Individual at Glen Parva

Circumstances surrounding the death of
a young man
at HMYOI Glen Parva in July 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2006
This is the report of an investigation into the circumstances surrounding the death on
28 July 2005 ofa young man, apparently by his own hand, in a cell he shared with
another prisoner at HM Young Offenders Institution Glen Parva. He was just19 years
of age.
The young man was foundby his cellmate just before 8pm. He was hanging from
ventilation holes in the door of his cell. Training shoelaces had been fashioned into a
noose and wrapped tightly around his neck. The young man had given no indication
that he might take his own life. He left anundated letter, probably written just before he
died, to his twin daughters.
I offer my sincere sympathy and condolences tohisfamily who have suffered the tragic
loss of a much­loved member of their family. Thefamily is closely­knit and I know they
will always mourn hisdeath. Staff and prisoners at Glen Parva share their feeling of
loss and incomprehensionthat the young man, who to all outward purposes seemed to
be coping well in prison, apparently took his own life.
At the time of his death,the young man was serving a sentence of 15 months
imprisonment in addition to completing an earlier sentence of 30 months imprisonment,
from which he had been released early on licence. The licence was revoked when he
committed further offences. At the time of his death, the young manhad been at Glen
Parva for about two months. He had been there on a previous occasion and was well
known to staff.
The investigation was carried out byone of my investigators. A comprehensive clinical
review on behalf of the South Leicestershire Primary Care Trust, for which I am
grateful. My thanks go also to the Governor and all staff at Glen Parva.
I make two recommendationsof my ownin section 9 of this report, and draw attention
to four of those in the clinical review. In the tragic circumstances giving rise to this
investigation, I have also been pleased toidentify threeareas of good practice in
respect of the exemplary actions of four members of Glen Parva staff.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2006
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Summary
The young man was born in Ireland. His family moved to Peterborough when he was
four years old, and he was brought up there. Immediately before being sent to prison,
he was living with his partner and mother of his twin baby girls. It was clear from
telephone conversations just before he died that it was unlikely thathe would return to
that home. Without doubt though, he could have returned to live with either his parents
or other members of his extended family, to whom he was very close. They supported
him throughout his sentence. Their letters were many, and consistent in their affection
and commitment to help him get back on his feet.
The young man’srelationship with his partner, in the four years they weretogether,
was variable. His parents told my investigator that it was ‘on and off’, and that,
following arguments,he would move out of the family home, returning some time later
when the pattern would repeat. The young mandrank heavily and alcohol always
played a part in his offending. He was often in trouble with the police, and from 2001
had been the subject of several sentencesin the community and in custody.
The circumstances leading to the sentence whichthe young man was serving when he
died arose when in May 2004 he was sentenced to 30 months imprisonment for an
offence of affray. He was released early from that sentenceon licence, in January
2005. In March, he committed another offence of affray and his licence was revoked.
In May,he was sentenced to 15 months imprisonment, to run consecutively to the
unexpired part of his earlier sentence. He was dueto be released from prison in
January 2006.
The young man was well known at Glen Parva and, although he was capable of
showinghis frustration, staff thought well of him, describing him as ‘quiet and
respectful’. He worked as an orderly in the wing laundry and was trusted to get on with
his work. He wrote and received many letters, and was in constant touch by telephone
with family and friends who visited him regularly at the prison. He committed no
misdemeanours, and to all intents and purposes was quietly serving his sentence.
Things changed somewhat in the days leading tothe young man’s death. His
relationship with his partner came to an end. Transcripts of telephone conversations,
recovered later, show that she instigated the separation and thatinitiallyheappeared
to accept the position. Telephone calls to his sister and to his mother during the two
days before he died paint a different picture, withthe young man asking questions
about his partner’s whereabouts and details of her new boy friend. On the evening he
died, in a final call to his mother he said, ‘I can’t do this no more.’ Within an hour or so
of that telephone conversation, the young man was found hanging in the cell they
shared by his cell­mate.
The young man had givenno indication to either staff or prisoners that he was about to
take his life. His cellmate remembers the daythe young man died as being a
particularly good one, and he shared the view of staff that, of all prisoners,the young
man was amongst the least likely to harm himself.
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It is not possible to say what was inhis mind when he tied the shoelace around his
neck. The transcripts of his last telephone calls show that he was more upset at the
break up of his relationship than he revealed to either staff or his cellmate. The letter
he wrote to his children shows also that he thought he had failed them as a father and
that he had little hope for the future.
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Investigation methodology
1. The investigation was opened on 4 August, when my investigator met with the
Governor, Safer Custody Manager, and other staff at Glen Parva. He was given a
full and very helpful briefing by the Governor on the events leading up to and after
thedeath. Ombudsman’s notices, identifying the scope and methodology of my
investigation, were issued to staff and prisoners. The notices also made clear that
staff or prisoners who wished to see the investigator should make themselves
known by contacting the liaison officer at the prison or by contacting my office direct.
Staff and prisoners in key positions or locations were identified and invited for
interview. All responded willingly. The local branch of the Prison Officers’
Association (POA) were briefed. They were helpful and offered constructive
comment and advice. In a follow­up visit, my investigator spent a full day visiting all
parts of the prison, talking to staff and prisoners, and observing the interaction
between them.
2. My investigator met with the Chair and one other member of the prison’s
Independent Monitoring Board (IMB). Their contribution was valuable, particularly in
their description of many prisoners at Glen Parva being some distance from their
homeson account of overcrowding in their local areas.
3. My investigator met local police at the prison. They shared freely all their
information and interview records, as did the coroner’s officer.
4. South Leicestershire Primary Care Trust carried out a clinical review.
5. My investigator, together with one of my family liaison officers met the young man’s
parents at their home. They were made to feel very welcome and learned much
abouthis life, his troubled state of mind and his unhappiness at the break up of his
relationship with the mother of his children.
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HMYouth Offenders InstitutionGlen Parva
6. Glen Parva, built in the early 1970s, started life as a borstal institution. Following
the abolition of borstal training, Glen Parva took on the role of a young offenders
institution, holding 800 young people, both convicted and unconvicted, and serving
a large catchment area of more than 100 courts. It is an extremely complex and
busy place.
7. All prisoners spend their first six nights in an induction unitbefore moving to
accommodation and activity designed to address work, training and offending
behaviour needs. The gaol’s design and standard of accommodation is acceptable
by the standards of over 30 years ago. Things have moved on, however, and grilles
in front of windows restrict entry of light. They also provide easy ligature points, as
do the ventilation holes on the inside of cell doors.
8. In a full announced inspection in October 2004, Her Majesty’s ChiefInspector of
Prisons noted that Glen Parva held a large number of potentially volatile young men
and was in the process of considerable change. Although her report found
shortcomings in education and noted the lack of an effective personal officer
scheme, it identified that many staff were embracing change. Senior managers had
a systematic approach to progress, and Glen Parva was a fundamentally safe
establishment with good work going on with some of the vulnerable and disturbed
young peopleit holds.
9. The Chair of the Independent Monitoring Board (IMB) told my investigator that Glen
Parva was running well in difficult circumstances. The IMB had a good relationship
with the Governor and his staff, and they felt their questions, observations and
concerns were given full weight when brought to the attention of senior managers.
The man was not known to the IMB. He had made no formal requests to them, nor
had he otherwise come to their attention. They were notified promptly of the young
man’s death and the Chair visited the unit wherehehad died. She also attended
the debriefing meeting held the day after he died and noted that all procedures were
followed in accordance with Prison Service instructions. The IMB felt that, 'The
incident was handled in a professional and sympathetic manner with all staff
working hard as a team in very unfortunate circumstances.’
10.Suicide and self­harm procedures at Glen Parva are good. The prison has adopted
recently the Assessment, Care in Custody,Teamwork (ACCT) system of managing
those prisoners at risk of suicide or self­harm. At least 94 per cent of staff have
been trained in the new procedures. Notices and other literature, notably in respect
of access to Samaritans and ‘Listeners’ (prisoners trained by Samaritans to befriend
other prisoners who are feeling low, and who prefer to talk to someone like
themselves) are widely displayed and available throughout the prison. The suicide
and self­harm committee meets monthly, has a full and appropriate agenda and is
well attended by staff, prisoners, and Samaritans.
11.In his follow­up visit to the prison, my investigator noted that staff and prisoners
talked freely to each other. The atmosphere was good and relaxed, if businesslike.
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Glen Parva is a complex establishment, and incidents of disruption occur daily.
Many young prisoners are active butnot always cooperative. Incidents are handled
efficiently, sensitively and with the minimum of fuss by staff. A family liaison officer
works in the visits hall and encourages family and friends to talk to him, or tocontact
him at any time,if they have anxieties about members of their family or friends in
the prison. My investigator concluded thatGlen Parva is not perfect, but within the
bounds of what is possible the Governor and staff work hard to give young people a
chance to make life­changing decisions.
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Key findings
12.In May 2004,the young man was sentenced to 30 months imprisonment for an
offence of affray. He was releasedearly from that sentence on licencein January
2005. In March, he committed anotheroffence of affray and his licence was
revoked. He was sentenced in May to 15 months imprisonment, to run
consecutively to the unexpired part of his earlier sentence. He wasdueto be
released from prison in January 2006.
13.Following the revocation of his licence,the young man spent two months at HMP
Peterborough. Following his conviction and sentence in May for the new offence,
he was transferredto Glen Parva, effectively serving a combination sentence (the
part outstanding on the old one, and the newone of 15 months). He did not seek
the move to Glen Parva, but Peterborough, which isa busy local prison, must make
space for new arrivals. Given the length of his sentence, it was inevitable thathe
would transfer to Glen Parva, the training prison within the catchment area.
14.The young man appeared to settle well at Glen Parva. He had been there before
and knew many members of staff. They in turn knew him as a steady, likeable
young man and anticipated that he would simply get on with his sentence and work
towards his release. Althoughhis parents said he had made an application to return
to Peterborough, there is no evidence of arecord of such a request. The young
man was a popular young man amongst his peers and seemed comfortable
enough, given the circumstances in which he foundhimself.
15.A Senior Officer, who workson Unit 2, knewthe young man well. The Senior
Officer has worked in Glen Parva for 15 years. Consequently he has long
experience of young men in custody. He describedthe young manas a prisoner
who behaved himself and was popular with other prisoners and prison staff. The
young man worked as unit laundry orderly, a position which reflected his good
behaviour and trustworthiness. He seemed to be getting on well with his sentence.
Although the Senior Officer was aware the young manhad fallen out with his
girlfriend, he had not seen him upset. He felt that,of all the prisoners in his care,
the young man was the one he would consider least likely to commit suicide. This
reflects the general perception amongst members of staffthathepresented alow
risk of self­harm.
16.Similarly,the young man’s cellmate noticed nothing untoward. He said that the day
hedied had been a particularly good one. He too was shocked, surprised and
dismayed that the young man, the most unlikely of people, should have taken his
own life.
17.The young man made four significant telephone calls in the two days before his
death on 28July. My investigator obtained transcripts. (All telephone calls from
prisoners are recorded. Prisoners and those who are telephoned are notified by a
voice warning when a call is connected. Few calls are monitored, although staff
have the ability to listen to them at the time or later. In practice, a random small
percentage is monitored. In addition some calls are targeted and monitored as a
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result of securityintelligence. He was a sensible and responsible young man in
prison and there was no reason for staff to monitor his calls.)
18.On 26 Julyat about 6.30pm, two days before his death,the young mantelephoned
his mother. The conversation was fairly straightforward. The young manasked
about his family, particularly his sister who had a new baby. He mentioned, almost
in passing, his partner, asking about her and where she might be. The conversation
then moved to his father’s painting of the kitchen at home. Later, at about 7.30pm
that evening he made a call to his partner where they discussed their relationship
and agreed to split up. It washispartner who instigated the separation, heinitially
appeared to accept the position. He asked her if she had found someone else.
She repliedthat she had not, and that she did not want anyone else. The young
man had his suspicions, however, and saidhe would kill any new boyfriendeven
though his partner said there was no­one. The young man’s main concern at that
time appeared to be the welfare of his twin girls.
19.On 28 July, the evening he died, the young mantelephoned his sisterat about 6pm.
He told her he had received the photographs of her new baby and then asked about
his partner. He told his sister that she had, in his words, ‘split up with me’, and he
asked where she was. His sister said that her mother had asked her not to tell him,
but his partner now had a new boy friend whom she named. The conversation
ended abruptly at that point. Ten minutes later, at 6.15pm, the young man
telephoned his mother. He was anxious and said,‘I can’t do this no more. I can’t
do this anymore. I ain't strong enough. His mother tried to cheer him up, buthe
became tearful. She asked him to send a visitingorder so that she and his father
and sister could visit him, but he continued in much the same vein, telling his mother
that he loved her and his father and the children and to tell the children that he was
sorry. The young man’s mother continued to try to cheer him up but he kept
repeating ‘I love you.’ The warning ‘pips’ were heard on the line, and the call
disconnected. The young manreturned to his cell where he had stayed throughout
much of that evening’s recreation period.
20.Just before 8pm, the young man’s cellmate returned from a period of recreation to
find him hanging from the ventilation holes above the door. He raised the alarm and
staff arrived quickly. The first officer to arrivecut the shoelace by which the young
man was suspended and along withanother Officer started resuscitation
procedures. A Senior Officer almost immediately took over. Urgent medical
assistance was requested and an emergency ambulance was called. Two nurses
arrived quickly with resuscitation equipment and a defibrillatorfrom the Healthcare
Centre. One nursetook over the resuscitation with the firstOfficer and continued
until the arrival of paramedics and the doctorof the prison medical staff at 8.13pm.
The ambulance left at 8.33pm. the young man was taken to Leicester Royal
Infirmary where a hospital doctor certified him dead at 8.52pm.
21.A note, apparently written by the young man to his daughters, was found in the cell.
It was retainedas evidence until police arrived and took possession of it.
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Followingthedeath
22.Thecell was sealed. Police arrived at 8.55pm and took control of the area. They
took the notethe young manhad written to his children and the coroner’s officer
made the preliminary investigation necessary for the coroner’s inquest.
23.At 8.55pm, the prison asked the police to visitthe young man’s partner, who had
beennamed byhimas his next of kin, ather home. Her home is a journey of about
one and a half hours from the prison. The police made the visit, and hispartner
passed on the sadnews to the young man’sparents who telephoned the prison for
information. AGovernor returned their call and gave them the information available
at that time. He visited them at their home a few days later, and theysay the visit
was helpful. The Governor made arrangements for the prison to pay the young
man’s funeral expenses. Hispartner, together with her sister and her mother,
visited the prison and met the governor, the family liaison officer, and Sister Theresa
of the chaplain’s team. A memorial service, attended by prisoners and staff, was
held at the prison for the young man.
24.All other actions set out in Glen Parva’s contingency plan were taken. An
immediate review of prisoners subject to ACCT was conducted. A debriefing
meeting was held and attended by staff and the IMB Chair. Samaritans visited the
prison and offered support to staff and prisoners. The prison care team was
mobilised and saw every member of staff who had been involved in trying to save
the young man’s life.
25.AConsultant and Home Office Pathologist, carried out a post mortem on 1 August
2005 at Leicester Royal Infirmary. He identified the cause of death as suspension
by a ligature around the neck.
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Clinical Review
26.AGeneral Practitioner and Clinical Governance Advisor to South Leicestershire
Primary Care Trust, conducted the clinical review. It was completed on 14
November 2005. The doctor found that Glen Parva employed all appropriate
current procedures, with no major omissions, in attempting to savethe young man’s
life. Inthe doctors opinion, having regard to the post mortem report’s finding that
the young manhad died from vagal inhibition as distinct from asphyxiation, staff
could not have saved him.
27.The doctorcommented more generally that in his view section 1.3 of the first health
reception screen process was not searching or detailed enough in its intention to
establish mental health history. He recommended that medical records should be
sourced from General Practitioner’s records at the time prisonersare received into
prison. He recommended that staff should re­accredit every three years their
certificate in first aid. He also recommended that the Prison Service should give
consideration to the routine monitoring of prisoners’ telephone calls.
28.The doctorconcluded that the young man’s action was probably the result of an
acute and impulsive reaction to the news that his partner had taken another boy
friend.
29.Three areas of good practice were identified.
The response of staff and their strenuous efforts to resuscitate the young man were
both professional and timely.
The prison has clear procedures relating to dealing with deaths in custody and these
were followed appropriately.
Prison staff were very open and co­operative in the conduct ofhis enquiry.
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Conclusions
30.On the face of it,the young man was living his life normally in prison. He had been
to prison before and knew what was required. He had good support from all
members of his family who wrote many letters to him and who visited him in prison.
Healso had many friends amongst his peers. He was a likeable young man,
accepted as a good member of the prison community and had no obvious
problems.
31.Staff at Glen Parva had the same view. They knewhimwell as a member of the
prison wing on which he lived. He caused no anxiety, did not get into fights or
scrapes and committed no infringements of the rules. He was trusted to get on with
his job as anorderly. Although one member of staff learned that the young man
had fallen out with his partner, his assessment was that hedid not appear unduly
distressed by the change in his circumstances.
32.The single eventthatappears to have knocked himoff balance probably happened
two days before he died when he telephoned his partner and realised that their
relationship was over. He learned also on the night he died that his partnerhad
another boy friend. It may be inferred that he became more and more frantic and
distressed. His final telephone call to his mother, an hour or so before he died,
found him in tears and without hope.
33.The young man gave no indication to prison staff or to his cellmate that he was
considering taking his own life. He was capable,by his mother’s account, of
‘bottling up’ his problems. It is impossible to say what was in his mind when he tied
shoelaces around his neck. It may be that the all­consuming regret at the loss of his
relationship led him to feel that he had no future to which he could look forward.
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Recommendations
1. Grilles should be removed from cell windows at Glen Parva. They severely
restrict available light, they are depressingly ugly and they provide obvious
and easy ligature points.
Not accepted: The young man was not located in a safer cell as he was not thought
to be at risk. There are currently 600 cells with these grilles at Glen Parva. The
fixings are tamper proof and would need grinding off, this would take approximately
eighteen months and have huge cost implications.
2. An alternative should be found to the ventilation holes inside the cell doors.
As with the window grilles, they provide obvious and easy ligature points and
were used bythe young manto suspend himself.
Not accepted: These type of doors can be found in a lot of establishments and to
replace all of them in ‘normal location’ cells would have huge cost implications.
I also support the followingrecommendationsof the clinical review:
3. Where possible, old prison medical records should be available at the time of
admission for review or requested as a matter of urgency and reviewed on
arrival.
Partially accepted: Medical records are not held centrally and would be held in the
last establishment that the prisoner was held. Medical records should be requested
within 24 hours.
4. All staff should receive appropriate and timely resuscitation training, which
should be documented and reviewed regularly.
Partially accepted: Currently we adhere to the appropriate number of staff being
trained in First Aid, meeting H&S regulations. All new recruits to the Prison
Service are trained in Heart start which is basic resuscitation. Locally we have run
two courses in Heart start for established staff.
5. Life support equipment should be regularly checked and where necessary be
covered by a regular maintenance contract. Records of these checked
should be kept.
Accepted: All three machines will be covered by HCE maintenance contract.
Records will be checked as an agenda item on the Clinical Governance meeting.
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Good practice
6. Staffshould be commendedfor their valiant and sustained efforts to savethe
young man’s life.
7. TheSenior Officer shouldalso be commended. Despite notbeing directly
involved in helpingthe young man, she stayed inGlen Parva until after
1.30amtosupport staff. She later drove one of them home and provided
overnight accommodation for yet another. Her support for her colleagues
was in the highesttraditions of the service.
8. The Family Liaison Governor showed sensitivity and thoroughness in his
dealings with the young man’s family. He is to be commended for the
obvious care and concern he puts into his work as Safer Custody Governor
at Glen Parva.
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