Individual at Guys Marsh

Circumstances surrounding the death of
a man on 20 September 2005,
following his release from
HMP Guys Marsh the previous day
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2006
This report concerns the death of a man on 20 September 2005, a day after his
release from HMP Guys Marsh. The man was pronounced dead after being found in
a multi-storey car park in Swindon.
The investigation was conducted in line with my discretionary power to investigate
deaths after release. I exercise that power when issues about the care offered by a
prison appear to be raised. In addition, a valid interpretation of the investigative
obligation under Article 2 of the European Convention on Human Rights is that some
post-release deaths may require an independent investigation of the kind my office
carries out.
I wish to express my condolences to the man’s family and friends. I have been
grateful for the assistance I have received from the Governor of Guys Marsh and his
colleagues, from the Wiltshire Constabulary, and from others I have consulted. My
particular thanks are due to the Head of Safer Custody at Guy’s Marsh who acted as
my liaison point.
I have made a number of recommendations to be considered by the Prison Service.
(Following circulation of this report in draft, I was delighted to learn that all
recommendations had been accepted.) However, this investigation was most
significant for what emerged about the man who died and the use of Anti-Social
Behaviour Orders (ASBOs). The man had been made subject to an ASBO in
September 2003. He subsequently breached the Order on no fewer than seven
occasions – each of which led to short periods of imprisonment. Yet during that time,
I can find no evidence that the cause of those breaches – the man’s drinking problem
– was ever addressed. Nor does he appear to have had any contact with probation.
While I understand the public nuisance issues that gave rise to the imposition of the
ASBO in the first place, his story is an essay in the use of breach proceedings
against those whose behaviour is addictive in nature and the futility of so many short
prison sentences.
The post mortem found the cause of death to have been a combination of drug
abuse and a pre-existing cardiac condition. At the inquest on 9 August 2006, the
Coroner recorded an open verdict. Although the man was found with drug-taking
paraphernalia around him, it did not contain traces of his DNA and the exact
circumstances leading to his death are not known.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2006
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Contents
Summary 4
How I went about the investigation 6
The man who died 7
The man’s offending and sentencing record 8
Family contact 11
HMP Guys Marsh 13
The man’s two months in custody 15
Preparation for release 18
On leaving prison 21
The policy framework 23
Clinical review 26
Conclusions 27
Recommendations 28
3
Summary
The man who died was released from HMP Guys Marsh on the morning of Monday
19 September 2005 with a travel warrant to Swindon. He had told staff that he could
stay with his mother in Devizes and he had also been given the details of a hostel in
Swindon (although this had no free spaces). In effect, he was released homeless.
The man accompanied three other prisoners released that morning as far as Bath
Spa station. He had already started drinking. It is assumed that he then caught a
train for Swindon.
The following morning, police were called to a multi-storey car park in Swindon where
the man had been found. The man was pronounced dead where he was found. The
post mortem found the cause of death to have been a combination of drug abuse and
a pre-existing cardiac condition.
This investigation has focussed on the response to the man’s offending record – he
was subject to an Anti-Social Behaviour Order that he breached seven times in less
than two years – and on such preparation as was made for his release.
The clinical review is also critical of some aspects of the man’s care.
My report is structured as follows:
• I explain that, having previously visited Guys Marsh myself, I decided to
conduct this discretionary investigation personally.
• I make a recommendation regarding the notification arrangements of deaths
occurring after a prisoner’s release from custody.
• I offer some details of the man’s life, listing his convictions from 1986 onwards.
Details are given of the Anti-Social Behaviour Order imposed on 22
September 2003 and of the breaches of that Order over the following two
years.
• I draw upon comments from the man’s former solicitors and extracts from
probation reports.
• I detail what the man’s mother told my Family Liaison Officer about her son.
• Drawing upon reports from the prison’s Independent Monitoring Board and HM
Chief Inspector of Prisons, I give details of HMP Guys Marsh.
• I set out what is known about the man’s final two months in custody between
July and September 2005. There are very limited entries in the man’s records.
• I focus on such preparations as were made for the man’s release. I explain
the application that was made for a place in a hostel in Swindon. In fact, the
4
hostel had no spare places on the day of the man’s release. I note too that
the man received no other guidance from Guys Marsh pending his release.
• I give such details as are available about what the man did on the morning he
left prison (19 September).
• My report summarises and reviews Guys Marsh’s Drug and Alcohol Strategy
document, the CARATS Pre-Release Information Pack, and the Resettlement
& Reducing Re-offending Strategy Document.
• Noting that the man had no contact with probation from mid-2003, I conclude
that Anti-Social Behaviour Orders are not well designed for those whose
offences have their roots in addictive behaviour.
I make eight recommendations. A further six recommendations are made in the
clinical review.
5
How I went about the investigation
My office was informed of the man’s death by the Prison Service within an hour of his
body being discovered on the morning of 20 September. The head of Safer Custody
at Guys Marsh rang the Prison Service’s National Operations Unit having himself
heard of the man’s death from the prison’s Police Liaison Officer. There is currently
no guarantee that either a prison or the Ombudsman’s office will learn of deaths post-
release and I suspect that only a minority are referred to me. Given that the Article 2
investigative obligation may be engaged by such deaths, the absence of a proper
notification system is not satisfactory.
I recommend the National Offender Management Service reviews arrangements
whereby deaths of recently released prisoners are referred to the Prison
Service’s National Operations Unit and onwards to my office.
In the case of post-release deaths, I have a discretionary power “to investigate, to the
extent appropriate, cases that raise issues about the care provided by the prison”.
Given that the man had died only 24 hours after leaving Guys Marsh, I determined
that this was a case when it would be right to exercise that discretion.
Having recently visited Guys Marsh, I also decided to undertake the investigation
personally. I visited Guys Marsh on 23 September, speaking to senior governors (in
the absence of the governing Governor, who was on leave), other staff and
prisoners, and arranged for notices to be issued. I received no response to either the
Notice to Staff or the Notice to Prisoners inviting the submission of evidence.
On that first visit, I also made contact with the local branch of the Prison Officers’
Association (POA) and the prison’s Independent Monitoring Board. The POA
requested that all interviews with its members be conducted formally. I had
anticipated conducting one formal interview but, in the event, concluded that this was
not required.
I also made contact with HM Coroner for Wiltshire and Swindon to alert him to my
investigation, and with the Wiltshire Police. The man’s former solicitors and the
Wiltshire Probation Area have provided very helpful background information.
Ms Emma Bradley, deputy ombudsman and a registered clinician, conducted a
clinical review of the man’s care while in custody. One of my family liaison officers
made contact with the man’s family. I am most grateful to the man’s mother for her
assistance. I have included many of the things she said within this report. I hope too
that it answers the questions she raised. (I was pleased to be able to meet
personally with the man’s mother and father and their two daughters, along with two
other members of the family, at the inquest on 9 August 2006.)
6
The man who died
The man was born on 12 March 1972 (some of his prison records incorrectly show 12
January). On 20 July 2005, he received a four months sentence for breach of an
Anti-Social Behaviour Order. In line with standard sentencing arrangements, he
served half of that term in custody and was released on 19 September. The next
day, he was found in a car park in Swindon with evidence of drug-taking around him.
He was pronounced dead at the scene. The man was 33 years old when he died.
The man was the eldest of three children, having two younger sisters. He was single
and had no dependants. His family home was in Devizes, Wiltshire.
He left school at the age of 16 and had no qualifications. He had held down a variety
of jobs after leaving school and through much of his twenties. Evidence heard at the
inquest referred to his voluntary work with physically handicapped people through the
organisation PHAB. However, in the last three years of his life, he was either in
prison or unemployed.
7
The man’s offending and sentencing record
The man’s Police National Computer print-out shows 31 convictions for a total of 45
offences. The details are as follows:
1 against the person
4 against property
22 theft and kindred
9 relating to police/courts/prisons
1 drugs
6 miscellaneous
2 non-recordable
He was first convicted on 10 December 1986 at the age of 14 on a charge of
burglary, but was not convicted again until 1992 (again for burglary). His offences
from 1995 onwards involved either theft or drunkenness. On 7 September 1999, he
was cautioned for supplying amphetamines. He received a Drug Treatment and
Testing Order (DTTO) on 2 September 2002, but a month later (7 October) was
sentenced to a total of six months imprisonment for being concerned in offering to
supply heroin and for failing to surrender to bail. This was his first custodial
sentence.
On 22 September 2003, the man was convicted at North Wiltshire Magistrates’ Court
of ten offences (three of shoplifting – total value £69.07, one of criminal damage, one
of failing to surrender to bail, one of breach of a DTTO, and four of drunkenness). He
was sentenced to two months imprisonment and an Anti-Social Behaviour Order was
imposed. The terms of the ASBO were that, from the date the man was released
from custody and for a period of two years, he should not:
1. Be found drunk within the Kennet and Devizes Town Council No Drinking
Bye-Law area;
2. Use threatening or abusive behaviour in a public place;
3. Be found consuming alcohol in a public place in the Kennet District
Council area;
4. Enter any licensed premises within the Kennet District Council area,
including the alcohol aisles of supermarkets.
I list below the man’s convictions from September 2003 onwards:
22 September 2003 Convicted of 10 offences - 2 months imprisonment
plus ASBO
3 February 2004 Breach of ASBO - 3 months
20 May 2004 Theft – fine £25
28 July 2004 Breach of ASBO (x 2) - 4 months
8
7 October 2004 Breach of ASBO - 5 months
27 January 2005 Breach of ASBO - 3 months
12 May 2005 Breach of ASBO - 3 months
Drunk and Disorderly – no separate penalty
20 July 2005 Breach of ASBO - 4 months
In effect, the man spent half of the two years between September 2003 and
September 2005 in custody as a result of seven short prison sentences, the last six
of which were for breach of the ASBO. To put it another way, he spent the
equivalent of a year in custody, so far as I can judge, as a result of his drinking in
public.
After his death, the man was described by the Western Daily Press as a “notorious
yob” and part of a gang of drinkers who ‘terrorised’ shoppers in Devizes.
I asked the man’s former solicitors for their views on the sentencing of the man and
for any other comments they might have in light of their professional relationship with
him. They replied as follows:
“On each and every Court appearance an argument was put to the Court that
imprisoning the man did nothing to address the underlying problem i.e. one of
alcohol addiction. The deprivation of alcohol during his period of imprisonment
no doubt detoxified him in the short term but just as soon as he was released
he returned to the habit. The only way such a pattern could be stopped would
be if there could be some form of residential rehabilitation to follow the period
of compulsory detoxification whilst in prison. Sadly this wasn’t available to the
man who inevitably died. He was very aware of his situation and of the danger
to his health.
“He had sought help in the past but had never been able to sustain any period
of abstinence. Family support to him had been spasmodic (understandably
so) and he presented therefore as being inevitably doomed. When in custody
and without alcohol behind him he presented as polite and co-operative. I
believe that numerous attempts had been made by the Probation Service to
provide him with counselling but the lack of self-motivation and commitment
had been lacking [sic].
“Regrettably the circumstances in which the man died would appear to
underwrite the fact that ASBOs should not be imposed upon chronic alcoholics
like the man as the draconian powers urged upon the Bench to impose upon
their breach simply leads to renewed incarceration without help.”
I am also grateful to the Wiltshire Probation Area for providing me with copies of four
reports prepared for the man’s court appearances. The most recent was a so-called
Nil Report, dated 6 July 2004, which said that, “due to the high number of reports
requested and staff training commitments”, a pre-sentence report could not be
9
prepared in time for the man’s next court hearing (for the second of the ASBO
breaches listed above). The report noted that, “Most if not all of [The man’s]
offending behaviour appears to be related to his misuse of alcohol and illegal drugs.”
It noted “a very limited success of previous periods of supervision”, said that
Probation would probably be unable to recommend a community sentence, and
invited the court to proceed to sentence without a report.
A similar Nil Report (dated 21 August 2003) had been submitted in the run-up to the
man’s court appearance in September 2003 at which, amongst other things, the
ASBO was imposed. This noted that the court had requested a pre-sentence report
but that the man had not attended an appointment. That failure had also placed him
in breach of his bail conditions.
Two full pre-sentence reports on the man were completed by two different probation
officers in 2002. The first of these reports was dated 26 July 2002 and was to lead to
the court’s decision to impose a Drug Treatment and Testing Order. The report drew
attention to the interchangeable nature of the man’s addictions by remarking that, “in
any attempt to cease [the man’s] heroin use, I would have concerns about a return to
heavy drinking if this is not managed properly”.
The second pre-sentence report was dated 1 October 2002 and was prepared for the
appearance at which the man was to receive his first custodial sentence (on 7
October). This report referred to the man as part of “a mini sub-culture in Devizes” in
which “a small and fairly tight-knit group of friends live in and out of one another’s
homes and use drugs on a daily basis”. It said the man had been addicted to heroin
for about three years but, before being remanded into custody, he had made a “good
start” on his DTTO. Like the earlier report, it drew attention to the man’s potential “to
again return to alcohol as a substitute for other illegal drugs”. The recommendation
was for a Community Punishment Order.
This last report was written by the current chair of the National Association of
Probation Officers. I spoke with him and he said he had known the man well. He
said he was angered at the way the ASBO was used and the way the man had been
vilified in the local media.
The man’s last contact with Probation appears to have been in mid-2003.
10
Family contact
One of my Family Liaison Officers contacted the man’s mother on my behalf. She
did so in a telephone call on Monday 17 October 2005.
Understandably, his mother said that her son’s death had come as a shock. This
was especially so as the family had not thought he was due out of prison for another
week. I am greatly indebted to her for assisting my investigation in such very sad
circumstances.
My Family Liaison Officer explained the nature of my discretionary investigation into
the man’s death. His mother said she was pleased the investigation was taking
place as she had not had much information from other sources. She wished to see
my report when it was completed. She and her husband are in close contact with the
man’s two sisters so she will inform them of my office’s involvement and show them
the report.
The man’s mother said that the police informed her of her son’s death at 2.40 pm on
20 September. Her husband had identified the body, but they were not given much
more information about what occurred. Her husband and their two daughters are
planning to attend the inquest.
The man’s mother talked about her son’s attempts to sort his life out in the past. She
explained that each time he came out of prison he tried very hard to do so, and she
really tried to help him. His mother did not feel that the man had much chance of
doing this in Devizes as he had several friends there with similar problems. She also
felt that the ASBO did not help as it prevented him entering so many areas and that
he could not get a job. Her son had enjoyed playing pool but could not go anywhere
locally to play. He could not even attend a family Christmas party in a local pub with
her as she had asked permission and been refused. This did nothing to help him,
and probably made him worse. The only place he could go was CASH - a local
homeless project, where he could eat and play pool.
She had last seen her son three days before he went to prison in July. She had not
been aware of his arrest at the time and this was the only time he had been in prison
and not called her. She thought her son was ashamed and had not wanted to upset
her. She did not know much about the circumstances of his arrest. She thought her
son had been seen in St John’s graveyard without alcohol on him, but was arrested,
as the police smelled it on his breath.
The man’s mother said she had always stood by and supported her son and he knew
that he could always come home. She said she would never have given up on him
no matter what he had done, and would never have thrown him out.
The man’s mother said her son had stopped using heroin around two years ago. As
far as his family was aware, he had not used it since. He had been different in these
two years and in a much better state, even though still drinking. Her son had talked
openly with her about his heroin problem, describing it as a monkey on his back
permanently saying ‘take it/don’t take it’. Her son had always been sorry for the
11
stealing he committed to fund his habit. He had low self-confidence and, although he
had attended a drugs programme, he had not been able to stand up and talk in the
group. He preferred the one-to-one sessions.
According to man’s mother, a female friend of her son had seen him in Swindon on
the Monday night before his death. The friend had since been to see her and told
her how well he had looked that night. She had been going into the theatre at the
time so had not stopped to talk properly. The man’s mother explained that it was not
unusual for her son to come home a day after his release, as he liked to go for a
drink with friends first. She did not understand why he went to Swindon as, although
he had a friend there, that friend was not there at the time.
Since her son’s death, her sister-in-law had been into the local Job Centre in Devizes
and seen the member of staff whom her son used to see. The staff member had
checked the computer records and discovered that her son had made an application
for a new starter loan in the Swindon Job Centre. The man’s mother wondered if her
son had decided to go to Swindon for a new start, and if he had hoped he would
have more chance of success there where he was away from his old peer group and
less well known.
The man’s mother had received some post for her son after his death. This showed
that he had withdrawn £96 from his Post Office account on 19 September, so would
have had this money as well as that with which he left prison. The statement did not
show where the money was withdrawn.
The man’s mother said she was sure her son did not commit suicide as they had
discussed this and he had always promised he would never take his life. She was
certain that, if he had died of a heroin overdose, this was by accident and not suicide.
She raised a number of questions that she said she hoped my investigation could
answer. In particular, she asked what help was available to her son from Guys
Marsh before and after his release, and if he made use of this.
12
HMP Guys Marsh
Guys Marsh is a category C prison and young offender institution situated to the
south of Shaftsbury in Dorset. One unit holds the young offenders, and the other
eight units are for adult prisoners. The prison is modern in design and attractively
landscaped. It can take up to 570 prisoners.
By coincidence, I had visited Guys Marsh at the invitation of the Governor during the
summer of 2005. In a letter dated 28 June, I had written of being really impressed by
what was being achieved: “the level of activity hours, the work of the Prison Council,
the generally can-do attitude”. (The Prison Council is elected by prisoners and meets
every fortnight. I thought it was an exceptional development.) I had also remarked
on the speedy way in which a couple of matters I had raised had been addressed:
“This was also a mark of a confident and high-performing establishment.” A copy of
that letter was on display in the gate when I visited again after the man’s death.
A similarly favourable view of Guys Marsh can be found in the most recent annual
report of the establishment’s Independent Monitoring Board. Covering the period 1
December 2003 - 30 November 2004, the report recorded “substantial progress” in
performance, including a “substantial reduction in the drug problem”. However, the
Board drew attention to the “short time the average prisoner spends at Guys Marsh”,
arguing that this made it difficult to equip prisoners to lead useful lives after release.
The Board wrote: “Increases in the average time spent by prisoners at Guys Marsh
and in the length of the working week are essential if the objectives of this training
prison are to be properly met.” (The Board reported that almost half of the prisoners
released from Guys Marsh had spent three months or less in the establishment.)
The Board also wrote about the need to co-ordinate all the activities that bear on
resettlement and to improve the effectiveness of the Resettlement Management Unit
(RMU). In light of what I was to find, I note too the Board’s view that the Personal
Officer scheme needed urgent improvement.
Paragraph 39 of the Board’s report is also of interest:
“ … the Dorset Drugs and Alcohol Advisory Service (DDAAS) could also
expand its important work in helping prisoners to address their alcohol related
problems, but funding presently precludes this.”
I met a member of the IMB. She confirmed that the shortness of time prisoners
spend at Guys Marsh was the Board’s biggest concern.
HM Chief Inspector of Prisons conducted a full unannounced inspection of Guys
Marsh between 18-22 October 2004. In her introduction to the inspection report, the
Chief Inspector, Ms Anne Owers, reported that, “Guys Marsh was a prison that was
liked by both staff and prisoners; it was in general a safe and respectful
environment.” However, her report called for “major changes” in respect of activities
and resettlement. She noted that, although the prison discharged hundreds of
prisoners a year, “resettlement work was in disarray”.
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In the body of her report, Ms Owers concluded that, “The personal officer system was
a good one and prisoners knew their personal officers, but it was not operating as it
should due to regular redeployment of staff.” The quality of written comments by
personal officers in history sheets varied greatly. In para 2.51, she wrote, “staff
should be encouraged to write positive and detailed comments in prisoners’ history
sheets …” She also called for a review of the resettlement function, “which should
include the identification of prisoner needs, the provision of resources and services to
meet those needs, and management arrangements to ensure monitoring and
performance.” Most prisoners “had little help with preparation for release”. Ms
Owers said that, “approximately 30% of all prisoners discharged from Guys Marsh
were released with no accommodation to go to”.
On substance misuse, the Chief Inspector reviewed the prison’s drug strategy
document (April 2004), noting that the prevention of harm was one of its aims.
However, Ms Owers also found that the strategy “lacked explicit guidelines on issues
relating to alcohol misuse”. She reported that the prison had “no facilities or
treatment for alcohol/drug detoxification”.
Ms Owers’s report also made reference to workshops on harm reduction and drug
overdosing run under the CARATS (Counselling, Advice, Referral, Assessment and
Throughcare) scheme, to the employment of an alcohol counsellor from DDAAS, and
to referrals from CARATS staff to education which ran an alcohol and drug
awareness course. As will be shown, the man was not referred (and did not self-
refer) to any of these services.
14
The man’s two months in custody
On 19 July 2005, the man was found drunk in Devizes Town Council Area. This
breached the Anti-Social Behaviour Order imposed under s1 of the Crime and
Disorder Act on 22 September 2003 by North and West Wiltshire Magistrates’ Court.
He was charged at 8.36 am on 20 July, having spent the night in police custody.
The man was sentenced on 20 July to four months imprisonment by North West
Wiltshire Magistrates’ Court for breach of his ASBO. He was received by HMP
Bristol that day, transferring to Guys Marsh as a category C prisoner on 28 July.
There is a Prisoner Escort Record (PER form) for 20 July covering the man’s journey
from Melksham Police Station to North West Wiltshire Magistrates’ Court in
Chippenham, and from there to HMP Bristol. The risk category for drugs/alcohol
issues has been ticked, but the word ‘drugs’ crossed through. The PER for 28 July,
when he transferred to Guys Marsh, is also ticked for drugs/alcohol issues – the
source being the earlier form.
On reception at Bristol, the man gave his address as his mother’s home in Devizes.
His unconditional release date was 19 September and his sentence expiry date was
19 November. His Home Detention Curfew (HDC) eligibility date was 20 August,
although in fact he declined to apply.
The Prisoner Induction Checklist completed at Bristol has been ticked ‘yes’ for
detoxification from alcohol. His first night interview indicated the man had previously
been in custody six to ten times, including previous periods at Bristol. The question
‘are you a drug user?’ has been ticked no, as has the question ‘Do you think you
would benefit for a detox programme?’ Boxes for self-harm and risk of self-harm
have also been ticked no. The man was described as polite and no problem by the
officer completing the form. He did not make a phonecall and declined the offer of a
Visiting Order.
The F2052B Record of Events was opened on 20 July with a note that the man had
been in custody before and was an alcohol abuser.
The Cell Sharing Risk Assessment at Bristol was completed by Officer Osborne.
Question 5: ‘Has the prisoner ever abused alcohol or drugs?’ is ticked yes and the
source code is I – meaning inmate. Question 6: ‘Is the prisoner currently dependent
on drugs or alcohol?’ has been ticked no with the same source. Somewhat
contradictorily, the Healthcare section of the form (Section 3) contains the following
exchange:
“Following the self-harm assessment, do you have any concerns? No.
“If so, what are they? Detox.”
15
A form used to determine the man’s appropriate allocation was ticked to show that he
was not dependent on drugs or alcohol and did not have identified offending
behaviour or resettlement needs. It was recommended he be allocated to HMP
Erlestoke. In the event, he went to Guys Marsh. His cell sharing risk assessment
there was low risk. Alcohol abuse (not drugs) was ticked, as was the box for not
currently dependent. This is all identical to Bristol.
The man’s first reception health screen on 20 July revealed he drank two bottles of
cider a day. In answer to a question about use of drugs in the last month, he said no.
The man was referred to the doctor regarding his substance abuse.
The man’s Prescription and Administration Record Chart shows that on 20 July he
received 20mg of Chlordiazepoxide. On 21 July, he received Thiamine 100mg for 14
days and Strong Vitamin B also for 14 days in recognition of his detoxification from
alcohol. His drinking was recorded as ten units a day.
The further reception healthcare screen at Guys Marsh (dated 28 July) reveals the
man reporting ‘yes’ to cannabis use (no other drugs were mentioned) but ‘no’ to
sharing needles, and he admitted again to drinking two bottles of cider daily. He also
said he smoked five cigarettes a day. (Further details of these healthcare screens
and related matters are in the Clinical Review.)
The Induction Labour Form at Guys Marsh shows the man asked to be considered
for ‘bikes, garden, farm’. The form is annotated “good on induction no problem” and
dated 3 August. The Induction Review is ticked to show that the drugs strategy
(including CARATS and DDAAS) has been covered and reads: “A good week. No
problems to staff.” However, there was no CARATS file, indicating that the man was
neither referred nor self-referred.
Indeed, I found little other paperwork at all. The man’s history sheets at Guys Marsh
include next to nothing except a note of his allocation to Cambria House (one of the
units), and a formal verbal warning he received under the Incentives and Earned
Privileges Scheme on 25 August for throwing an item over the farm buildings towards
the greenhouse. There are no weekly entries.
I subsequently discovered that the man had not been allocated a personal officer at
Guys Marsh. This probably explains the absence of entries in his history sheets.
Systems for identifying prisoners slipping through the net were clearly not effective,
and I conclude that the personal officer scheme as a whole is still not operating as it
should.
I recommend that the Governor urgently reviews the personal officer scheme,
in particular to ensure that prisoners not allocated a personal officer are
identified by managers.
I further recommend that the Governor reminds all staff of the importance of
maintaining regular records in prisoners’ history sheets.
16
Week 2 of the induction programme at Guys Marsh includes a module entitled
Introduction to Going Straight. Notes read: “Stopped taking heroin 2003 … Needs
area in Swindon, hostels … Wants to work ... Mum supportive.” It was noted that the
man’s offences were alcohol-related. His release address was recorded as Swindon.
I interviewed the prisoner who had been the man’s next door neighbour in Cambria
House for around a month before his release. He said the man had been friendly
and helpful. He was laid-back and largely kept himself to himself. The prisoner did
not believe that the man had received any visits while in custody (this is confirmed by
the prison’s records).
The prisoner said he and the man had talked out of their cell windows. He did not
think that the man took drugs in custody (although the prisoner said there were drugs
in the prison if you wanted to find them) and they had never discussed drugs. They
had helped each other out with tobacco but, so far as the prisoner was concerned,
the man did not drink nor brew hooch (prison-brewed alcohol).
According to the prisoner, the man’s demeanour had not changed as he approached
his release date. He had said he was going back to Swindon and had been looking
forward to getting out and to having a pint.
17
Preparation for release
On 5 August, the man submitted an Application for a Discharge Grant. (This was the
same day he opted out of consideration for HDC.) He wrote:
“I [am] hoping to go to a hostel. I’ve got to see housing about it. I am
generally homeless because my mum has washed her hands of me now.”
The same day he put in a Prisoner Application:
“Can I see someone from Resettlement please because I haven’t got nowhere
to live when I get out.”
He was told in reply that a Resettlement Orderly in the library would be able to assist
with his search for accommodation.
Accordingly, four days later the man put in a further application to see the Housing
Orderly in the library. Guys Marsh is unusual in that a prisoner acts as Housing
Orderly, assisting probation with planning for prisoners’ resettlement.
An application form for Stonham Housing Association’s Bridge Services in Swindon
is dated 11 August. The man has completed his part of the form as follows:
“Move on and benefits and help with getting work. All I want is somewhere to
live for a few weeks till I get somewhere to live permanently.
“All I want to tell you is I’ve been on a ASBO for two years. It stop[s] three
days after I get out. Now soon it stops all I want to do is to get somewhere to
live and a job and hopefully get somewhere to live permanently.”
The remainder of the form has been completed by the Housing Orderly. It says,
“Applicant was NFA [No Fixed Abode] in Swindon before arrest.” Under reason for
referral, it says, “Will be NFA upon release.” The section reading “Does the applicant
have any drug/alcohol issues of which you are aware?” has been left blank.
The accompanying Resettlement Action Plan minute sheet, also completed by the
Housing Orderly, reads as follows:
8/11/05 (sic) “Given [the man] Bridge Services Hostel App to be filled out by
him and returned to me as soon as possible.”
13/8/05 “Given to [Probation Service Officer] Bridge House app to be
faxed off and sent to them.”
15/9/05 “Spoken to [Probation Service Officer] and Bridge Services.
Have no space as yet. Spoken to [the man] who told me he was
going to live with his mum anyway.”
18
19/9/05 “[The man] discharged and going to mothers.”
21/9/05 (sic) “Spoken to Bridge Services and told them [the man] won’t be
turning up on day of release.”
I understand that last minute was written after the man’s death was known but
referred to a conversation on 19 September.
I interviewed the Probation Service Officer who told me she had been working at
Guys Marsh since December 2004. She said that her practice when receiving an
application for a hostel place was to send either a fax or a hard copy. She did not
recall which method she had used when sending the man’s application to Bridge
Services in Swindon. She said it was not a hostel she knew.
On 15 or 16 September, she had spoken to someone at the hostel (she did not know
their name but thought it had been a woman). They had said that they had not
received the fax but the man could turn up on the day of his release and they would
interview him. However, they had also said they did not have any beds for the
Monday [19 September, the date of the man’s release].
The Probation Service Officer said there was nothing unusual about not hearing back
from a hostel when an application was sent through. They tended to leave the
hostels to get on with their own jobs. The system depended on the resettlement
orderly bringing forward the paperwork. She added that the fax machine currently in
use did not have a function confirming that a fax had been sent successfully.
The Probation Service Officer said that, if the man had asked for help, then they
would have found him a B&B and paid for it through a discretionary grant.
A formal recommendation is not required, but as a housekeeping point the Governor
will wish to review the specification of the fax machine currently in use by probation.
The Housing Orderly’s account in his interview coincided with that of the Probation
Service Officer. He said that he had identified three possible hostels for the man in
Swindon, but one was a ‘dry house’ and one was for under-25s, so Bridge Services
was the only relevant one. Like the Probation Service Officer, the Housing Orderly
had had no previous contact with Bridge Services.
He confirmed that, following her telephone conversation with the hostel, the
Probation Service Officer had said they had suggested that the man simply turn up
on the day. She had said that there was no need to tell the man that the fax had not
turned up. (In a letter to the Hostel Manager of 12 October 2005, I asked if these and
other details could be confirmed. I have received no reply.)
The Housing Orderly added that the man had seen him on Saturday 17 September to
thank him for having helped out. He described the man as a bit forceful at times but
okay.
19
The Housing Orderly reported that since becoming the Resettlement Orderly in June
he had helped between 100-150 prisoners with their accommodation on release. He
said it was unusual for someone to leave Guys Marsh with nowhere to live but it had
happened to five or six of the prisoners whom he had helped.
Aside from the help – such as it was – with accommodation, the man who died
received no other guidance from Guys Marsh pending his release. The Head of
Resettlement told me that those prisoners in contact with CARATS would have been
given a booklet warning, amongst other things, of the dangers of drug use post-
release. However, as the man was not in touch with CARATS this did not apply. I
have been pleased to learn that the booklet will now be given to all prisoners on
discharge as part of a tightening up of procedures following the man’s death. This
will also form part of the pre-release course to be delivered a week before discharge.
(The Head of Resettlement said some of this information would have been delivered
on induction and that the man would have had an Alcoholics Anonymous talk.
However, as in most prisons, I have not sensed a real focus on alcohol as an issue in
resettlement.)
20
On leaving prison
On the morning of Monday 19 September, the man was released from custody after
serving two months of his four month sentence, under s.33 (1) (a) of the Criminal
Justice Act 1991. In accordance with s.116 of the Powers of the Criminal Courts
(Sentencing) Act 2000, he was liable to be returned to custody if convicted of a
further imprisonable offence before his sentence had fully expired. The F2052B
Record of Events completed at Guys Marsh on the day of his discharge simply reads
“No special needs. No outstanding complaints, property in order, discharge clothing
issued.”
The man left prison with a travel warrant to Swindon (not to Devizes where his
mother lived), a small amount of personal property, cash, discharge clothing and a
discharge grant of £46.00.
He left Guys Marsh at around 10.00 am in the company of three other prisoners: one
who was heading for Bristol, one who was heading for a hostel in Taunton, and one
who was on resettlement licence to his home in Wales. I have not sought to trace
the first two men but have interviewed the third prisoner following his return to Guys
Marsh after his resettlement leave.
The picture that emerges is of the four men being driven by an Officer Support Grade
(OSG) to Gillingham station. The man apparently went off on his own at the station
and returned with four cans of strong lager and started drinking. I calculate that the
men most likely caught the 10.42 train to Salisbury where it arrived at 11.15. There
they would have waited for the 11.41 train to Bristol which arrived at Bath Spa at
12.31.
On the platform at Salisbury, the man stole a sandwich from the buffet and words
were exchanged between the men. The prisoner I interviewed told me the man was
“three parts cut” on the train to Bristol and that he spoke confusingly about whether
he was returning to Swindon or to Devizes, but also said he intended to buy drugs.
The man got off the train at Bath Spa and the other three men carried on to Bristol.
If he caught the first available train at Bath Spa (12.42 pm), the man would have
arrived in Swindon at 1.10 pm.
The next morning, at 10.10 am, police were called to Fleming Way Car Park in
Swindon where the man was found unconscious. An ambulance was called and
paramedics pronounced the man dead.
The final post mortem findings were not available until the end of January 2006. The
cause of death was recorded as drug overdose and dilated cardiomyopathy
(enlargement of the heart). Dilated cardiomyopathy (DCM) is a relatively rare
condition, more common in men than women, and sometimes caused by alcohol or
drug misuse.
21
The toxicology results indicate that the man had taken heroin before he died, albeit
not in large quantities. It seems likely that his reduced tolerance to the drug,
combined with a pre-existing cardiac weakness, combined to cause his death.
22
The policy framework
I am grateful to Guys Marsh for supplying me with three documents.
Guys Marsh’s Drugs and Alcohol Strategy document 2005-2006 is dated April 2005.
DDAAS Ltd provides brief alcohol counselling therapy to prisoners referred by the
CARATS workers. Fortnightly AA meetings, held in education, are open to prisoners
across the estate.
The document also says:
“Needs Analysis has shown that the Guys Marsh population has a binge
drinking culture prior to custody. Any prisoner identified with an alcohol
problem will be referred to CARATS for assessment. Their approved disposal
is through DDAAS. Due to the continued long waiting list for this provider
some one to one work may be considered by the CARAT worker or referral to
the education alcohol (sic) awareness course. If funds were to become
available or an alcohol pilot was to be run we would expand our alcohol
strategy appropriately.”
In light of the findings of this report, I recommend that the Governor and Area
Manager review the services available under the alcohol strategy.
The throughcare of drug using prisoners represents one of the strands of the drug
and alcohol strategy. Drug awareness training should be received by all prisoners on
induction. In addition, the strategy says all prisoners should be assessed for
substance abuse on reception, and all prisoners with such problems should be
assessed in turn by CARATS.
A CARATS/Health Care Referrals & Liaison Protocols document is appended to the
strategy. Section 3.1. says:
“Subject to consent all prisoners who present at initial reception Health Care
screening with drug misuse problems should be referred to the CARATS team
for assessment.”
Section 3.4. adds:
“If the prisoner refuses to give his consent, he must be advised of the
CARATS self-referral process.”
The document makes no reference to alcohol.
I also received a copy of the CARATS Pre-Release Information Pack. This includes
advice under six headings:
• What to do if you think someone may have overdosed.
• Cravings.
23
• HIV and HEP C facts and figures.
• Taking a drug after a period of abstinence.
• High Risk Behaviour.
• Useful Numbers/Addresses.
The advice under the fourth heading includes:
• Just take a little (“Remember, your tolerance level will have dropped. Taking
at your old levels may cause you to O.D.”)
• Try not to inject.
• Use with someone that is used to it.
• Do your research.
• Give the drugs time to take effect.
• Don’t purchase more than you intend to use.
• Know your dealer.
• Don’t mix.
This is all sensible and well-intentioned. However, I wonder if the warning about
reduced tolerance is sufficiently strongly worded. A lecturing tone may be self-
defeating but there is no merit in being mealy-mouthed about the dangers ex-
prisoners may run by returning to drug use.
I recommend that the governor reviews the content of the CARATS Pre-release
Information Pack.
The final document was Guys Marsh’s Resettlement and Reducing Re-offending
Strategy Document, dated August 2005. This says:
“Guys Marsh aims to ensure that all its prisoners are prepared for release, by
enabling them to address their individual needs, identified in pre- and post-
sentence Offender Assessment System (OASys) processes, personal
assessment interviews at admission, and a systematic, two-week Induction
programme, and, by doing so reduce re-offending and enhance protection of
the public.”
On Accommodation, the document says:
“Guys Marsh will provide practical help, advice and guidance to assist those
looking to retain existing accommodation via the library and the housing team
including the Probation department and offenders being empowered to locate
and secure accommodation and to help and support each other … Additional
links are being sought to assist in providing short and medium term
accommodation for all prisoners indicating they are NFA on release.”
Under Drugs and Alcohol, the document reads:
“Referrals for assessment for treatment by specific methods/models for all
drug-related offending will be made through CARATS staff, who will then
advise on the necessity for treatment and suggest the methodology required.
24
Access to NA [Narcotics Anonymous] and relapse support groups will be
made available. To ensure effective response to throughcare and aftercare of
offenders with problematic alcohol use. Appropriate referrals to DDASS for
prisoners identified with alcohol related offending. Access to AA and alcohol
dependency support groups will be made available. The availability of drugs,
alcohol and other mood-altering substances within Guys Marsh will be
reduced as part of the ongoing Drug Action Plan. Information, support and
education will be provided to reduce the likelihood of drug-related death
following release. Post-treatment peer support mechanisms will be
established to maximise positive treatment outcomes.”
Under the heading Personal Officer Scheme, the document records that a Head of
Personal Officers will be identified to develop the role of the Personal Officer within
the establishment.
Amongst the document’s Strategy Outcomes is to reduce “the amount of No Fixed
Abode (NFA) discharges of all prisoners”.
I note that the document says that a pre-release board (also referred to as the
discharge board) should take place six to eight weeks prior to the prisoner’s
discharge.
I recommend that the Governor reviews discharge arrangements for prisoners
at Guys Marsh who have less than eight weeks to serve.
The Resettlement Strategy also refers at one point to the organisation Narconon as
being a possible supplier of drugs interventions. I was alarmed to see this as
Narconon is closely associated with the Church of Scientology. The Church of
Scientology is not recognised by the Prison Service as a bona fide religion and is not
an appropriate partner for the Prison Service.
One of my Assistant Ombudsmen spoke with the Prison Service’s Drugs Co-
ordinator for the South West. He said he had recently learned of the reference to
Narconon and had confirmed with Headquarters that they should not be engaged.
The Governor of Guys Marsh had been informed and had removed them from the list
of service providers. As a housekeeping point, the Governor will wish to amend the
Resettlement Strategy documentation. However, the implications go wider than
Guys Marsh.
I recommend that the Prison Service issues advice to all Governors confirming
that Narconon should not be engaged as a supplier of drugs interventions.
25
Clinical review
I am most grateful to my colleague, Ms Emma Bradley, for her clinical review. Based
on her assessment of the clinical record, Ms Bradley concludes that appropriate
referrals and information were not provided to the man to enable him to address his
addictive behaviour and associated problems.
Ms Bradley is critical of other aspects of the man’s care and makes six
recommendations that I endorse.
I am also indebted to the Director of Primary Care, South West Dorset Primary Care
Trust, for her helpful comments on the draft of this report.
26
Conclusions
Guys Marsh’s resettlement strategy sets ambitious targets. However, the man left
the prison homeless and with nothing having been done about the alcohol problems
that had repeatedly led to periods of imprisonment. His documents show no referrals
to DDAAS or to Alcoholics Anonymous. Apart from on induction, he had been given
no advice about the dangers of using illicit drugs.
The man had opted out of consideration for HDC. Nor did he have a Discharge
Board before leaving prison since these normally take place six to eight weeks before
release. With one minor exception, his custodial behaviour was ordered and he
neither sought nor came to attention. Next to nothing was written about him during
his seven weeks in Guys Marsh.
Insofar as he was seen at all, the man was regarded as a good (that is, compliant)
prisoner and little was done to help him prepare for the challenges he would face
once again on release from custody.
This investigation also calls attention to the effectiveness of Anti-Social Behaviour
Orders (ASBOs) and the penalties for breach. After being made subject to an ASBO
in September 2003, the man breached the Order on seven occasions – each of
which led to short periods of imprisonment. Yet during that time, the cause of those
breaches – the man’s drinking problem – was never once addressed. Nor did he
have any contact with probation.
The man was punished again and again for minor anti-social behaviour, the roots of
which were addictive in nature. Rarely can one person’s story have so illustrated the
futility of repeated, short custodial sentences. I endorse the view expressed by his
former solicitors: “ASBOs should not be imposed upon chronic alcoholics … as the
draconian powers urged upon the Bench to impose upon their breach simply leads to
renewed incarceration without help.”
I recommend that a copy of this report is sent to the Head of the Home Office’s
Anti-Social Behaviour Unit, to the Chief Officer of Wiltshire Probation, and to
the Chair of the Wiltshire branch of the Magistrates’ Association, for their
consideration.
27
Recommendations
(cid:131) I recommend the National Offender Management Service reviews
arrangements whereby deaths of recently released prisoners are referred
to the Prison Service’s National Operations Unit and onwards to my
office.
(cid:131) I recommend that the Governor urgently reviews the personal officer
scheme, in particular to ensure that prisoners not allocated a personal
officer are identified by managers.
(cid:131) I further recommend that the Governor reminds all staff of the
importance of maintaining regular records in prisoners’ history sheets.
(cid:131) In light of the findings of this report, I recommend that the Governor and
Area Manager review the services available under the alcohol strategy.
(cid:131) I recommend that the governor reviews the content of the CARATS Pre-
release Information Pack.
(cid:131) I recommend that the Governor reviews discharge arrangements for
prisoners at Guys Marsh who have less than eight weeks to serve.
(cid:131) I recommend that the Prison Service issues advice to all Governors
confirming that Narconon should not be engaged as a supplier of drugs
interventions.
(cid:131) I recommend that a copy of this report is sent to the Head of the Home
Office’s Anti-Social Behaviour Unit, to the Chief Officer of Wiltshire
Probation, and to the Chair of the Wiltshire branch of the Magistrates’
Association, for their consideration.
Recommendations in Clinical Review:
1. Healthcare professionals should retrieve previous clinical records
when prisoners are received into custody and ensure these
records are merged with the current record.
2. Healthcare staff should be reminded of the need to fully complete
clinical assessments to enable appropriate care planning.
3. Prisoners identified as having substance misuse problems should
be referred to local drug support services in a timely manner.
4. Staff should be reminded of the need to provide a comprehensive
and documented assessment of clinical problems, needs and
treatment.
28
5. When electronic and paper records are being used together,
entries in both must reflect the care and treatment administered to
ensure a seamless approach to patient care.
6. A multi-disciplinary/agency programme to promote health and
well-being should be developed to ensure that, prior to release
from prison, prisoners are provided with relevant multi-
disciplinary advice and information.
29