Individual at Hull

Investigation into the circumstances
surrounding the death of a man at HMP
Hull on 3 October 2004
Report by the Prisons and Probation
Ombudsman for England and Wales
January 2005
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Contents
Foreword 3
Summary 4
Personal Background 5
HMP Hull 7
Investigation Process 8
The events leading up to the death of the man 9
* Reception 10
* Induction Unit A wing 11
* The incident 16
* Post incident 20
* Family contact 20
* Support for staff 21
* Concerns of the man’s family 21
* Post mortem 23
* Clinical review 23
* Operational issues 24
Findings and conclusions of the investigation 25
Recommendations and good practice 26
Glossary of terms 28
List of Annexes 30
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The sad death of the man at HMP Hull was unfortunately not the first at the
prison. Under transitional arrangements agreed with the Prison Service, a
senior investigating officer is appointed to work directly to me and conduct the
investigation, and I am pleased to concur with his conclusion that the man’s
state of mind was properly assessed by prison staff and that they took the
correct actions when his death was discovered. His family is perplexed by his
suicide and I regret that I am unable to provide any explanation for them.
The investigation team has already expressed their condolences to the man’s
family and I would like to take this opportunity to add mine. I hope that at
least some of their questions will be answered by this report. Their concerns
for the wellbeing of his cellmate and for the staff involved are appreciated.
I would also like to acknowledge the hard work of the two investigators, who
carried out a thorough investigation. Their draft report has been amended
only for purposes of style and their conclusions are accepted. My family
liaison officer met the man’s mother, fiancée and uncles and a colleague from
my office liased with all involved in the investigation. I am grateful to Eastern
Hull Primary Care Trust for carrying out a timely review of the man’s clinical
care whilst he was at the prison. Finally I thank the Governor and staff of
HMP Hull for their continuing help and cooperation with this investigation.
The assistance of Humberside police is also much appreciated.
The report contains one national and a number of local recommendations,
particularly relating to the availability of detoxification medication at the
weekend and the terms of the out of hours GP contract. However it is
essential to stress that this led to only a slight delay in a doctor attending and
that unfortunately the man was already dead by that time. A number of
examples of good practice have also been identified, especially concerning
the actions of the Oscar 2 officer and the nurse who attended the incident.
STEPHEN SHAW
PRISONS AND PROBATION OMBUDSMAN FOR ENGLAND AND WALES
January 2005
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Summary
1. At the time of his death on Sunday 3 October 2004, the man was 25
years of age. He was arrested three days earlier on Thursday 30
September along with his fiancée. She was released the following day,
but he remained in Police custody until his court appearance at the
Magistrates Court on the morning of Saturday 2 October. He was
remanded in custody for theft, assault of a Police Officer and
obstructing a Police Officer.
2. The man arrived at HMP Hull at 12:35 on Saturday 2 October. He
underwent initial interviews in the prison’s Reception area before
transferring with several other new arrivals to A Wing shortly after
lunchtime. A Wing is the prison’s First Night and Induction Wing.
3. He was interviewed by a member of the prison’s Healthcare staff and
an A Wing Officer. He was given sufficient credits to use the telephone
and used them to ring his fiancée, at their home address at 15:23.
4. He was then shown by an officer into cell A6/9. Already present in that
cell was his cell mate, who had also arrived at the prison that morning.
He collected a meal and a breakfast pack for the following morning at
about 16:30 and the cell was then locked for the night.
5. His cell mate informed the investigation team that they watched
television together, before he went to sleep on the bottom bunk. He
woke briefly during Match of the Day (scheduled between 2030 and
midnight) and then went back to sleep. He slept fitfully, but was
awoken by two members of the night staff (both OSGs) calling to him
through the door at about 05:05 on Sunday 3 October. They asked
him to locate the man, who was not in his own bunk and could not be
seen by them. His cell mate saw the man seated in the toilet recess
area of the cell and tried unsuccessfully to wake him. He got out of his
bunk and tried again to wake him, but realised he had a ligature around
his neck and informed the staff.
7. The night staff alerted others by radio. An officer attended and opened
the cell door. He examined the man but could not identify any vital
signs of life. The Night Orderly Officer and a nurse attended shortly
afterwards and the nurse also examined him, concluding that there was
nothing that she could do to help him. CPR was not attempted.
Contingency Plans were activated. An ambulance crew attended A
Wing at 05:36 and declared that he was dead. A police doctor also
attended at 06:30.
8. The post mortem carried out on 3 October 2004 established that the
cause of his death was due to hanging.
9. A Clinical Review was commissioned, to examine the medical aspects
of his care whilst in HMP Hull. The author of the report is Eastern Hull
Primary Care Trust.
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Personal Background
10. The man was born on 15 June 1979 in Scotland. His parents
separated, but were reconciled briefly at the time of his birth,
separating again shortly afterwards and subsequently divorcing. The
mother and her son moved into her parents’ household. When he was
aged five his grandfather died, followed three years later by his
grandmother. At this stage he went into the care of the local authority,
in which he continued until 1994. He had weekly contact with his
father, but this tailed off and they had no contact for some time prior to
his father’s suicide in 1989.
11. The man started using cannabis in 1992/1993. He left school in 1993.
The first record of his offending was in September 1994, with several
court appearances in Dumbarton Courts during 1995 for a variety of
types of offences.
12. There was a break in his offending until 1998, a year in which he
started use temazepan. In May of that year he received his first
custodial sentences, namely three sentences in a Young Offenders’
Institute ranging from 30 days to six months.
13. Later in 1998 he and a friend moved to Lancashire and commenced
work in a factory. Part of the reason for moving from Scotland was to
distance himself from the drugs scene in Dumbarton, however he
subsequently appeared at courts in Blackburn and Doncaster. At this
stage almost all his offences involved shoplifting to finance his misuse
of drugs, a pattern which continued for the remainder of his life.
14. In 1999 he started using heroin, and was found guilty of a charge of
possession of heroin by Doncaster courts in May. In November he was
sentenced to 18 months in a Young Offenders’ Institute for burglary
and breach of a probation order. In 1999 whilst in the custody of HMP
& HMYOI Doncaster, he harmed himself by cutting his wrists.
15. He was released on license in April 2000 from HMP & HM YOI
Moorland, but was recalled in July due to sporadic attendance of
appointments with his supervising officer. As a result of this
imprisonment he lost his accommodation.
16. His first adult custodial sentence was in September 2000 when he
served three months sentence for assault, and was released a month
later.
17. At court appearances in November 2000 he received sentences
totalling nearly five years for a variety of offences and entered HMP &
HMYOI Moorland. He remained in contact with his mother by
telephone and letters.
18. By April 2002 he had transferred to HMP Channings Wood (in the
south west of England), where he attended a drug treatment
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programme. He was in contact with his mother and friends, but was
expecting no visits and appeared “socially isolated”. After completing
half of the programme, he withdrew from participation. It was proposed
that he be released in West Yorkshire and so he transferred back to
Moorland prison. Before transfer he was assessed as being in good
health (physically and mentally), settled, motivated and positive about
his future.
19. His release on licence from Moorland was agreed in October 2003 and
in December he began the relationship with his fiancé. Soon
afterwards his licence was revoked and he returned to custody. His
fiancé says this was because he “did not get on” with his Probation
Officer. He returned to HMP &YOI Doncaster where he underwent
detoxification from drugs but refused assistance from the Probation
Service. During this sentence he wrote to his fiancé to propose
marriage. There were records of poor behaviour during the sentence.
He was released on 9 March 2004.
20. The relationship with his fiancé continued and they decided to move in
together. His addiction to drugs continued and they used to shoplift
together to fund his drugs misuse.
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Establishment background
22. HMP Hull was opened in 1870 and is now a Category B local prison
serving the courts in East and North Yorkshire and North Lincolnshire.
Hull receives prisoners, such as the subject of this report, directly from
court.
23. A major expansion programme, completed in late 2002, added 356
places to the prison’s operational capacity and a further 40 places were
added in March 2004. The operational capacity (the maximum number
of prisoners who can be held in the prison) is 1,071 and the CNA
(certified normal accommodation) is 812.
24. In March 2004, HM Chief Inspector of Prisons carried out an
announced visit and reported that the prison was providing a largely
safe and decent environment. Additionally, the prison has undergone a
full Standards and Security Audit in 2004 and has been rated “good” in
both areas.
25. A Wing contains the prison’s First Night and Induction unit.
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The investigation
26. Following the man’s death, on 11 October, two colleagues from the
Prison and Probation Ombudsman’s office, as well as the investigator
and assist investigator visited HMP Hull. Arrangements were made to
notify staff and prisoners of the investigation and meetings took place
with the Governor and representatives of the POA and IMB. The
internal documents relating to the man’s few hours in HMP Hull were
also obtained.
27. The Ombudsman’s representatives also contacted the office of the HM
Coroner of East Riding and Kingston upon Hull and the investigating
police representatives.
28. The Ombudsman’s Family Liaison Officer contacted the man’s family in
Scotland and visited his mother and other family members on 22
October. The Family Liaison Officer and the investigator visited his
fiancée, on 2 November.
29. The Ombudsman’s office commissioned a clinical review of the man’s
medical care whilst in the prison from the Director of Professional
Development at Eastern Hull Primary Care Trust. The Coroner’s office
provided a copy of the report of the post mortem carried out by a
Professor of medicine. The investigating police officer, a Detective
Constable provided his police custody record. I am grateful for the
ready co-operation of all those involved in this process.
30. HM Prison Services’ Safer Custody Group provided the investigation
team with an analysis of self inflicted deaths by ligature types, an issue
of concern raised by his family.
31. The investigators interviewed four prisoners and 17 staff who had
contact with him during the few hours he was in the prison. Another
prisoner who was in a cell adjoining cell A6/9 on the night of the man’s
death was released shortly after the incident. Efforts were made to
trace him, but without success.
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The events leading up to the death of the man
32. Whilst living in Grimsby, the man and his fiancée continued to shoplift
to raise money for his drugs. At 20:30 on Thursday 30 September,
both were arrested for allegedly stealing sweets and frozen food to the
value of £7.44. Later he was also charged with assaulting a police
officer and obstructing a police officer by giving a false identity, though
this charge was later changed to attempting to pervert the course of
justice. Within a short period of time his true identity was known to the
police and it was also established that he was wanted by the police for
failing to attend court.
33. At 08:02 on 1 October, whilst in police custody, he asked to see a
doctor who attended at 15:10 that day. He was given dihydracodeine
and zopiclone later in the day and two amounts of dihydracodeine the
following day. These medications are prescribed to deal with drug
withdrawal and related sleep disturbance. The police records include
observations of the man, visits to him, food and drink given and that he
made a telephone call at 14:30.
34. On the same day his fiancée was cautioned by police and released.
She says that she asked the police to see him, but the request was
denied.
35. After formally being charged later in the afternoon of 1 October, he
undertook a drugs test via a saliva sample. The record states that he
said that he had taken no medication in the past 24 hours, but had
used heroin and crack (cocaine) “yesterday” (30 September). The
results were positive for heroin and cocaine.
36. At 08:35 the following day, he was transferred to court by the escorting
contractor (GSL). On the PER form the police alerted GSL to his risk
factors, that is a history of violence, weapons and drug use (heroin).
He appeared in court at 09:39 and was remanded into custody.
Arrangements were made for him to transfer to Hull. At 11:26 GSL staff
opened a suicide/self harm warning form, after he informed them that
he “made a serious suicide attempt at HMP Doncaster five years ago.
States he has not thought about self harm suicide since then. States
he is addicted to heroin.” He was then transferred to Hull.
37. At 12:35 a GSL vehicle containing three prisoners, including the man,
travelled from Grimsby and Scunthorpe courts and was booked in at
the prison gate. The two other prisoners shall be known as Prisoner A
and Prisoner B. Prisoner A met the man in Grimsby police station on
the Saturday when they were in a holding cell together. He described
how they talked of the man’s girlfriend in Grimsby and said that he was
addicted to heroin. Prisoner A said he saw him showing the first signs
of withdrawal as he shivered and had goosebumps. They chatted
whilst in the cellular transport from court, but said nothing significant.
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Reception
38. The man and Prisoner A continued to chat in a holding room in the
reception area, where they were each given a meal, though Prisoner A
thought the man may have left his.
39. The man was interviewed by an officer with 14 years experience,
including two years in reception. The officer checked in any valuables
and cash, searched him fully and offered him a shower. He completed
his property record and started his Cell Sharing Risk Assessment
(CSRA), completed his cell card and took his photograph. The Senior
Officer in Reception booked him onto the prison’s computer system.
40. The primary purpose of the CSRA is to assess an individual’s risk to
other prisoners if they were to share accommodation, but there is also
some reference to the potential for self-harm. The officer described the
man as being calm and polite, though not very talkative. The officer
examined the PER and noticed the self-harm warning form completed
by GSL staff earlier in the day. He also noticed that a form F2052SH
had been opened previously and the man informed him that he was
currently dependant on drugs and alcohol. He informed the officer that
he would have no problems sharing a cell with someone else and was
assessed as presenting a low risk when sharing with others.
41. The officer noted that the GSL Suicide/Self-Harm form had been
opened due to the incident five years previously. He recorded that the
man had no thoughts of self-harm of suicide and emphasised this by
triple underlining the word “no”. He noted that the man had an
addiction to heroin and described himself as an alcoholic. His fiancée
has disputed this subsequently, stating that he drank only small
quantities of alcohol. It is possible that he said this as an attempt to
receive detoxification medication more speedily, although this is
speculation only.
42. When discussing the self-harm five years previously, the officer
recalled the man telling him “look that was a load of rubbish, that was
five years ago, it’s in the past and I said, well look can you tell me
…have you any thoughts – and it’s again the way I worded it – have
you any thoughts of suicide or self-harm. In other words will you try
and hurt yourself”. The officer then said “I remember quite clearly he
said “no gov it was in the past”. The officer recalled that at the time of
this conversation the man “wasn’t distressed, upset, he was quite
calm”.
43. The officer had no concerns of his risk of self-harm or suicide. In the
interview with the investigation team he demonstrated full knowledge of
the procedures to open an F2052SH and initiate the appropriate
monitoring procedures.
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Induction Unit – A Wing
44. In the early afternoon after the Reception interviews, the man and the
other new receptions were transferred to the Induction Wing (A Wing).
This was the first time that his cell mate met the man. During the
afternoon there were further interviews and, in between, they were in a
holding room where there was a television. There were four to six
prisoners there including the man, his cell mate and Prisoner A. His
cell mate said that he seemed “normal” and “easy”. Prisoner A said
that the man made a telephone call before both were transferred to
their respective cells on A Wing. The man was allocated cell A6/9 and
not one of the four “safer cells” as he had not been assessed as being
at risk of self-harm or suicide. Safer cells are especially designed to
reduce risks as their design includes reduced ligature points. His cell
mate, remained separate from the others, and did not join in with their
conversations.
45. Another prisoner, Prisoner C, began chatting with the man and they
found they had mutual acquaintances. Prisoner C described him as
talkative. He was aware that he was a heroin addict, but he did not
mention withdrawing and Prisoner C did not see any signs of it. He
also knew that the man collected a “smokers pack” and £1 telephone
credit used to make a telephone call.
46. He was interviewed by two members of staff. The officer saw him as
part of the A Wing induction. Prior to his prison service, the officer
worked as a nursing assistant in a psychiatric unit. He has worked for
the prison service for four years, the last two being on A Wing during
which he undertook training on the Mental Health Assessment of
prisoners.
47. The officer was aware of the self-harm warning form as raised by GSL
staff and recalled asking him about the incident of self harm of five
years earlier. He recalled that the man appeared “tired and he just
wanted to go to bed”. He completed with him the First Night
Centre/Induction Unit Questionnaire which included a question “Do you
feel like harming yourself?”, with a rider “If YES, open a F2052SH”. The
officer ticked “No”, and explained to the investigation team that he was
satisfied that the man’s answers to his questions were consistent with
the way he presented himself. He told the first induction officer that he
had not self-harmed since that incident five years before and said that
he had no intentions of doing so.
48. The induction process was completed and the officer signed that he
issued him with an induction leaflet, which included information about
how to contact the Samaritans and the Listeners, and other basic items
such as a £1 telephone credit and cutlery.
It is recommended that the contents of the induction leaflet are
reviewed, as the print is small and the contents, especially of the
initial pages, is complex and not of immediate relevance to those
who may be at risk.
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It is good practice that induction leaflets are issued routinely to
prisoners on their arrival.
49. The officer completed the induction interviews and attended the
landings to assist unlocking the prisoners for the tea meal. He did not
recall seeing him again that day. The following day he was asked by
the police to identify his body in cell A6/9.
50. Some time after the interview with the induction officer, the man was
also interviewed by a Staff Nurse. The Staff Nurse is not a direct
Prison Service employee, but works for Eastern Hull Primary Care
Trust. He has worked within the prison since March 1994, and
previously for two and a half years as a G Grade Nurse in a
Community Drug and Alcohol Team. He qualified as a Psychiatric
Nurse in 1994 and is also a Registered Mental Nurse.
51. The Staff Nurse completed the First Reception Health Screen form,
which assesses prisoners’ medical and mental health needs. He
recorded that the man declared acute alcohol and heroin misuse, but it
did not record that he also used cocaine, as identified the day before
when he was in police custody. The man’s father’s suicide was also
recorded, as was the self-harm episode of five years earlier. The Staff
Nurse recorded that he appeared to be fit and healthy, but was noted
as being referred to a doctor due to his substance misuse.
52. On Saturday the doctor only attends the prison during the morning and
so the first opportunity for the man to have been seen would have been
the following day, Sunday 3 October. Any medication prescribed to
assist his withdrawal from drugs and alcohol would not have been
dispensed until later that day, or Monday 4 October. He had been in
police custody since the evening of 30 September. He received some
medication, including dihydracodeine at 05:30 and 07:35 on 2 October,
whilst in their custody. On entering prison custody it would have been
well in excess of 24 hours before being assessed for further
medication.
It is recommended that the weekend arrangements for assessing
and dispensing detoxification medication are reviewed.
53. The section of the First Reception Health Screen form relating to
mental health should have recorded the need for a referral for mental
health assessment. However this did not impact detrimentally to the
man who died as a doctor would not have been available to see him
until later on Sunday 3 October and drug workers would not have been
available until Monday 4 October at the earliest.
The incorrect completion of this form is addressed as learning
point within the Clinical Review.
54. The Staff Nurse then completed section three of the CSRA, assessing
him as a low risk to others and stating that no concerns had been
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raised following the self-harm assessment. The Suicide/Self Harm
Warning form (box 8) was signed by the Staff Nurse at 15:15 on 2
October, and was effectively closed as the question whether “F2052SH
(or ACCT) opened” was answered in the negative.
55. The man was described by the Staff Nurse as not being overly anxious
or distressed during the interview and said that he gave him no major
cause for concern. He was lucid, was not negative about his
circumstances and did not show signs of serious alcohol withdrawal
symptoms.
56. He was allocated cell A6/9 by the Movements Officer. As neither the
first induction officer nor the Staff Nurse notified any problems about
him, the allocation would have been based on the information on the
cell card, that is his name, number and that he was held on remand.
57. At 15:23 on 2 October the man used his telephone credits to contact
his fiancée, the call lasting six minutes 41 seconds. The tape of the
conversation was listened to by the investigating team who were of the
opinion that he did not sound distressed or concerned. His fiancée
described him as seeming “happy”. He confirmed that he was in Hull
and was due to appear in court via videolink on the following
Wednesday, and expected to be transferred to HMP & HMYOI
Doncaster shortly afterwards. The call continued with the man talking
to his fiancée’s sister and discussing how they were going to visit and
send some money in. He informed her that he would not be receiving
detoxification medication until the Sunday, and she advised him not to
take his medication all at once. Towards the end of the conversation
he told his fiancée that he would be writing to her that night but this
letter has not been found.
58. The man’s cellmate had been allocated and entered cell A6/9 before
the man arrived there. He had discovered that the kettle and television
needed to be replaced, and had organised this by the time the man
arrived some 45 minutes later, between 16:00 and 17:00.
59. Prisoner A had been aware that the man collected his meal and
breakfast pack but, as it would have been eaten in his cell, he did not
know whether he ate it. Prisoner B and Prisoner D were located in cell
A6/10, next door to A6/9. The only time Prisoner B saw him was when
he saw him enter A6/9 with his tray of food and take the upper bunk.
His cell mate said that he “seemed alright”, but that he was worried
about coming off drugs. His cell mate confirmed that he ate his meal,
and that he ate his breakfast pack at this stage as well.
60. After the man and his cell mate collected their meals and breakfast
packs, the cell door was closed, no specific member of staff having
been identified as doing so. Each cell on A Wing, including A6/9, had
Samaritan contact details stencilled on the cell wall.
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The investigation team commend the prison for giving prisoners
on the First Night Centre the Samaritans’ contact details in this
way.
61. Shortly after 16:30, the Duty Governor, followed routine practice and
examined the man’s CSRA and noted that there were “No current SH
[self-harm] issues, can cell share.”
The investigation team recognise the good practice of the Duty
Governors examining all CSRAs and recording their comments
routinely.
62. Prisoner A told the investigation team that he heard the emergency cell
bell sound repeatedly through the evening, and thought it might have
been the man who is the subject of this report sounding it, but said that
he could not be certain of this. Neither Prisoner A nor Prisoner B heard
anything untoward during the night and they found out about the man’s
death later the following day.
63. His cellmate stated that the man was restless, that he was “up and
down a lot…just getting up and not doing a lot really”. A lot of noise
was caused by other prisoners talking from their windows, but he said
that the man did not join in. His cell mate said that the man told him
that the noise was “doing his head in”. They watched television
together during the evening. His cellmate fell asleep, waking to watch
part of the Parkinson Show together and laughing at some of the
content. They then turned over channels to watch Match of the Day,
beginning at 22:00. His cellmate again fell asleep, waking only briefly
during the programme when he said that the man was still awake at
this point, and he fell asleep again. At some point in the night his
cellmate woke up, saw the man sitting in the toilet recess and asked if
he was alright. He got no reply and assumed he was asleep. His
cellmate then slept restlessly until he was woken by staff at about
05:00. He said that he was not aware of the man sounding their
emergency cell call bell during the evening or night.
64. Two Wing officers completed a full count of prisoners on A Wing at
about 16:30 and again between about 19:00 and 19:15. The first Wing
officer could not recall any contact with the man during the evening.
The second Wing officer named another prisoner from opposite to A6/9
who he believed was using his emergency cell call bell frequently
during the evening. The emergency cell call bell system on A Wing
does not include a facility to identify which cell bell has been sounded.
The two officers handed over to two OSGs, all stating that there was no
information of particular significance in the handover.
65. The two OSGs carried out a further roll check of prisoners at about
20:30. A Response Officer was also located on A Wing during that
night. He carried radio call sign Oscar 3 and as such, was not
allocated a cell key.
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66. During the night period neither OSGs recall being called to cell A6/9.
They carried out periodical patrols, which were recorded by means of
an electronic device called a pegging gun. The Night Orderly Officer
(NOO), a Senior Officer, was responsible for checking these records
the following day, before passing them to the Duty Governor. The NOO
found no anomalies or inaccuracies with the pegging records for A
Wing on the night of 2/3 October 2004. The investigation team have
also examined these records and have no concerns with them.
67. Neither OSG recalls being called to cell A6/9 during the evening of 2
October or the night of 2/3 October, either by the emergency cell call
bell being sounded or otherwise. At the time of the incident the cell call
bell system did not provide a record of which cell had rung their bell. It
is good practice that the prison is currently considering installing an
addressable call bell system in the planned refurbishment of A wing.
None of the prisoners in the adjoining cells to A6/9 who spoke to the
investigation team, recalled hearing anything untoward during that
night. The cells below A6/9 were unoccupied that night and A6 landing
is the top landing on that part of the wing.
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The incident
68. At about 05:00 both OSGs commenced a full physical count of
prisoners on A Wing. This was in line with the guidance in the “Night
Patrol Information Pack” for A Wing (effective from 1 August 2004)
which states that:
1 There will be two routine roll checks at night, conducted by Night
Staff. These will be:
i) At the commencement at duty (at 2115 hrs)
ii) Before day staff commence (at 0630 hrs).”
69. Staff informed the investigation team that it was usual to start this
check from 05:00. On 3 October the OSGs started their check at the
end of A Wing furthest away from cell A6/9, each taking one side of
each landing and on reaching landing A6, the first OSG checked the
side including A6/9. The statements completed by these staff were
identical and, therefore, not entirely accurate.
It is recommended that staff at the prison give their own
individual account of events when making statements after an
incident.
70. When he reached A6/9. the first OSG opened the observation hatch on
the door to look in, he could not see the occupant of the top bunk and
so called the second OSG across from the other side of the landing.
The second OSG knocked on the door and called out to wake up the
man’s cell mate. The first OSG moved to the observation point
(spyhole) which gives enables staff to see into the toilet recess area of
the cell. The first OSG stated that he could not see the man at the
centre of this investigation, as the vision was not sufficiently clear and
the light was insufficient to see him.
71. The man’s cell mate told the investigation team that he was woken by
staff shining a torch through the observation hatch, putting on the
nightlight (in the cell) and being asked where his cellmate was. The
first OSG informed the investigation team that the night light (which can
be turned on by staff from immediately outside the cell) was insufficient
to allow him to see the man, as it is not as bright as the in-cell light,
which can be operated only from within the cell.
72. The investigation team found that the OSGs acted in accordance with
the current guidance at the prison. The Night Patrol Information Pack
states:
2 Roll checks are conducted to ensure:
i) That the roll is correct
ii) That every prisoner is in the correct cell
3 Night staff must assure themselves that prisoners are in the cell
by obtaining a clear view of them – if necessary by waking them.
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73. His cell mate tried to wake the man by reaching from his bunk and
nudging him with a chair. He could only see his legs as the wall
between the toilet recess and the cell/sleeping area juts out slightly.
He failed to get a response, and was asked by the second OSG to get
out of bed, switch on the in-cell light and wake him up. The cell mate
complied with the instruction. He informed the second OSG that he
appeared to him to be dead and had hung himself as his cell mate had
seen a lace leading from his neck to, what he thought, were the
window bars. The man was wearing a t shirt and boxer shorts.
74. The second OSG held a cell key in a sealed pouch but did not
use it to effect entry into the cell and both OSGs stated that they did
not use it to enter the cell because, being OSGs, neither were C&R
trained. The cell was double occupancy and one of the occupants was
visible and mobile. On the grounds of personal safety, the
investigation team view this decision as appropriate.
75. The first OSG tried to radio for assistance, but the battery on his radio
failed immediately and the second OSG used his instead. The
message was timed on the log kept by the Control Room operator at
05:15. There are varied accounts of the content of the radio message,
but it was sufficient to alert other staff to the incident. The second OSG
states he used the term “Code Blue” in the message which is a
recommended “traffic light” system to alert staff that the incident
includes a person who is in difficulties with breathing, including
incidents of suspension and enables them to respond with the
appropriate equipment. No other members of staff recalled hearing the
term “Code Blue” in the message.
76. One member of staff stated that he heard the term “we’ve got a
swinger” or “someone’s swinging” but the second OSG denied that he
would use either term and no other staff say they heard either term,
most saying that the message was indistinct. The NOO told the
investigation team that the Control Room operator interrupted the
message to inform him that there was an incident on A Wing.
It is recommended that all staff at HMP Hull use the correct
terminology and avoid inappropriate terminology when
broadcasting radio messages.
76. The second OSG stated that the A Wing Response Officer attended
“within seconds” of the radio message. Within a minute the Oscar 2
officer arrived from D Wing and as Oscar 2 he carried a cell key. The
Oscar 2 officer failed to get a response from the man by calling through
the door and could not see him via the toilet recess spyhole or
observation hatch. He was the first officer to enter the cell. He saw the
man’s cell mate sat on the bottom bunk and appearing in shock and
the man in a seated position in the toilet recess area, under the window
at the back of the cell.
77. The Oscar 2 officer saw a ligature from around the man’s neck to the
window catch above, and he lifted his body up slightly and cut the
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ligature. He checked him for vital signs – breathing, pulse and
heartbeat, but found none present. He described to the investigation
team the discolouration of his body and initial indications of rigor
mortis. He noticed a training shoe near to him had a lace missing and
rechecked the ligature and realised that it was a lace.
78. The Oscar 2 officer and others described that he was seated in the
toilet recess area, under the window with his legs stretched out straight
in front of him. Initially the Oscar 2 officer prevented other staff from
entering A6/9 in order to preserve evidence.
79. The NOO heard the radio message from the second OSG. As it was
indistinct, he was contacted by Control Room staff to inform him of an
incident on A Wing. He contacted the nurse by telephone and, as
nurses do not carry keys during the night duty period, he arranged for
her to be collected by a member of the response team. He then
attended A6/9 and at 05:15 he and the Oscar 2 officer were joined
there by the nurse.
80. The nurse examined the man and concluded that there were no vital
signs and, given the appearance of his body, that there was nothing
more she could do for him. She comforted his cell mate, who was still
seated on the bottom bunk and visibly distressed.
The investigation team considers that the decision by the Oscar 2
officer and the nurse not to attempt CPR was in accordance with
the prison’s guidance, which states …In cases where death has
occurred sometime prior to discovery and rigor mortis has set in
e.g. body stiff, dependant discolouration etc. resuscitation should
not be attempted.
Staff involved in dealing with the incident are to be commended
for their speedy response.
81. The NNO allowed the man’s cell mate to get dressed and he was
moved to another cell on the same landing, the nurse accompanying
him and arranging for a hot drink to be provided. Within a few minutes
he was transferred to B Wing and located in a cell with two Listeners
for support.
The investigation team consider that the support given to the
man’s cell mate was sympathetic and entirely appropriate.
82. However in allowing the cell mate to dress in his own clothing and
move cells potentially compromised the preservation of evidence. The
NOO described that he could not preserve his clothing as he had no
access to evidence bags of an adequate size.
It is recommended that the NOO’s office is supplied with an
adequate stock of varying sizes of evidence bags. Cell A6/9 was
treated by the police initially as a crime scene.
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83. The NOO and the Oscar 2 officer went out of the cell. The Oscar 2
officer commenced a log of those attending the scene and the NOO
began the activation of the prison’s relevant Contingency Plans.
The investigation team acknowledges the commendable actions
of the Oscar 2 officer. He acted entirely appropriately in applying
the actions in an attempt to preserve life and in the preservation
of evidence.
84. The nurse remained near A6/9 and briefed the two paramedics who
arrived on A Wing at 05:36. They entered the cell and informed the
nurse shortly afterwards that there was nothing they could do for the
man who is the subject of this report. The nurse then left and returned
to the Healthcare Centre.
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Post Incident
85. Following the prison’s contingency plans, a doctor was contacted and
requested to attend. At the time of the incident the doctor cover was
provided by a locum service, and the doctor on call refused to attend
the prison. However a police doctor was contacted and attended at
06:30. Other police officers attended from 05:50.
It is recommended that the agreement with the locum service is
reviewed as a matter of priority and that a specific condition that a
doctor is required to attend the prison in such circumstances is
included.
86. The Staff Care Team representative arrived on A Wing at 06:20, an
Independent Monitoring Board member at 06:50 and the Duty
Governor at 06:53. The man was identified to the police by an A wing
officer at 08:30.
87. At 08:20 prisoners on both sides of A6/9 were relocated to alternative
accommodation on the wing. Of the prisoners interviewed by the
investigation team, none had been aware of the nature of the incident
until later in the day.
88. At 10:04 undertakers attended and removed the man’s body from the
prison and the cell was again secured.
89. Notices to inform staff, prisoners and visitors of the man’s death were
issued later on 3 October by a prison governor.
Family contact
90. Attempts were made to contact the man’s relatives. He had provided
the telephone number and an incomplete address for his next of kin,
his mother. However the telephone number gave a “discontinued
service” tone. The man’s fiancée was listed as a further contact at their
address in Grimsby and she was visited by the police that afternoon
and informed of his. She had no contact details for his mother, who
was traced by police and informed on 4 October.
91. The Governor of Hull wrote to his mother and fiancée offering
condolences and providing contact details on 5 October.
92. The man’s mother asked the prison to communicate with one of the
man’s uncles and this was undertaken by a prison governor, who also
kept in touch with his fiancée, until the Ombudsman’s Family Liaison
Officer took over responsibility for family contact.
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Support for staff.
93. Generally staff involved were supported by the Duty Governor and the
Staff Care and Welfare Team after the incident and a “Hot” debrief was
held by the Duty Governor. The staff informed the investigation team
that they felt adequately supported.
Specific concerns represented by the man’s family
95. Through their communication with the Family Liaison Officer, the man’s
family raised a number of matters, which are listed below together with
the findings of the investigation:
* concern about the wellbeing of his cellmate and the prison staff
involved in the incident, issues which have been covered earlier
in the report
* they asked why he was not on a “suicide watch”.
In the short time that he was in the prison he was assessed in
some depth by three separate members of staff, all of whom
were suitably experienced and qualified. None of the staff
identified that he presented a particular risk of self-harm or
suicide. This was ratified on the CSRA by the Duty Governor.
Consequently, it was appropriate that he was allocated a
standard shared cell with another prisoner. Also he had talked
to several other prisoners whilst in police custody and the
prison, several of whom had been in custody previously. None
of those prisoners thought he was at particular risk.
* it appears that he used a shoelace, possibly from a training
shoe, as a ligature and some of his family believed shoelaces
were removed from prisoners upon arrival.
When this question was asked it was explained that laces are
not routinely taken from prisoners. He had not been found guilty
of an offence and was held on remand and so entitled to wear
his own clothes and footwear. He chose to wear prison clothing
with his own trainers.
Subsequent enquiries of Prison Service Headquarters give
further reasons for not routinely removing shoelaces include:
• removal of shoelaces (or other items) could displace the means of
suicide to other materials
• many prisoners might find removal of such items distressing and
humiliating
• the attention of other prisoners could be drawn to vulnerable
people, by the absence of shoelaces or other items, whose distress
would then be worsened
• knowledge by prisoners that admission of suicidal feelings would
result in removal of items might discourage such prisoners from
seeking help.
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* his family requested details of other materials known to be used as
ligatures.
HM Prison Service have data indicating that bedding is the most
common material used as a ligature. Between 1999 and 2004
bedding was used in this way in an average of 67% of self-inflicted
deaths by suspension and shoelaces in 17%. The other specified
ligatures include clothing and belts.
* his family asked what other potential ligature points are in prison
cells.
As well as window catches, there are other potential ligature points
in standard cells, including window bars, taps, tubular metal bed-
ends, cell door hinges and light fittings.
HM Prison Service is converting some cells into “safer cells” with a
reduced number of ligature points. A Wing has four such cells, all
designed for single occupancy. As he was not identified as at risk
of suicide or self harm, he was not located in a “safer cell”.
It is recommended that the Prison Service reviews the
provision of “safer cells” on the First Night/Induction unit at
HMP Hull, to establish whether it is feasible and desirable to
provide double occupancy safer cells in that area.
It is also recommended that the draft First Night Centre Policy
Document is formally introduced and publicised as soon as
practicable, as some staff remained confused as to the
purpose of the safer cells on A Wing.
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The post mortem
96. A copy of the post mortem report is attached as an annex to this report.
97. The post mortem was conducted on 3 October and concluded that the
cause of the man’s death was by hanging. Opiates (which include
heroin), morphine, dihydracodeine and a trace of cocaine were
detected in his body, but it was concluded that the drugs did not
contribute to his death.
The Clinical Review
98. A review of his medical care whilst in custody was undertaken by
Eastern Hull Primary Care Trust and a copy of her report is attached as
an annex to this report.
99. The clinical review addressed six specific questions, which are listed
below together with the findings:
• Why was a suicide self harm form opened by the police?
It was actually opened by the escorting contractor’s staff (GSL).
• Was this due to the history of self harm five years ago?
Yes.
• On suicide self harm form Q5 what does intermittent observation
mean?
This is not relevant in his case as such a form was not opened.
Observation frequency is normally specified in the
documentation in form F2052SH or, if the circumstances of an
individual case require a different frequency, it should be
specified.
• First reception health document completed by a nurse, but what
qualifications does he possess?
The nurse’s qualifications and experience is explored earlier in
this report.
• Action Plan section states referral for substance misuse, but
does not state as to when this should occur.
This was due to completed once the man saw the doctor, due
on Sunday 3 October.
• What provision had been made to ensure that he was managed
during his withdrawal from both drugs and alcohol?
This is dealt with earlier in this report. The follow on care was
due to be formulated when he saw the doctor which was due on
Sunday 3 October.
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100. Four learning events were identified in the Clinical Review:
• That notes should be clearly written, signed, timed and dated.
The person writing the notes should also print their name and
designation.
• The documents require to be fully completed and if deviating
from instructions then reason why stated on the record.
• When recommendation is for onward referral details of this
require to be recorded.
• Identified follow on care to be documented.
Operational issues
101. Following major incidents a Post Incident (Operational) debriefing
should be carried out. No such debriefing took place following the
man’s death and there appears to be no provision for such a debriefing
in the prison’s contingency plans.
It is recommended that the prison’s contingency plans are
amended to include provision for Operational debriefings to take
place following major incidents.
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Findings & conclusions drawn from the
investigation
102. I am satisfied that the man who is at the centre of this report was
assessed appropriately regarding his potential risk of self-harm and
suicide. In the few hours he was at Hull, he had considerable contact
with several staff and other prisoners. He underwent three interviews
by experienced staff during which his risk was assessed. The
evidence is that he presented no signs which require the
commencement of self-harm or suicide monitoring procedures or the
need to locate him in anything other than a standard shared cell.
103. This is reinforced by several other prisoners who had contact with him
during this period, all of whom were surprised and shocked at the news
of his death. As well he spoke to his fiancée and her sister during the
Saturday afternoon. His tone of voice, general demeanour and the
conversation about future events gave no rise for concern.
104. The man’s cellmate gave a detailed account of their interaction during
the late afternoon and evening period of 2 October, which gave no
indication that he was particularly upset, unwell or distressed. There
are no indications that he tried to alert staff during the evening or
overnight. He left no written indications of his state of mind at this time.
105. He had expressed concerns about receiving a long sentence this time,
and knew that he was due to appear in court (via videolink) on
Wednesday 6 October. He had previously told his fiancée of his
worries that, should he get a lengthy sentence, she might not wait for
him. He was also concerned that he had a chronic and acute drug
problem.
106. There are concerns regarding the lack of provision of assessment and
dispensing of detoxification. He received medication whilst in police
custody but, because he arrived at the prison on Saturday morning,
there would have been a lengthy delay before he would be assessed
for medication and a further delay for it to be dispensed.
107. The action of the staff attending the incident was appropriate. The
OSGs rightly did not enter the cell and did raise the alarm. Staff
attended very quickly and an ambulance was called, which also came
promptly. The Oscar 2 officer showed commendable presence of mind
in checking for the man’s vital signs of life and taking action to preserve
evidence, to the extent that he commenced a log of those entering the
cell. Both he and the nurse decided not to attempt CPR and, given
their description of the appearance of his body, this was in line with the
prison’s guidance.
108. The prison’s contingency plans were correctly put into operation. With
one exception, all staff interviewed said they were adequately
supported. I also consider the care and support extended to the man’s
cell mate to have been appropriate.
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Recommendations and good practice
National Recommendations
1. The Prison Service should review the provision of “safer cells” in the
First Night/Induction unit at HMP Hull to establish whether double
occupancy safer cells are feasible and desirable.
Local Recommendations
2. The induction leaflet should be reviewed as the print is small and the
contents, especially of the initial pages, is complex and not of
immediate relevance to those possibly at risk.
3. The arrangements for assessing and dispensing detoxification
medication at the weekend should be reviewed.
From arrival at the prison it would have been more than 24 hours
before the man would have been assessed for such medication.
4. The First Night Centre Policy Document should be implemented as
some staff remained uncertain as to the purpose of the safer cells on A
Wing.
5. Staff at the prison should be reminded that individual statements must
be made following an incident.
6. All staff at the prison should use the correct terminology and avoid
inappropriate terminology when broadcasting radio messages.
7. The NOOs’ office should be supplied with an adequate stock of varying
sizes of evidence bags.
8. The agreement with the locum service should be reviewed as a matter
of priority and include a specific condition that a doctor is required to
attend the prison in circumstances such as these.
9. The prison’s contingency plans should be amended to include
provision for Operational debriefings following major incidents.
11. The learning events identified in the Clinical Review should be used to
improve practice:
• Notes should be clearly written, signed, timed and dated. The
person writing the notes should also print their name and
designation.
• The documents require to be fully completed and if deviating
from instructions then the reason why should be stated on the
record.
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• When a recommendation is for onward referral, details of it must
be recorded.
• Identified follow on care must be documented.
Good practice
12. The method of providing prisoners on the First Night Centre with
Samaritans’ contact details by stencilling the information on interior cell
walls is good practice.
13. The decisions by the Oscar 2 officer and the nurse not to attempt CPR
were appropriate and in accordance with the prison’s guidance, which
states “…In cases where death has occurred sometime prior to
discovery and rigor mortis has set in e.g. body stiff, dependant
discolouration etc. resuscitation should not be attempted.”
14. The actions of the Oscar 2 officer were commendable. He acted
entirely appropriately in attempting to preserve life and preserve
evidence.
15. The support given to the man’s cell mate was sympathetic and entirely
appropriate.
16. It is good practice that induction leaflets are routinely issued to
prisoners on arrival.
17. It is good practice that Duty Governors examine all CSRAs and
routinely record their comments.
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GLOSSARY OF TERMS
ACCT Assessment, Care in Custody and Teamwork (a
revised monitoring system for those at risk of self
harm/suicide – not yet introduced in HMP Hull)
CARATS Counselling, Assessment, Referral, Advice &
Throughcare Service (for prisoners with substance
misuse problems)
CC Crown Court
Comm Service Community Service
Contingency Plan An emergency plan of action following a serious
incident
CPR Pertaining to Chest (Heart and Lung) resuscitation
C&R Control & Restraint
CSRA Cell Sharing Risk Assessment
DC Detective Constable
Detox Detoxification
DTTO Drug Testing and Treatment Order
EMT Emergency Medical Technician
F 2050 Prisoners Main Core Record
F 2050a Prisoners Wing Record also called History Sheet
F2052SH At Risk of Self Harm Record
F2169 First Reception Health Screening Form
FTS Failure to Surrender (to Court)
Gov/Governor Governor (Senior Managers), Graded A-F
GSL Global Solutions Limited (contracted escort
service)
HCO Health Care Officer
HCSO Health Care Senior Officer
HMP Her Majesty’s Prison
HMCIP Her Majesty’s Chief Inspector of Prisons
HMYOI Her Majesty’s Young Offenders Institution
Hotel Radio Call Sign for medical staff
IEP/IEPS Incentive and Earned Privileges (Scheme)
IMB Independent Monitoring Board (was Board of
Visitors)
IMR Inmate Medical Record
JR’d Judge’s Respite (convicted but unsentenced)
Juv Juvenile
Listener A prisoner trained by the Samaritans to provide
support to other prisoners
Mags Magistrates (Court)
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MC Magistrates Court
MHIRT Mental Health In-Reach Team
MO Medical Officer (doctor)
NOO/Night Orderly Officer Member of staff in charge of the prison at night
NoK Next of kin
Observation Book A general compilation of staff observation of
prisoners in a particular area
Off/Officer Prison Officer
Oscar 1 Radio call sign for the Night Orderly Officer
OSG Operational Support Grade
Pegging A system allowing managers to check whether a
Night patrol has patrolled their area during the
night
PER Prisoner Escort Record
PO Principal (Prison) Officer or Probation Officer (in
context)
POA Prison Officers’ Association
PPO Prisons and Probation Ombudsman
PSI Prison Service Instruction
PSO Prison Service Order
Remand Prisoner held in custody before conviction
Roll check A visual check and count of all prisoners
SO Senior (Prison) Officer
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List of Annexes
1 Terms of Reference
2 Post mortem report
3 Clinical review report
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