & RC Glen Parva
Events prior to the man’s death
Events surrounding the man’s death
Events after the man’s death
Clinical review
Findings and conclusions
Recommendations
Summary
1. Rotherham Magistrates’ Court remanded the man into custody on 8 April
2005. After a number of remands and changes of location, he arrived at
HMYOI & RC Glen Parva on 27 June.
2. On 18 August, he had a visit from his brother and his family. The visit went
well and his brother had no concerns about his well being when they left.
3. That evening at about 7.45 pm, the man asked a member of staff if he could
speak with a Listener. There were security concerns relating to the man, his
associates and the unit Listener, and he was told that he could not see that
Listener. He was offered the use of the Samaritans phone, which he
declined. The staff started to make arrangements to move the unit Listener
out and bring in two others. The man was asked if he had any thoughts of
harming himself to which he replied that he did not. He also said that he
would wait and see a Listener in the morning.
4. The man was seen in his cell shortly after 8.20 pm. At 9 pm, an Officer
Support Grade noticed that his cell light was out as he made his rounds. He
knew of the man’s request and believed that he had probably settled himself
down for the night.
5. At 9.32 pm while making his rounds, the OSG flicked on the man’s cell light to
check on him. He could not see him in the main part of the cell, but when he
looked into the toilet area he saw him hanging from the light fitting. The alarm
was raised and the cell entered. The man was cut down and staff started
Cardio Pulmonary Resuscitation (CPR). An ambulance was requested but
there was a delay in getting through to the emergency services. CPR was
continued until the paramedics arrived at 10.10 pm.
6. the man left Glen Parva at 10.35 pm and was taken by ambulance to the
Leicester Royal Infirmary where he was pronounced dead at 10.55 pm.
1
Investigation Methodology
7. The investigation was opened at Glen Parva on 24 August 2005. The
Governor and his staff produced the man’s core record and a large number of
other documents for examination. Notices were distributed around the
establishment notifying staff and prisoners of the investigation.
8. A number of prison staff were formally interviewed on tape. Interviews were
also held with several prisoners, but these were not taped at their request.
9. My investigator liaised with the officers from Leicester Police who were
conducting an enquiry on behalf of Her Majesty’s Coroner.
10. Her Majesty’s Coroner was contacted to inform him 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 with his enquiries
into the man’s death.
11. One of my Family Liaison Officers, contacted the man’s family to inform them
about my investigation. On 15 September, my investigator and the FLO
travelled to Leicester to meet with them at the man’s brother’s house. My
investigator summarised the events surrounding the man’s period in custody
at Glen Parva and his death, as he had discovered during his investigation so
far. He was able to clarify a number of matters for the family and noted some
concerns that they had. One of the matters raised was that they had been
told that the man had been assaulted in the showers by a group of prisoners
from the Bestwood area of Nottingham. My investigator spoke to the officer
who had told the family of the incident. The incident was apparently less
violent in nature than the family had believed and had not happened recently.
2
The man
12. He was born in Nottingham on 24 August 1985. When he was 11, he
discovered that his ‘mother’ was not his birth mother and linked his temper
control difficulties at school to that time. The man was permanently excluded
from his school before he took his exams.
13. He had been convicted of a number of minor drug and driving offences and
had previously been in Young Offender Institutions on two occasions.
14. The man’s family described him as a very neat and ordered young man who
took a lot of pride in his appearance and surroundings. Whilst the man was at
Glen Parva, he requested and was given paint to spruce up his cell. He had
an argument with an officer because a routine cell search had left it untidy just
after he had tidied it.
15. The man had been in a relationship with his girlfriend for about a year and
they had been living together for six months. Since he had been remanded
into custody, his girlfriend had, according to his family, been keeping in
contact with him inconsistently. They believe it was an attempt on her part to
‘play with his head’. After the man’s death, rumours were circulating in Glen
Parva that his girlfriend was pregnant by another man and there was
speculation that he had heard that before his death.
16. The man’s family said that they believed that he had not intended to take his
life but that it was a cry for help. He was only 19 years old when he died.
3
HMYOI & RC Glen Parva
17. Glen Parva was constructed in the 1970s as a borstal and has always held
young offenders. It now serves a catchment area of over 100 courts, holding
a mixture of sentenced, unsentenced, and remand prisoners. It has an
operational capacity (maximum crowded capacity) of over 800.
18. In the Prison Performance Ratings for the first quarter 2005/06, Glen Parva
has a level three rating (out of four). That level is defined as: ‘Meeting the
majority of targets, experiencing no significant problems in doing so,
delivering a reasonable and decent regime.’
19. During the time that my investigators were at Glen Parva, they witnessed
friendly and respectful interaction between staff and prisoners. The
introduction to the December 2004 inspection report by Her Majesty’s Chief
Inspector of Prisons ends with the following: ‘Glen Parva, at the time of the
inspection, was an establishment on the move: indeed, there was discomfort
among some staff about the pace of change. Other staff, however, clearly
welcomed the opportunity to develop new skills and ways of working.
Managers had taken a systematic approach to the task: building on the
considerable strengths of a relatively safe and ordered environment, while
increasing the opportunities for young prisoners, and developing and
supporting the role of residential staff. These are the key building blocks for
an environment which can begin to tackle the persistently high re-offending
rate among this age group.’
20. There had not been a death at Glen Parva for almost five years prior to July
2005. In July, another young man took his own life, although the issues
raised by this man’s death are not similar.
4
Events prior to the man’s death
21. Rotherham Magistrates’ Court remanded the man into custody for burglary on
8 April 2005. He was sent to HMP and YOI Doncaster, which is privately run
by Premier Prison Services Ltd. There were no indications of him being at
risk of self-harm in the answers he gave to the questions posed during the
First Reception Health Screen either at Doncaster or later at Glen Parva.
22. On 5 May, a drugs dog gave a positive indication to the man’s visitor which
resulted in a closed visit.
23. He appeared at Nottingham Magistrates’ Court on 6 May, further charged with
conspiracy to commit burglary and theft. He was remanded into custody and
taken to Glen Parva. After an appearance at Rotherham Magistrates’ Court
on 13 May regarding the original burglary matter, he was remanded to
Doncaster again.
24. The man began to get into conflict with the staff at Doncaster. On 15 May, he
was late to his door and was reported as having a bad attitude when
challenged. On the same day, he was caught associating in another cell.
Two days later, he received a formal warning for his bad attitude and for
swearing at an officer. On 3 June, the man became abusive to staff when he
was told to go outside on exercise and had to be escorted out. The following
day, he was on the phone when he should have been outside, late to his door
at lunchtime lock-up, and in the servery when told not to enter. He was given
a formal warning. Three days later, he was given another formal warning for
continuously being late to his door. On 9 June, the man was caught trying to
open a waiting room door with his ID card before going to court. He was
given another formal warning but continued to be disrespectful to the escort
staff en route to court.
25. At Rotherham Magistrates’ Court on 9 June, the original charges were
dismissed. He returned to Doncaster and was placed on basic regime. On 9
June, the man closed his cell door on an officer’s arm. He was placed in the
Violence Reduction Unit on 17 June. It appears that he was well thought of
on that unit, being referred to as a very polite young man in a number of
entries on the file.
26. He appeared at Nottingham Magistrates’ Court on 27 June and was
remanded to Nottingham Crown Court for trial. He returned to Glen Parva,
telling staff that he was happy to be there. He was housed in a double cell in
Unit 12.
5
27. On 8 July, the man pleaded guilty at adjudication to using threatening,
abusive or insulting words or behaviour towards a member of staff. His
punishment of loss of 50% of his earnings and loss of canteen facilities was
suspended for three months. On 18 July, he pleaded guilty to a similar
charge. On that occasion, his punishment was loss of 75% of earnings for 14
days, and forfeiture of canteen, association and TV privileges for 14 days.
28. On 12 July, the man was removed from the gym for two weeks for
continuously upsetting the session. The entry in his personal record adds,
‘very poor attitude, behaviour needs to change to have any consistency in the
gym’.
29. On 19 July, the man was overheard by a member of staff to say to another
prisoner, “Are you ready if those Iraqis start?” On 20 July, he put in a
complaint stating that, on 17 July, five prisoners approached him in an
aggressive and threatening manner. Also, that on the 18 July, after
witnessing an assault on an Iraqi prisoner, an Iraqi prisoner came to his cell
and told him that the ‘Iraqi lads’ were going to change his face. The assault
he was referring to involved some aggressive verbal posturing by a prisoner I
shall call Y, towards a prisoner of Iraqi appearance, backed up by other
prisoners, including the man. The man’s cellmate then threw hot water over
the Iraqi man. As a post script, the man who is the subject of this report
added that he could not go to the Muslim service for fear of trouble and
therefore he was unable to pay his respects as a Muslim.
30. The man was interviewed on 22 July and told the officer that unidentified
Muslim prisoners were preventing him from attending Muslim prayers by
threatening him. He admitted that he had not applied to attend Muslim
prayers. The man’s declared religion was Church of England but the officer
told him that he could apply to change his religion and that applications to
attend Muslim prayers were taken on Fridays.
31. On 25 July, it was noticed during breakfast that the man’s new cellmate had
felt pen drawn on his face and neck. The man found it highly amusing saying
he had done it for a laugh, but his cellmate was very distressed. The man
was moved to another cell on his own and placed on the second stage anti-
bullying scheme. Stage two of the scheme is designed to encourage
prisoners to alter their behaviour through target setting and personal/landing
officer intervention. The man’s attitude improved over the next few days and
he was removed from the scheme on 5 August.
32. On 14 August, an entry in the man’s personal record states, ‘Refusal to speak
to staff and immature attitude’.
33. On the morning of 18 August, another prisoner who was a friend of the man’s
asked to be put into the cell with him as he thought the man was feeling ‘a bit
6
down’. The prisoner was told to put the request in writing as required by the
procedure. The officer, of whom the request was made, believed that it would
have been unlikely that the two would have been allowed to share as they
both had been perceived as engaging in bullying.
34. That afternoon, as the man was walking to his visit with his brother and his
brother’s partner, he asked an instructional officer in workshop four, to try and
get him into the workshop the following day. The officer asked the man if he
was alright and he replied that he was. The visit went well and his brother
left, believing the man to be in good spirits and having no concerns about his
well being or mental state.
7
Events surrounding the man’s death
35. At about 7.45 pm on 18 August, the man asked to speak with a Listener. An
officer put an entry in the unit observation book at 8 pm as follows: ‘the man
has asked to see a Listener, seems very down and reluctant to speak. Has
been told that Listener is not available until morning. Declined Samaritans
phone and wishes to see Listener in morning. Needs to be observed regular
intervals during tonight. In morning must see Listener on another unit not
ours.’ The last was underlined, and then the following was written in red,
‘Asked directly if he will self harm or kill himself and the man replied, “No”.’
36. The officers on duty had concerns about the man’s request. The Listener on
the unit was apparently being threatened over a debt his brother owed. The
person suspected of making the threats was prisoner Y. The subject of this
report was thought to be part of prisoner Y’s group and it was feared that the
request to see a Listener was a means of being alone with that particular
prisoner. As a result of those concerns, attempts were made to move the unit
Listener off the unit and bring in two from another unit. At the same time, he
was offered the use of the Samaritans phone, which he declined. The man
agreed that he would wait and speak with a Listener in the morning. During
later interviews, staff said that the man appeared to be his normal self and
that they had no concerns that he would self-harm in any way.
37. The officers considered, but decided against, opening an ACCT document.
This is a document that is opened when there is concern that a prisoner may
self-harm or has suicidal thoughts. Prisoners on an open ACCT document
are observed at intervals and a multidisciplinary team reviews their cases on
a regular basis. (There can be many reasons why a person would ask to
speak with a Listener and not just because they are at risk of self-harm. A
number of officers said in interview that they believe there are times when the
scheme is abused by the prisoners making the request to see them.)
38. The night OSG came on duty whilst the above decisions were being made.
He was aware of the request that the man had made and the final decision
that he would see a Listener in the morning. He checked the man in his cell
as part of his routine landing checks, probably between 8.20 and 8.40 pm, but
nothing stood out as unusual. The OSG patrolled the landings again shortly
after 9 pm, and noted that the light was off in the man’s cell but did not think it
unusual.
39. At 9.32 pm, the OSG was again outside the man’s cell. He flicked on the cell
night-light and looked in. He could not see him in the main area of the cell, so
he looked into the toilet area. He saw the man by the toilet but he appeared
8
lower than if he was using it. He put out an emergency call over his radio and
then kicked the cell door a couple of times but got no response from him.
40. The Senior Officer was in the healthcare unit at the time of the call, a nurse
who was with him called up on the radio to ascertain if medical assistance
was required. When that was confirmed, both the SO and the Nurse made
their way to unit 12. Meanwhile, other officers had arrived at the cell. Three
officers arrived about a minute after the emergency call. One officer opened
the cell and they entered. They saw the man hanging from the light fitting in
the toilet area, suspended by a torn bed sheet. His weight had pulled the light
fitting away from the ceiling, although the wiring was still intact.
41. The first officer cut the ligature whilst the other officers supported the man’s
weight. An officer felt for a pulse and believed he found one although the
man’s eyes did not react when touched. One of the other officers thought that
the man was breathing, so they put him into the recovery position. The nurse
arrived with the SO at that time. She placed a pulse monitor on the man but
there was none. Nor was he breathing. She told the SO to call the duty
doctor and an ambulance. The nurse and the first officer then began cardio
pulmonary resuscitation. Another nurse arrived shortly after and took over
the CPR from the officer. The first nurse attached the defibrillator that her
colleague had brought from healthcare. The machine instructed that CPR be
continued, which it was, until the paramedics arrived at 10.10 pm. The duty
doctor arrived a few minutes later. The doctor and the paramedics rotated
CPR and the paramedics set up an intravenous line and administered
medication in an attempt to restart the heart.
42. There had been confusion and difficulty in contacting the emergency services
system that resulted in a delay in the arrival of the ambulance. The staff at
the gate were dialling 9999 but were getting an engaged tone. Eventually the
officers managed to contact the local police and the ambulance service was
contacted.
43. At 10.35 pm, the man left Glen Parva in the ambulance and was taken to the
Leicester Royal Infirmary where he was pronounced dead at 10.55 pm.
Events after the man’s death
9
44. The police were contacted with a view to notifying the man’s next of kin of his
death. (his family lives in Nottingham; Glen Parva is around 30 miles away,
just to the south of Leicester.) The man’s father was notified and had already
passed the news to the man’s stepmother and brother by the time the police
contacted them.
45. In the man’s cell, officers found a piece of burnt letter, a crumpled letter, a
recently received letter from a girlfriend of a friend, and a writing pad which
may have writing indentations on. The investigating police team took the
originals of all of these. The piece of burnt letter bears the following hand-
written script, ‘my last word’s to my dearest bro matt I carnt tack this cold
would’ (sic).
46. All of the staff involved attended a hot debrief between 1.35 am and 2.15 am.
The purpose of a hot debrief is to give staff the chance to talk through what
has occurred. Staff were offered the services of the prison’s Care Team.
Later that morning, notices were issued to inform both staff and other
prisoners of the man’s death. The prisoners on open ACCT documents were
reviewed and the Samaritans came in later in the day to speak with the
Listeners.
47. The Governor spoke with the man’s brother by telephone that morning and
offered any support needed. When my investigator met with the family they
said that they were happy with the response from the prison.
48. The Governor also wrote individually to the officers involved, thanking them
for their efforts in trying to revive the man. The Governor visited the family a
few days later, when he agreed to pay for the funeral expenses and arranged
for the family to visit the prison.
49. The difficulty experienced by the gate staff contacting the emergency services
was investigated by a Principal Officer. It appears that as the officers were
dialling the 9999 number from the gate they were in fact trying to dial their
own telephone. The confusion arose as the staff believed that they had a
direct dial facility, which they did not. The Governor issued a notice to staff
on 19 August informing them of the correct procedure to use to contact the
emergency services.
Clinical review
10
50. A doctor was asked to complete a clinical review by the South Leicestershire
Primary Care Trust. I am grateful for his report.
51. He concludes that the man’s presentation at 7.45 pm on the night he died
was an opportunity to initiate an ACCT document. He notes that, had the
document been implemented, then the 9 pm check would have been a direct
visual check and the man’s actions discovered earlier.
52. Attention is drawn to the habit of issuing notices to prisoners informing them
about a death. The doctor suggests that too much information could lead to
‘copy-cat’ attempts and refers the reader to a report in the British Medical
Journal in 1999.
53. The doctor comments on the fact that a prisoner’s medical record does not
follow the prisoner to the prison from their General Practitioner. He also
notes that it is recognised as good practice to inform the GP practice of a
patient’s death. In this case, when the doctor contacted the surgery in late
September it was the first official confirmation of his death they had received.
54. He makes a number of recommendations at the end of his report and also
draws attention to good practice he found during his review.
Findings and conclusions
11
55. During his time in custody, the man had the reputation for being disruptive
and someone who tended to associate with the ‘wrong crowd’. When, on the
evening of 18 August, the man asked to see a Listener there were concerns
about his motives. He had not presented as a person in crisis. In fact, his
brother - who had seen him that afternoon - believed him to be in good spirits.
In addition, one of the young men whom the man associated with (prisoner Y)
was suspected of bullying the Listener on their unit.
56. The staff took the man’s request seriously but for security reasons would not
allow him to be put in the cell with the unit’s Listener. They told the man their
decision and offered him the use of the Samaritans phone for the night, which
he refused. At the same time, they had told the unit’s Listener to prepare to
move to another unit whilst they rang around to arrange for an alternate
Listener. He was asked outright if he was going to self-harm or kill himself
and he said that he was not. At that point, the man agreed that he would wait
and see a Listener in the morning. The staff did not consider his situation
warranted the opening of an ACCT document. The officer who spoke with the
man was a trained ACCT assessor although it was not suggested by the
officer that he had conducted a full ACCT assessment during the brief
conversation at the cell door.
57. I acknowledge the clinical reviewers view that, had he been on an ACCT
document and checked at 9 pm, his actions might have been discovered
earlier. However, neither man’s family, nor the staff who saw him on a day to
day basis, believed that his mood had dropped to a level where he was at risk
of self-harm or would consider taking his own life.
58. When the OSG put out his emergency call, it was not clear whether medical
assistance was required. A number of establishments have introduced a
coded radio system to add clarity to emergency calls. Consideration should
be given to introducing such a system at Glen Parva.
59. A delay in being able to summon an ambulance to the prison could have
serious consequences but, the clinical reviewer noted, this was not the
situation in this case. Senior management at Glen Parva reacted swiftly to
rectify the situation and I commend their actions. Nevertheless, I recommend
a full review of their emergency response to ensure a robust system is in
place.
60. The clinical reviewer calls attention to the fact that the man’s death was not
officially notified to his GP’s surgery. Now that the majority of prison
healthcare is either provided or commissioned by the local Primary Care
Trust, there is the opportunity for much closer liaison between a prisoner’s GP
surgery and prison healthcare. Certainly, I believe that it should be possible
for a prisoner’s GP to be informed of his or her death. More positively, I also
12
hope that a prisoner’s GP medical record can be made available to prison
healthcare, more frequently and more speedily than is currently the case at
present.
13
Recommendations
Operational
1. The Governor should ensure that all staff are aware of the correct
methods for contacting the emergency services and consider a full review
of the emergency response procedures to ensure a robust system is in
place.
Health
2. The Governor in conjunction with the PCT should consider the introduction
of a coded emergency call system to aid clarity during a medical or other
emergency situation.
3. The PCT in partnership with the healthcare manager should ensure that
there is a robust system in place for timely information sharing amongst
health and social care agencies.
4. The Governor should take steps to ensure that the prisoner’s GP is
notified if he dies in custody. Prison Health should also consider
implementing a similar policy across the estate.
14