Individual at Jersey

Circumstances surrounding the death of a man at HMP La
Moye in September 2006
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2007
This is the report of my investigation into the death of a man at HMP La Moye,
Jersey, in September 2006. He had been received in the prison less than 24 hours
earlier. I offer my sincere condolences to his family, friends and all those touched by
his passing. The man was 29 years old.
Since April 2004, the office I lead has been responsible for investigating all deaths in
prisons in England and Wales. My terms of reference also encompass the deaths of
residents of probation hostels (Approved Premises) and those held in immigration
detention. By September 2006, I had initiated over 500 such investigations.
I have not conducted this investigation under my formal powers – which do not
extend to Jersey – but as a result of an invitation from the Minister for Home Affairs.
Her letter made clear that, notwithstanding the absence of any official locus, I was to
conduct the investigation in line with the policies and protocols I had developed over
the previous 30 months in relation to the Prison Service of England and Wales. I
should emphasise that I have been afforded the utmost assistance and courtesy from
all the authorities and others in Jersey.
Both because I believe it is right in principle, and because it is required to ensure
compliance with Article 2 of the European Convention on Human Rights, an
important element of all my investigations is to involve the bereaved family. I am
most grateful to the man’s parents for agreeing to meet me at this most painful time
in their lives. I have endeavoured in this report to address the many questions they
raised.
I am also most grateful to the Governor of La Moye and to the Chief Probation Officer
and their respective colleagues. I must also thank the staff at Silkworth Lodge, a
residential treatment and rehabilitation centre for alcohol and substance abusers.
They have all given most willingly of their time and, in turn, I have endeavoured to
feed back my emerging findings to them. I should also mention the huge assistance I
have received from the Jersey Police. They conducted a comprehensive
investigation of their own, and this has enabled me to limit the number of additional
interviews required and to concentrate on wider issues of policy and practice.
I am conscious that some of my recommendations have significant resource
implications. I fear that is unavoidable. As in England and Wales, the majority of
prisoners entering La Moye are drug users with all the vulnerabilities associated
therewith. At the current level of resourcing, the prison cannot properly exercise its
duty of care to those in its charge.
Stephen Shaw CBE
Prisons and Probation Ombudsman for England and Wales March 2007
2
Contents
Summary 4
How I went about the investigation 6
The man’s history of self harm 8
Jersey Probation and After Care Service 10
HMP La Moye 12
Previous deaths in custody in Jersey 15
The man’s previous periods in La Moye 16
Preparation for release 18
The man’s short period at liberty 20
Silkworth Lodge 21
Contact with probation 22
A last chance 24
Police custody 25
Reception at La Moye 27
The discovery of the man hanging 33
Contingency plans 35
Post mortem 36
Family liaison 36
Examination of the issues 37
Resettlement 37
F2052SH 37
Alleged bullying by staff 39
Discharge from Silkworth Lodge 41
The man’s missed appointment with the Probation Service 42
ADS 43
Sharing of information 45
Reception at La Moye 45
Detox 47
First night arrangements 47
The man’s cell 48
Food 49
Anti-bullying 50
CPR 51
Conclusions 52
Recommendations 53
3
Summary
The man was found hanging in his cell in HMP La Moye at lunchtime on Saturday 2
September 2006. He was 29 years old and had been received into the prison the
day before. This was by no means his first spell in custody and he was well known to
prison staff and other prisoners alike.
The man had been released from a two year sentence on 7 July. He had gone from
prison to Silkworth Lodge, a residential treatment and rehabilitation centre for alcohol
and substance abusers. However, he did not adjust well to the strict regime there,
and was asked to leave after just 10 days. He slept on a friend’s sofa for a few days,
but then found himself accommodation and secured a place at college to study for a
degree. He soon reverted to drug use. He sought help from the Alcohol and Drugs
Service (ADS), but they were unable to offer him an appointment until 4 September.
In the interim, the man was arrested by the police in connection with allegedly
receiving some stolen mobile phones. He spent two days at the police station before
being remanded to prison.
The man was withdrawing from drugs at the time of his reception and had been given
diazepam whilst in police custody. He was prescribed dihydrocodeine and diazepam
at the prison.
No risk of self-harm was identified during the reception process at La Moye, but the
man asked straightaway to be segregated from other prisoners as he feared
repercussions from some of them. (He did not explain the nature of his problems
with these other prisoners.) He was allocated to E wing, which serves as a
vulnerable prisoner unit1 (VPU) and a segregation unit. The man was given a meal
when he arrived on the wing, but thereafter refused to leave his cell to collect food.
In fact he left his cell just twice (both times escorted by an officer) - once to collect hot
water and once to use the phone.
Nevertheless, a number of staff came into contact with him at various times. The
man apparently seemed his normal self, if a little more subdued and quiet than usual.
No one identified a risk of self-harm.
At about 1:00 pm on the day of the man’s death, an officer went to his cell to give the
man his medication. He found the cell door flap covered. On entering the cell, he
saw the man hanging from a pipe running the length of the ceiling. The officer
summoned assistance and staff tried for some time to resuscitate him. An
ambulance arrived at 1:30 pm and took over the resuscitation attempt, but the man
was pronounced dead on arrival at the hospital at 2:28 pm.
1 The vulnerable prisoner unit in La Moye does not carry the same connotations as it would in an
English prison, where it would largely (but not exclusively) signify a wing reserved for sex offenders
and those who have committed crimes against children. The unit reflects the small island community
that the prison serves in that many prisoners (and staff) will know each other and may well have
reason to avoid one another. The VPU principally holds those who may face bullying on the standard
wings. HM Chief Inspector of Prisons found that many of the prison’s ethnic minorities (principally
Madeirans) were lodged in the VPU.
4
The man’s parents’ principal concern relates to the period between their son’s
release from prison and his return there. They have asked questions about the
support he was given to stay clean of drugs and stay out of prison. They have also
questioned why their son was not watched more carefully on his return to prison, and
have suggested that he might have been bullied by staff during his previous time
there.
I have explored what happened between 7 July and the date of the man’s death. I
conclude that the man’s release was well planned and that appropriate support
mechanisms were in place. I have some concerns about the decision to ask the man
to leave Silkworth Lodge2 and the absence of a fall back plan. Having said that, I am
satisfied that appropriate support was available to the man from the Probation
Service and that they took steps to help him. However, I am critical of the fact that
the ADS was unable to give him an appointment until 4 September.
A number of factors might have pointed to the man being considered at risk of
suicide on his reception at La Moye – he had self-harmed several times in the past,
he was withdrawing from drugs, he feared repercussions from other prisoners. He
was also returning to prison just two months after being released, as he had said, for
the last time, and he felt he had let everybody down. Nevertheless, I am satisfied
that he was properly assessed for risk and it would not be appropriate for me to
second guess the conclusions of the staff who saw and spoke to him at the time.
Nevertheless, I am concerned about shortcomings in information sharing and that the
man was not put on intermittent observations on account of his withdrawal from
drugs. In addition, I am critical of the withdrawal process in operation at La Moye. I
also note that the man did not have a television in his cell.
I have considered the family’s concerns about bullying by staff, but have found no
evidence to substantiate them. However, I consider whether the prison’s response to
the man’s fears of repercussions from other prisoners was adequate, and whether
they might have been expected to read more into the fact that the man took no food
for some 20 hours. I suggest that staff might to some extent have been conditioned
in their response to the man by their experience of him during his previous periods in
custody.
I have nothing but praise for the response of staff after the man was found hanging.
They acted promptly and professionally and I am satisfied that everything possible
was done to try to save his life. Systems for giving the ambulance access to and
egress from the prison also worked well. Finally, I commend staff at the prison for
the way they have engaged with the family since the man’s death. The man’s
parents were grateful to a particular member of staff who attended the prison on his
day off to speak to them. In addition, they especially asked that I should single out a
another officer for praise and thanks. They told me that their son thought the world of
this officer, and they particularly appreciated the fact that he and others attended the
funeral. In the sad circumstances leading to this report, I am more than happy to
record their comments here.
2 Silkworth Lodge is a private organisation, and it is beyond my remit either to criticise or (directly to)
make recommendations.
5
How I went about the investigation
On 7 September 2006, I received a faxed letter from the Minister for Home Affairs in
the States of Jersey. The letter invited me to investigate a death that had occurred at
HMP La Moye. It promised the full cooperation of the Governor and his staff and
unfettered access to all prison information, documents and individuals.
The Minister advised that my investigation should follow the policies and protocols I
had developed whilst investigating deaths in custody in England and Wales and
asked that I should:
• Establish the circumstances and events surrounding the death, especially as
regards management of the man by the relevant service or services, but including
relevant outside factors;
• Examine whether any change in operational methods, policy, practice or
management arrangements would help prevent a recurrence;
• Examine relevant health issues and assess clinical care;
• Provide explanations and insight for the bereaved relatives; and
• Assist the Viscount’s inquest by ensuring as far as possible (in line with
obligations arising out of Article 2 of the European Convention on Human Rights)
that the full facts are brought to light and any relevant failing is exposed, any
commendable action or practice identified and any lessons from the death
learned.
Given the nature of the request, I determined that I should conduct the investigation
personally. I have been assisted in this by one of my Deputy Ombudsmen, who is a
registered clinician and who conducted a clinical review of the man’s care. Her
review is annexed to this report. (The normal arrangements in England and Wales
whereby the relevant Primary Care Trust commissions its own clinical review as part
of my investigation do not apply in Jersey where all General Practitioners are in
private practice.) I was also assisted by one of my Family Liaison Officers (FLOs)
and an Assistant Ombudsman.
I first visited Jersey on 11 September. I met the Governor, saw part of the prison and
inspected the cell that the man had occupied. I also spoke to other senior staff, the
Chairman of the Prison Officers’ Association and the Vice Chairman of the prison’s
Board of Visitors. I also obtained copies and originals of the man’s prison records,
including his medical record.
In line with my normal practice, I asked for notices announcing my investigation to
both staff and prisoners to be posted. These explain the nature of my investigation
and invite people who have any relevant information to contact me. (In the event, no-
one did.)
I was fortunate to meet a Detective Inspector and a Detective Sergeant of the States
of Jersey Police with whom I agreed arrangements for the sharing of information in
line with the protocol between my office and the Association of Chief Police Officers
(ACPO). With their agreement, I immediately took a statement from the Roman
Catholic chaplain at La Moye.
6
The same day, I met with the Deputy Viscount of the Royal Court to explain the
nature of my investigation, its likely timetable, and the contribution I hoped it would
make to the inquest over which the Deputy Viscount would preside. He readily
agreed to supply the post mortem examination and toxicology reports. In turn, this
report and all the evidence upon which it is based will be submitted to him.
Finally, I met the Minister and the Chief Officer of the Home Affairs Department. I
told the Senator that my investigation would need to look at the man’s contact with
police and probation, as well as his time in prison custody. She kindly agreed to
facilitate this with the relevant authorities. Subsequently, the Minister chaired a press
conference at which I spoke to members of the local media.
I returned to Jersey two days later when I received a dossier of the documents and
statements that the police had gathered so far. I visited the custody suite at Rouge
Bouillon Police Station where the man had been held following his arrest and
received a very useful briefing. A meeting with a Superintendent was also extremely
helpful in explaining the nature of the crime problems that Jersey faces. I also took
the opportunity of returning to La Moye to collect additional documentation, to meet
the designated liaison officer (a senior unit manager), and to share some initial
thoughts with the Governor and his deputy.
Accompanied by the FLO, I met members of the man’s family on Thursday 16
November. I am most grateful to the Family Liaison Officers appointed by the States
of Jersey Police for making the arrangements.
On the same day, the Assistant Ombudsman visited the prison and interviewed three
of the prisoners from whom the man had said he feared repercussions and who had
been reported as threatening him between 1 and 2 September. She also interviewed
the prison’s drug counsellor.
The Assistant Ombudsman returned to Jersey on 29 November to visit Silkworth
Lodge and speak to staff there. She also met the Chief Probation Officer, with three
of his colleagues. They gave her a considerable amount of their time and provided a
very useful briefing comprising background information and details relevant
specifically to the man. The Assistant Ombudsman also obtained from them various
documents relating to the period between the man’s release and arrest.
Finally, The Assistant Ombudsman obtained statements from some staff at La Moye,
and interviewed others, addressing specific questions relating to the man’s care at
the prison.
A copy of the draft report was sent to the Governor of La Moye and to the man’s
family. Relevant extracts were sent to the Probation Service, Silkworth Lodge and
the Alcohol and Drug Service. This final report reflects their comments.
I should like to emphasise that I and my colleagues have received the very fullest
cooperation from all the authorities in Jersey and from staff at Silkworth Lodge.
7
The man’s history of self-harm
The man had some history of self-harm. The 2005 social enquiry report noted:
“What are of increased concern are issues relating to self-harm or suicide. He
made a number of attempts to take his own life, during 2004, when he
discovered that his partner became pregnant with a baby he knew (correctly)
would be born addicted to heroin. [The man] said that he tried to hang himself
in June 2004 and later attempted suicide by overdose. He said he is more
tempted to do this when his problems become too difficult to deal with and it
offers him some form of resolution to his difficulties. In 2001, he described
again attempting suicide through carbon-monoxide poisoning. When in
custody, [the man] said that he feels fine and has never attempted to self-harm
or commit suicide whilst in prison. He states that this risk has reduced since
last year as his relationship issues appear to have stabilised and he does not
presently have suicidal intentions.”
The police statement given by the man’s girlfriend and mother of his younger child is
a powerful document. She recounts one of the 2004 instances of self-harm. She
was pregnant and she and the man had had a disagreement:
“As I walked into the room, [the man] had a belt around his neck, he was
standing on a step ladder and he was connecting the other end of the belt to
the electric cable which hangs down from the ceiling and is connected to the
light bulb. I had to climb up the ladder to loosen the belt which was getting
tighter around his neck …”
This turned out to be a chilling foreshadowing of what was to come.
The next day, the girlfriend asked the man why he had done this. He had replied that
he got these thoughts, felt he was a bad person and that it would be better for
everyone if he was not here. She had told no one else about this.
In August 2004, the man had told someone from the Alcohol and Drugs Service that
“he was depressed and suicidal. No particular reason just woke up feeling that way.
Says this sometimes happens and may not last too long …”
On previous sentences at La Moye, the man had been subject to monitoring under
the F2052SH system.3 The first time was in August 2005 after he was found to have
inflicted a wound to his chest with a razor blade. He also threatened to swallow the
blade. The F2052SH recorded that he self-harmed because he had been moved to
the block [segregation unit] and felt victimised by staff. The form was closed after the
man was adjudicated upon, given a suspended punishment and warning and
returned to his cell. It was noted that the trigger for his self-harm had therefore been
removed. The form was closed the day after it was opened.
3 F2052SH is a Prison Service process for caring for and monitoring those identified as being at risk of
suicide or self-harm.
8
The second occasion was in April 2006, after he again inflicted (superficial) cuts to
his chest and a cut to his head. The form recorded that he said he felt unable to
cope – he was due to be released in 13 weeks and did not feel strong enough to
resist drugs. He also said he felt under threat both within the prison and on the
outside and was concerned about bullying by another prisoner. The form was again
closed after about 24 hours.
9
Jersey Probation and After Care Service
Jersey Probation and After Care Service (JPACS) is a department of the Royal Court
(the equivalent of the Crown Court in England and Wales). Some Jurats from the
Royal Court form the Probation Board.
The Chief Probation Officer (CPO) told The Assistant Ombudsman that JPACS is a
service that has not lost its traditional social work approach. It provides information
to the courts and supervision to offenders via probation orders, community service
orders and voluntary contact. Most of the probation officers are generalists, although
there are a small number of specialists. JPACS has 38 employees (27 full time
equivalents), and compiles 600 – 700 reports and administers approximately 200
Probation Orders and 200 Community Service Orders per year. Automatic prison
throughcare started only on 1 July 2006. JPACS is also involved in family court
welfare work for which they prepare about 24 reports a year.
HM Chief Inspector of Probation inspected JPACS in 2005. The Chief Inspector
commented:
“We … have been impressed by the willingness of managers and staff to be
subject to external scrutiny. We see all this as very indicative of the service’s
innovative approach to the supervision of offenders, improving wherever
possible the current levels of performance, and continuing to enjoy the respect
of government, sentencers and the various other organisations with which it
works.
“The service has many strengths. It is well managed, has excellent
information systems, and pays significant attention to the outcomes of its work.
“… The introduction of a computerised case management and management
information system had been a very positive step, providing ready access to
relevant data for both practitioners and managers. The service had achieved
most of its KPIs4 in 2004 and was constantly looking to improve service
delivery, arranging evaluations, inspections and reviews of its work, both
internally and externally. Standards for the delivery of supervision had been
introduced across most areas of practice. The service was also an innovator
and had introduced a number of schemes such as mentoring, volunteer tutors
and restorative justice to complement and add value to the work of busy
probation staff. The extent of partnerships with other organisations - statutory,
contracted and voluntary - was excellent, with partners and courts having a
positive view of probation as a trustworthy, can do organisation.
“… There was a high completion of the assessment of reoffending using LSI-
R5 and interventions were targeted accordingly.
“… Inter-agency work in terms of liaison with partners and the reinforcement of
the work they had undertaken was a real strength, as was the range of
4 Key Performance Indicators.
5 Level of Service Inventory-Revised.
10
programmes available for a relatively small service. There was much positive
work on reintegration issues but, on occasions, more direct work on offending
behaviour both pre and post-programmes and with those not undertaking
programmes would be desirable ... Alcohol has been identified both by the
service and our inspection as a significant factor in crime, and we would
suggest a review of interventions available for this need.
“… There were some good examples of work to reintegrate offenders back
into the community, including linking them with partner organisations to
achieve this ... The service had an excellent record of measuring progress
through reductions in LSI-R scores and was able to both demonstrate success
and identify who would be most likely to benefit from intervention. Work had
been undertaken with sentencers to try to reduce the number of inappropriate
cases being placed under supervision.”
Of probation orders closed in 2004, 81 per cent of medium to high risk probationers
and 51 per cent of highest risk probationers reduced their risk of reoffending as
measured by LSI-R.
11
HMP La Moye
La Moye is Jersey’s only prison, and for this reason serves a wide variety of
functions. It is a prison for both men and women, for adults and young offenders,
and for both remand and sentenced prisoners. In total, it had 184 places at the time
of the man’s death (a new wing has since been opened). The Vulnerable Prisoner
Unit is made up of two wings - C and E. C wing has three levels, totalling about 23
cells. E wing has two levels and 21 cells. The normal daytime staffing level is three
staff for E wing and two for C wing.
The purpose of a death in custody investigation is quite separate from that of an
inspection by HM Chief Inspector of Prisons. However, I necessarily audit policies on
such matters as anti-bullying and safer custody, and I also review how far the
findings and recommendations of the Inspectorate have been implemented. I have
therefore reviewed those aspects of the Chief Inspector’s reports that seem to me to
be relevant to the circumstances of the man’s death.
La Moye has been inspected twice by HM Chief Inspector of Prisons. The first
inspection was carried out by a team led by the former Chief Inspector between 2 - 6
April 2001. The former Chief Inspector’s report was written explicitly, “with the aim of
providing a platform for further development”.
Relevant to this investigation are the then Chief Inspector’s findings that:
• A high population of prisoners felt safe on their first night in custody.
• “The suicide awareness policy was good and this was reflected in practice. There
was a need for ongoing staff training in this important area.”
• An anti-bullying strategy should be introduced throughout the prison.
• An exceptionally high percentage of prisoners said staff-prisoner relationships
were either good or very good.
• Few cells had integral sanitation. This was “disrespectful to prisoners.”
• The drug detoxification programme offered to prisoners “was not comparable with
that provided in the outside community.”
• Drugs offences accounted for over half the offences with which prisoners had
been charged.
• The Inspectorate were impressed by the quality of many of the staff conducting
reception procedures. “Prisoners identified as at risk of self-harm or suicide were
risk assessed in Reception and all new receptions were seen by a member of the
Healthcare Team as part of the initial reception procedures.”
• Prisoners “did not always have access to a range of suitable activities to occupy
themselves during their first night.”
• “Prisoners should receive … a comprehensive, multi-disciplinary induction
programme, which should include useful information about: Anti-bullying …
Copying with custody … Drugs Awareness … Listeners Scheme/Samaritans …
Suicide Awareness … [35 other subjects]”
12
• “There were many ligature points in cells … we recommend examination of the
‘Safer Cell Project’6 established by the Prison Service of England and Wales.”
In para 4.06 of the Report, the then Chief Inspector noted in respect of drug using
prisoners:
“On entry into the prison all prisoners were screened by Health Care staff for
substance misuse. For those addicted to heroin or opiates there was a
standard programme based on the use of dihydrocodeine to reduce the
severity of withdrawal symptoms. While this was an adequate response for
some prisoners, it was not sufficient for those who had been using larger
quantities of drugs such as heroin or methadone … in respect of drug using
prisoners, prescribing decisions should be made according to individual need
rather than to a standard formula … Health Care staff should liaise with the
Community Alcohol & Drug Service to develop new guidelines for the
detoxification and treatment of those with substance misuse problems.”
On suicide and self-harm issues, HMCIP commented:
• “… we found a staff culture which implied that ‘suicide’ issues belonged
primarily in the medical and nursing domain … We recommend that refresher
training in suicide and self-harm awareness be given to all staff at least once
in every year following the year of appointment.”
• Entries in F2052SH (Self-Harm & Suicide Alert Form) were generally good.
The Suicide Awareness Group should meet at least bi-monthly. Links with the
Samaritans were strong but there was not a dedicated Samaritans telephone
line.
• The immediate screening of all new receptions by Healthcare staff for self-
harm risk was “an example of local good practice.”
• The Vulnerable Prisoner Unit was “well managed”. Only four out of the 24
prisoners held there were sex offenders. There was “absolutely no systematic
and effective casework intervention to address the needs of the VPU prisoners
nor any visible attempt to transfer them to normal location in the prison and
both issues should receive urgent remedial action.”
• Healthcare services were rated highly by prisoners. The Chief Inspector said
the introduction of a clinical computing system should be considered.
A second inspection was conducted at La Moye between 27 June -1 July 2005 by the
current Chief Inspector. In the introduction to her report, she recorded that few of the
recommendations the Inspectorate had made four years earlier had been actioned:
“As a consequence, the safety and security of prisoners and staff, and the likelihood
of prisoners’ rehabilitation, were compromised.” HM Chief Inspector reported:
• “La Moye lacked proper first night or induction procedures, and a large
proportion of men and women felt unsafe on their first night.”
6 The objective of this project is to provide cell design solutions to minimise impulsive suicide attempts
without stigmatising the occupant, so that, for example, all obvious ligature points and sharp edges are
removed.
13
• “Prisoners told us that bullying was a serious problem, yet there were no
systems to deal with it …”
• “ … the vulnerable prisoners unit … was itself a location for bullying.”
• “Suicide and self-harm procedures were in place, though they relied too much
on healthcare staff …”
• “The detoxification protocols were not in line with best practice, and resources
were insufficient to introduce methadone. The treatment regime was judged to
be safe, if not ideal.” (I note that 41 per cent of the prisoners she surveyed
reported experiencing drug problems on arrival at La Moye.)7
I judge these findings to be particularly relevant to this case. HM Chief Inspector’s
report also repeats many of the other findings made by her predecessor four years
earlier. I note, for example, the very limited extent to which prisoners’ resettlement
needs are met. This again is relevant to this story, given the repeated nature of the
man’s offending and periods of imprisonment.
HM Chief Inspector noted that the proportion of prisoners who said they felt unsafe
on their first night had doubled since the earlier inspection to 30 per cent. She wrote
as follows:
“An example of some of the comments we received was from an adult male
prisoner who said: ‘the first night, I won’t forget for the rest of my life how
depressed and painful I was in the cell.’”
She was also strongly critical of the physical conditions on E wing (the Vulnerable
Prisoner Unit, in which the man was located).
Three aspects of the prison relevant to this investigation were praised by the Chief
Inspector: the strength of staff-prisoner relations; the approach to suicide prevention;
and the clinical care given by Healthcare.
A central plank in the Chief Inspector’s recommendations was the establishment of a
Prison Improvement Plan. I understand this is now in place and work has begun, but
the full-year costs are in the region of £1 million plus some 'one off' capital costs.
7 The Chief Inspector also recommended that a properly constituted complaints system be introduced.
Although not relevant to this investigation, as an Ombudsman for prisoners I cannot let pass the fact
that La Moye does not have such a system. I strongly endorse the Chief Inspector’s proposal.)
14
Previous deaths in custody in Jersey
Two prisoners who were known to each other killed themselves at La Moye in quick
succession in 1995. One, aged 24, died by hanging on 18 July 1995. His friend,
aged 21, died by the same means on 9 August. He had actually attended his friend’s
funeral.
I understand a 64 year old prisoner died in early 2006, following an accident at the
prison when he broke his leg. He was taken to hospital and operated upon, but died
as a result of complications arising from the operation several days later. My
experience generally in England is that non-self-inflicted deaths also benefit from an
independent investigation. In particular, such an investigation can consider whether
the prisoner has received equivalent care to that he or she would have received in
the community, as well as decisions about temporary release, access to
hospitals/hospices etc. I recommend:
The States of Jersey should consider what arrangements are in place to review
deaths in custody from natural causes.
15
The man’s previous periods in La Moye
I have not felt it necessary to review all of the man’s back records covering previous
periods in custody. However, I am grateful to the prison authorities for providing me
with a variety of papers that throw light upon his personality and character.
A note in his F2052A Record of Events (history sheet) of 27 March 2005 reads,
“Hasn’t taken him long to get back to his old ways i.e. trying to manipulate staff and
constantly demanding.” Other entries refer to the man being idle at work,
argumentative, disruptive, “keeps trying to beat the system.” Notes on 30 April 2005
and 3 May 2005 refer to allegations that he was bullying others. There are other
references to disagreements with staff and prisoners, to threatening to assault a
member of staff, and to climb on the roof. He faced several disciplinary
adjudications. A not atypical entry reads, “Has had a fairly quiet week by his
standards although we know he’s probably up to something.”
The man appears to have been by turns both bullied and bully and this was
instrumental in determining where in the prison he was located. In a letter to the
Minister for Home Affairs dated 14 July 2005, he refers to his location in the VPU
“because I get bullied on the main wing.”8
There are further references to bullying on 8 September 2005 (“He uses his [i.e. the
victim’s] religion, race and language as tools”) and two on 13 September (“Bullying
several other inmates for canteen and medication.” “Due to threats from [the man] it
has become necessary to move [named prisoner].”) The man who died was
removed to the segregation unit as a consequence. On 14 September, an entry
reads, “I received information today that [the man] was planning to scald [another
named prisoner] with boiling water.”
Subsequent entries include:
25.12.05 “… demanding all day”
01.01.06 “Still trying it on all the time”
04.01.06 “Constantly disruptive and demanding”
There was also evidence of fallings out with other prisoners:
05.01.06 “[The man] … said he was under threat on ‘C’ wing”
14.01.06 “… allegedly involved in a fight”
21.01.06 “[named prisoner] … told me that [the man] had spat in his
window”
25.01.06 “[The man] is trying to control the weaker inmates”
8 The letter, which concerned a relatively trivial matter that should have been settled much earlier, also
contains the poignant line, “This is not my first time in prison, yet I hope it will be my last.”
16
30.01.06 “[The man] is up to his bullying tactics again …”
05.02.06 “[The man] has been bullying [named prisoner] …”
15.02.06 “I was informed today that [the man] is down to his old tricks of
bullying again”
These entries, which continued until his release, were made by a number of different
officers.
The Record of Events (F2052B) indicates an unwillingness to be unlocked at the
same time as another prisoner (21-22 March 2006). On 10 April 2006, an entry
reads: “He made a comment about nobody listening to him and that he might have to
cut himself to get listened to. I told him this was not the way to get people to listen to
him. He agreed.” It is not apparent that any other action was taken. The same
officer also records on 19 April: “Became very demanding. Trying to get me to do
something for him (seemed like anything would do).”
The man spent at least two periods in segregation, one of which lasted for several
months. It is not clear whether this was as a result of his bullying others, his attitude
to staff (the reason he was apparently given for being segregated), or for his own
protection (the reason Unit Manager gave The Assistant Ombudsman for his
segregation). An entry on 10 April 2006 reads:
“He is under threat from [named prisoner] and possibly [named prisoner] and
others, he has bullied [two named prisoners] on ‘E’ wing. He is under threat
from [named prisoner] and has threatened [named prisoner] on ‘C’ wing.”
During June, two entries record that the man had given up his work because of fears
for his own safety.
On 20 June, he was due to meet the prison probation officer but, seeing people from
the VPU in the yard, the man refused to walk past them. The escorting officer said
he could not lock everyone up just so that the man could have a visit and so he
decided to return to his cell.
He was released from La Moye on 7 July.
The man kept a diary whilst he was in prison. This provides an interesting
counterpoint to the official record. The diary mainly sets out issues and concerns the
man faced rather than detailing his daily life at the prison. It records the many small
irritations and frustrations that follow the loss of liberty. For example, the man
devotes quite a lot of space to the delay in issuing him an aerial for his television as
well as difficulties in resolving a complaint about his laundry having gone missing.
He also refers to a long running saga over the wearing of work boots which he said
were too small. The diary describes his interactions with various other prisoners and
members of staff and his thoughts about them. At various times, he appears to have
been in conflict with different people (both staff and prisoners). A strong sense of
frustration and injustice also permeates the diary, and it is clear that the man thought
17
some staff were unnecessarily rigorous in their application of the rules. He also
complains that people failed to get back to him when they said they would, and about
being given different information by different people.
The diary and the wing record together provide a telling account of a challenging
relationship as seen from both sides.
The Unit Manager told The Assistant Ombudsman that by the end of his sentence,
the man was not coping well with imprisonment. Staff and prisoners alike were
familiar with his scams and ruses and he found it more difficult to manipulate them.
He had also caused a lot of friction with prisoners throughout the jail, so that
wherever he went he was likely to face a degree of hostility from some quarter or
other.
Preparation for release
In her police statement, the prison’s drugs counsellor spoke of her role at La Moye
and of first meeting the man in October 2003. She said he participated in both group
work and one-to-one sessions on drug and alcohol awareness. This included
relapse prevention work, leading her to be quite sanguine about his prospects on
release:
“Before he left in July 2006, he had improved dramatically, he was focussed
on his goals to remain drug free, make a life for himself and return to higher
education … I really felt when he left he was ready for life outside prison and
to achieve the goals he had set himself … [The man] had been so positive
planning his future, he had not shared or shown any suicidal tendencies at all.”
She told The Assistant Ombudsman:
“I had known [the man] for three or four years. My first contact with him was in
prison. We did some one-to-one work and I also treated him with
acupuncture. In addition, he attended group work, completing all the
assignments. The course consisted of 12 sessions and included talking about
addiction, neuro-biology, relapse prevention, blood borne viruses, sexually
transmitted diseases and the impact of drug use on the family.
[The man] genuinely engaged with the programme ...
He had made plans to prevent his relapse following his last release from
prison. He had worked on this during the previous five months and completed
a large number of assignments very well. I was not expecting him back at all.
When I heard he was back, I thought it was perhaps the final small relapse
before he finally got himself sorted out. One of the things that convinced me
of [the man’s] genuine intent to sort himself out was that he never once said
that he would never go back to prison. Lots of the drugs users said this, but
[the man] never did. I got a strong sense from him that he had had enough of
being the way he was. This was perhaps a sign that if he did relapse, he
would not be able to cope with it ... He had stopped smoking and was
hyperactive in setting up plans for his release.
18
[The man] had a place to live on release and was going to work on the 12 step
programme. This included assignments, one-to-one counselling and group
sessions. At first, he was nervous about going to Silkworth Lodge because it
was a very structured environment. However, I talked to him at length about it
and prepared him thoroughly for the move.”
In her police statement, the prison’s psychologist also refers to the man’s positive
approach at the end of his two year sentence: “He was at the end of his sentence
saying that this would be his last sentence as he had to now change and knew his
biggest hurdle was the heroin problem.” Like every other witness, she had no
concerns about self-harm.
On 2 May, a RAMAS9 meeting was convened, as probation staff were aware that the
man had a history of domestic violence and that he was planning to live with his
girlfriend on release. They therefore wanted to assess the degree of risk presented.
The meeting was attended by representatives from probation, psychology, the prison,
housing and Midvale Road (a halfway house). A note of the conference (which the
man attended) recorded amongst other things that he was “highly institutionalised”
and that there were indications of personality disorder. It was proposed that he
should be formally assessed. It was noted that he had used heroin since 1998 and
that he minimised or did not acknowledge his alcohol use. Apart from the proposed
treatment at Silkworth Lodge, the man was reported as saying he would maintain
contact with ADS. His probation officer was also to chase up the man’s application to
attend Highlands College, while Midvale Road was to assess him whilst he was at
Silkworth Lodge. The man was assessed as being at medium (level 3) risk of self-
harm/suicide with high (level 4) risk of seriousness (that is, that if he self-harmed or
attempted suicide it would be serious).
The plan drawn up at the meeting was that the man would complete the programme
at Silkworth Lodge (paid for by the States of Jersey) before moving to a halfway
house for a further period before he was released fully into the community. In
addition, the man had applied for, and been granted, ‘voluntary aftercare’.10 This is
essentially a support mechanism for those who are in some way vulnerable. It would
have meant a probation officer helping over securing welfare benefits, visiting him at
Silkworth Lodge and monitoring his substance misuse.
9 Risk Assessment, Management, and Audit Systems. The Probation Service uses RAMAS for risk
assessment, partly because it looks at both risk to the self as well as risk to others.
10 Voluntary aftercare or supervision is a client led arrangement, which continues for as long as the
client feels it has value.
19
The man’s short period at liberty
Silkworth Lodge
Silkworth Lodge is an in-house rehabilitation centre. Its programme follows the AA
12 step model, which provides a model for living. It takes a holistic approach to
alcohol and substance misuse. Clients stay for around eight weeks, completing four
or five of the steps. The programme mainly revolves around group therapy (three
sessions a day are held, dealing with different issues), but there is also individual
counselling. All potential clients are carefully assessed beforehand. Part of the
purpose is to establish whether their motivation is sufficient to complete the course.
It claims a high success rate amongst those who do so.
The man had the option of a ‘celebratory weekend’ after leaving prison, but chose
instead to go directly to Silkworth Lodge.11 The Assistant Ombudsman spoke to a
counsellor at the Lodge. He told her that every day is completely structured and
there are fairly strict house rules. These are set out in detail in writing, but a member
of staff also goes through them verbally with each new resident. Clients are required
to sign up to the rules because they form part of the therapy – they help to provide
structure and discipline to people whose lives can be chaotic. It is about re-
establishing moral standards and providing a bridge to normal living.
The counsellor said the man was clean and sober when he arrived and was initially
quite positive, even enthusiastic. However, within a week, it became clear that he
was not fitting in with his peer group. The work involved delving into honesty levels
and, while the man was sometimes honest, he did not always tell the whole truth. He
was challenged about this by his peer group, but there was never any sign that this
annoyed him - he was quite laid back and would apologise to the group for whatever
he had or had not done. The counsellor said the group accepted this for a while, but
soon tired of it. In addition, the man was not keen on doing his TDs (Therapeutic
Duties – housekeeping tasks around the Lodge, which all clients were expected to
carry out as part of the regime). Although he started to engage with the programme,
it was quickly apparent that it was not working for him.
Commenting on a draft extract of this report, a Senior Counsellor at Silkworth Lodge
advised that disruption, “which may involve a client’s lack of commitment to the
treatment programme, can have a damaging and negative influence on the whole
peer group.” She said this was addressed by the counselling team and a clinical
decision was made to discharge the man. She added that, “transition from a prison
environment can always be a difficult period for a client and every effort from the staff
at Silkworth is made to address this crucial ‘settling in time’”.
The discharge summary from Silkworth Lodge said:
11 The placement was (swiftly) facilitated and funded by ADS. The Director of ADS, advised that the
national picture for access to residential rehabilitation would normally be three months or more, but
that the man who died was admitted to Silkworth Lodge on the day of his release.
20
“Response to treatment
[The man] appeared at first to settle in quite well. He had no problem with his
stepwork but could not or would not adhere to the disciplines set down at
Silkworth and constantly challenged staff.
In the end he was asked to leave the group who all agreed with the decision.
Treatment outcome
[The man] was asked to leave Silkworth on Monday 17 July 2006.
Prognosis
If [the man] wishes to remain clean he must attend AA/NA12 meetings, without
this the prognosis for [the man] is not good.
Follow up support
[The man] has the fellowship of AA and NA.”
The man’s parents had a number of concerns about why their son was “expelled”
from Silkworth Lodge. His explanation for his eviction was that he did not report
someone else for leaving the hostel via the window when they should not have been
going out.
The family had also heard that the manager who agreed to their son’s enrolment was
off sick so was not there to advise on his management. They had also heard that the
decision might have been made by a vote taken by the other residents. They
wondered if their son had refused to do group work within the hostel as residents
were permitted to smoke during these sessions, whereas their son had recently given
up smoking.
The Assistant Ombudsman asked about each of these. She was told that the man
constantly flouted house rules. The counsellor said the man continually had to be
asked to do things or not do things and was told the same things day after day. This
had a negative impact on the group and that was why they voted for him to go. (The
senior Counsellor said in her letter that it he was discharged as the result of a clinical
decision, not a client group vote.) The counsellor also said that the activities of
another resident had absolutely nothing to do with the man’s departure (in fact, he
was accommodated in a single room).
The counsellor advised that the Director was absent from the Lodge at the time due
to ill-health, but said all the staff were fully qualified (one was a trainee) and they
were overseen at the time by the Board of Trustees. Nothing was done any
differently in the man’s case from what would normally happen.
12 Alcoholics Anonymous and Narcotics Anonymous.
21
Finally, the counsellor said there were no issues about people smoking in the group
session. There was only one small area in the Lodge where people could smoke.
The whole of the rest of the building is non-smoking. If anything, it would have been
the smokers who suffered.
Contact with probation
The Assistant Ombudsman spoke to the Chief Probation Officer and his colleagues
(including the man’s most recent probation officer) at Probation Service HQ. They
said that successful completion of the Silkworth Lodge programme was an important
element of the man’s post custody care. The man’s probation officer met him and
the programme co-ordinator at the Lodge on his first day there and visited him again
on 10 July. She recorded:
“He looked well and said that his first weekend, at liberty, had gone very well
… We had a general discussion about [the man’s] situation and, as usual, he
said all the right things – he does not wish any contact with [his girlfriend] or
the baby whatsoever as he feels that he will be lured back into his previous
lifestyle, including drug misuse – he said that when [the boy] is old enough he
will try to seek him out and he is ok with that. He does not wish any
distractions whilst he is at Silkworth and wants to concentrate on maintaining
abstinence and focusing on his college course. I agreed to write to [named
person] Highlands, giving her the information she needs … Although, this is a
voluntary arrangement, we agreed on weekly contact, in the first instance.”
On 17 July, the probation officer received a letter saying the man had been asked to
leave Silkworth Lodge.
The man went to Probation on the day he was discharged, and was seen without an
appointment. He said he felt he was victimised at Silkworth Lodge as he was the
only drug user – all the others were alcohol users. He did not consider he was
getting the same service as everybody else. Staff at the Lodge said he was not
ready to go through the programme, but the man said this was not the case. He said
he was motivated. However, he had issues with some people there who queried why
he was taking up valuable resources when he had just come out of prison and was
clean and sober.
The Probation Service offered the man help to find accommodation but he declined
it, saying he wanted to sort something out himself. On 21 July, he called at the office
with his son (his girlfriend had offered him contact) and said he had found a rented
property but did not have enough money for the deposit. He had saved a significant
sum whilst in prison but needed an additional £40. The Probation Service lent him
the money and also provided him with an Active Card, which gave the holder free
access to a gym and pool. They wanted to help the man use his time constructively.
He attended the probation office as agreed on 24 July and then again unplanned on
25 July and was still actively engaged in sorting out his accommodation and pursuing
arrangements with the college. However, on 31 July, the man missed a pre-arranged
22
appointment and was sent a letter on 8 August offering him another appointment for
14 August.13 He duly attended but said he had relapsed.
The man had approached ADS following his release in July. He wanted an
appointment so that he could get a prescription but was told he could not have one
for three weeks. On 14 August, the probation officer took the man to see a colleague
at the Probation Service14, as he said he was using again. (The probation record of
contact said, “he feels [his ADS appointment] is too far away and that he will be in
prison before this appointment”.) The colleague contacted the Alcohol and Drugs
Service on his behalf, informing them that the man had reported that he had been
using a £50 bag of heroin a day for the last three weeks. He explained that the man
had been given an appointment for 4 September, but that he said he could not wait
that long. The colleague added that the man had contacted a doctor, but the doctor
could not help until the man had been seen at ADS. ADS advised the next day that,
“We are down in staff and people on holidays. This is the first available appt. If there
is a cancellation he can have it but otherwise he will have to wait. Everyone else is
the same.”
The colleague suggested that the man should provide a sample so that he could be
given a prescription on the day of his appointment (ADS will not prescribe without a
positive sample15). The man had not been able to provide a sample at the time, but
had surprised the colleague by going back later and giving one.
The man’s girlfriend described to the police his strong feelings for his son but the
pressures he was under:
“[The man] was saying he was getting sorted, he had his flat which he was
proud of. He was going to college and was wanting to go on the subutex,
which he had to wait three weeks for … He was fully aware he had to prove he
was getting himself sorted before I would fully take him back.”
“I know [the man] was back on heroin … Even though he was upset about
getting sorted, the heroin was just an infill until he got the subutex, he was
counting down the days. He had a future and had a future with his son if he
got himself sorted.”
She confirmed that the man was under the influence of heroin when he was arrested.
13 Some time between 31 July and 8 August, the Assistant Chief Probation Officer met the man by
chance in the street. The man indicated that all was well and said he was grateful for the probation
officer’s help.
14 The colleague straddles the Probation Service and the Alcohol and Drugs Service (ADS), spending
three days each week with the former and two with the latter. The role ensures there is a strong
working relationship between the two organisations.
15 The issue of prescribing methadone and subutex in Jersey has been very controversial because of
concerns that they would become available illicitly. However, DF118s (dihydrocodeine) had been a
huge problem in itself and it was eventually agreed that methadone and subutex may be prescribed in
very carefully regulated circumstances. ADS may prescribe the drugs. They are administered daily
under very tight supervision, and always washed down with water thereby preventing ‘spits’. The
strategy has proved successful so far with no ‘leakages’.
23
Despite this, she said she had no reason to fear the man might take his own life on
his return to La Moye. However, he had expected “to get probation once arrested as
we spoke about this before the police arrested him.”
The man was arrested on 29 August. Following his arrest, he phoned his probation
officer twice from the police station. He was coherent and not upset or crying, but
was concerned about having let everyone down. He was disappointed in himself.
The probation record of contact said:
“[The man] was very apologetic and said that he had tried everywhere to get
help with his heroin addiction but no one wanted to know. He felt that he was
going to end up back in prison and would lose his accommodation. I said that
… he should tell the Magistrate that he has been seeing me on a voluntary
basis. The Magistrate may then bail him and ask for background reports (this
is a bit of a long shot but may help prevent him being remanded in custody).”
The probation officer briefed the Probation Service court duty officer about the man’s
circumstances so that the Magistrate would be aware that the Service was providing
support to him (the man) should he (the Magistrate) decide to grant bail.
A last chance
A statement from the Roman Catholic chaplain helpfully offers details of the man’s
short period at liberty.
He had first met the man on C wing in March 2006. The man was not religious but
the two men had gone to the same school (Victoria College). The chaplain had
visited the man in the segregation unit and they had talked about what would happen
on his release. The man had indicated a wish to remain in touch.
The man had been very positive about Silkworth Lodge at first, but after 10 - 14 days
he had been discharged and called at the chaplain’s house. With assistance from St
Saviours’ Parish, the chaplain had helped him find a home (a single room in a
house).
The two men then lost contact until Sunday 27 August when the man arrived at the
chaplain’s door, obviously in a bad way and asking for money. That evening he
returned, agitated and distressed.
The chaplain’s statement says that the man regarded this period of liberty as his last
chance. However, the chaplain says that, despite his swings of mood, he never
indicated to him a desire to self-harm.
24
Police custody
Following his arrest, the man spent 48 hours in police custody before being
remanded to La Moye. (I am struck that people spend far longer on average in the
police custody suite than would be the case in England.)
I visited the custody suite. Although I have no expertise in policing matters, it
appeared clean and fit for purpose. However, I am told it is very busy at the
weekends with intoxicated/addicted prisoners and there may be staffing implications
therefrom.
According to the police custody record, the man was arrested just before 9:00 pm on
29 August on suspicion of breaking and entering, larceny and receiving stolen goods.
He arrived at Rouge Bouillon Police Station just before 10:00 pm. He told the police
he had a “banging headache”. As is normal practice in police stations, his belt was
removed from him and placed in a sealed bag. It was returned to him on transfer to
court.
The Risk/Medical Assessment form recorded under question 7, ‘Have you ever tried
to harm yourself?’: “In 2001 attempted suicide by carbon monoxide poisoning.”
However, the custody sergeant judged there were no present concerns regarding
self-harm.
The medical form recorded, “He is on diazepam.” The man was prescribed two 5mg
tablets of diazepam and a paracetamol for his headache. The medicines were
dispensed at 10.42 pm. The diazepam was repeated at 12.50 pm on 30 August with
a further single tablet at 9.30 pm. The man continued to request medication and
further single dosages of 5mg of diazepam were dispensed at 10.35 am and 7.20 pm
on 31 August.
In her police statement, the police surgeon who treated the man on 29 August said
that he had told her he was on diazepam detox and was taking six 5mg tablets daily.
He told her he had taken two tablets that morning as well as two Neurofen plus. The
following day, she ascertained that the man was only actually prescribed four 5mg
tablets daily and was due to be reduced to three. (However, as noted, he was
actually prescribed less than this reduced dosage while in police custody.) In a
second statement, the surgeon said the man had denied using any non-prescribed
illicit drugs. She said that, from previous dealings with him, she knew he was a poly-
drug user but she was “unable to confirm this at that time as he would, or could, not
produce a urine sample.”
By chance, the same doctor also examined the man after his death. Her statement
concludes: “[The man] was seen on the 29th August 2006 whilst in custody and he
did not overtly or covertly make any mention or suggestion of self-harm. I was
therefore surprised and saddened to examine his body …”
A statement from the Forensic Medical Examiner who saw the man on 30 August,
reports that the man said he had never self-harmed or taken street drugs since 2004.
When the man gave a sample of urine for testing (he had declined to do so when
asked by the police surgeon the previous day), it was positive for cannabis, opiates
25
and benzodiazepines. The man claimed that he could have been exposed to
cannabis accidentally and accounted for the finding of opiates by saying he had
taken two Neurofen Plus. The doctor’s statement doubted that the threshold for the
opiate test would have been met by Neurofen Plus. He said of his assessments of
the man: “I have no reason to believe that [the man] was at greater risk of self-harm
than any other prisoner.”
The police officer who gave the man his breakfast on 1 September also recorded that
he had no undue concerns and was “quite shocked to find out what had happened to
him.” The officer on duty at court (who had known him for ten years) also said he
showed no evidence of wanting to take his life.
Whilst in police custody, it was recorded that the man made repeated use of the cell
buzzer and that, “It was made clear that this behaviour was unacceptable and that he
needed to realise and understand that whilst his needs will be catered for that will be
done at our pace and not his.” He also frequently requested cigarette breaks but
declined meals on a number of occasions.
On Wednesday 30 August, the man phoned the chaplain. The chaplain noted in his
statement to the police that the man’s attitude to the police could be confrontational
and he kept ringing the bell. The chaplain offered his help and advised the man to
tell the police the truth.
In his conversation, the man was worried about his accommodation and offered the
chaplain the keys. (The chaplain declined after consulting with police.) He made a
further call asking for motorcycle magazines and puzzles. The man asked the
chaplain to attend court and he saw him there at 9.45 on Friday 1 September. He
recorded that he had no sense of any suicidal ideation at that time. (The chaplain did
not know what amount of heroin the man was using or what detoxification he was
receiving.) Unfortunately, the man’s case did not come before the magistrates before
the chaplain had to leave some 1¼ hours later.16
The man was charged with five counts of larceny. He pleaded not guilty to all the
charges and was remanded in custody by the magistrates until 15 September.
So far as I can judge from police statements, he ate a police breakfast (a bacon roll
and a cup of tea) on the morning of 1 September, and had two cups of tea while at
the Magistrates’ Court.
16 The chaplain’s police statement includes the following: “At no time whilst with [the man] did I get the
impression of suicidal ideation … Again, whilst at the police station on Thursday did I not get any
impression from [the man] of suicidal ideation.”
26
Reception at La Moye
In her police statement, the man’s mother said her son was not expecting to go to
prison so soon after his release a month earlier and that he was not expecting to be
kept in custody when he went to court on Friday 1 September.17 She added:
“When I spoke to [the man] he said everything had gone wrong. His Probation
Officer did not attend [court]. He thinks she may have gone to the Royal Court
and [the chaplain] who had been there for him had to leave because his case
was so late. The court did not believe he had a flat, and that he had asked for
help at probation and drug and alcohol as he knew he was slipping.”
On arrival at La Moye at about 1:00 pm, the man was first processed through
reception by an officer. The officer said: “[The man] is moody but I’ve never
considered him to be depressed. I certainly never thought he would take his own
life.” Because he was not subject to an Exceptional Risk Form (a form that comes
with the prisoner from court or the police), he returned to the man the bag of
possessions that had been taken from him at court. These included his leather belt
He said in his police statement, “On the say so of the Healthcare Team, I issued [the
man] with his belt back.”
In a second police statement, the officer said he was not aware of live self-harm
forms on the man’s personal records, as these files were not kept in the reception
area. No reference is made by (discipline) reception staff to existing prison records
during the reception process.
The man signed a Private Cash/Property Handing Out form to hand out two sets of
keys to clear property from his flat. The keys were to be picked up by his mother or
by the Roman Catholic chaplain. He had the clothes in which he had been arrested
and £2 in cash. He gave telephone details of his mother, the chaplain, probation, St
Saviour’s welfare and a friend.
During the reception process, the officer opened a new prison record for the man.
He noted that the man was using drugs and would be seen by healthcare. Under
‘any other comments’ he noted the following:
“Stated he cannot go onto normal location and has been threatened by friends
of the residents of E-wing.”
The officer listed four named prisoners from whom the man said he expected
repercussions. The man completed a Request for Segregation form. The
segregation under Rule 38A form was witnessed by the officer and countersigned by
the Unit Manager. The reason for segregation was given as “Due to threats that I
expect from other prisoners.” Further detail is given as follows:
17 The police advised me that no other outcome was likely. However, it is possible that the man might
have been influenced by his probation officer telling him that he should apply for bail on grounds of his
voluntary contact with the service, his placement at the college and the fact he had secured
accommodation for himself. Her view when Miss McMurray spoke to her was that the decision could
have gone either way, but that the court were probably swayed by his recent release from prison and
his offending record.
27
“Expects repocutions [repercussions] from prisoners: [four named].”
The man explained in his police statement that ‘Senior Management’ considered that
the safest location to place the man would be an area on E landing, which was part
of the VPU. He said this was judged to be the most appropriate area as the man
could mix with other prisoners but, if there was trouble, his area could be made safe
by closing a dividing gate between it and the rest of the unit. I understand that the
governing Governor was present by chance during this discussion and that he
agreed.
The Assistant Ombudsman asked why the man had not been placed instead on C
wing, given that several of the prisoners from whom he feared repercussions were
located on E wing. She was told that the man had on other sentences been involved
in various problems with prisoners located on C and E wings, and it was felt that E
wing was the best option at that point in time, partly because of the ability to gate off
part of the corridor and partly because of the higher staff to prisoner ratio. The Unit
Manager told The Assistant Ombudsman that staff would have expected that the
man would gradually integrate with the prisoners (including those with whom he had
difficulties) over time. He said it was not possible to overstate the man’s
interpersonal skills and that he would have been able to overcome any antipathy
towards him.
The man went from the officer to a healthcare officer for a health screen. (All
Healthcare Officers are nurse-qualified; the prison’s doctors are from a local GP
practice.) The healthcare officer’s incident report form, following the discovery of the
man’s hanging, included details of the first reception health screen:
“… I was satisfied that [the man] showed no subjective signs of low mood, and
he denied any thoughts of self-harming or suicide … he maintained good eye-
contact … there was no indication or symptoms to suggest low mood. In
addition, there was no Exceptional Risk Form from the police … I did not deem
it necessary to place [the man] on an F2052SH …”
In his police statement, the healthcare officer said he conducted a drug/alcohol
history with the man in which he admitted to using half a gram of heroin a day which
he smoked: “He denied cannabis use, but he did say he used Benzodiazepines,
specifically Valium, which he was prescribed 20mgs a day by his GP, and all illicit
supplies he could get hold of.” The man had said he had been treated for depression
in the past (as an in-patient) but denied being low in mood or having suicidal
thoughts.
In a separate police statement, the healthcare officer said he was aware of two self-
harm forms held on the man’s personal records file but, from his overall assessment
and based on his interview with the man, he did not consider it was necessary to
place him on special observations.
The healthcare officer advised The Assistant Ombudsman that, during reception
healthcare screening, he would refer to previous Inmate Medical Records (IMRs),
Bomic (the healthcare database) entries, any correspondence from police/probation
28
and previous custodial records - either paper or electronic, where available. He said
Exceptional Risk Forms were listed on Page 1 of the database and that all events
(including self-harming) are held on Bomic.
The healthcare officer repeated that the man came over as generally pleasant and
“his usual self”. His only concerns were with regard to his medication/detoxthe
healthcare officer said the man did not mention previous instances of self-harm but
that he asked him if he had any thoughts of harming. The man denied any such
thoughts. The healthcare officer said he would have recorded if he observed any
objective symptoms of low mood (guarding, poor eye-contact, monosyllabic
responses), but none of these was noted. He added that the man was coherent and
his speech was not slurred (the reception officer concurred with this).
The Governor told me that the prison does not offer methadone as it does not have
the resources to administer it properly. The main GP is not convinced that
methadone is clinically the best method of detoxification. The man was therefore
prescribed dihydrocodeine and diazepam. (I understand that this prescription
differed from that the man was given in police custody because he admitted at the
prison that he had been smoking 5g of heroin per day – something which he had not
admitted to the police surgeon. A urine sample also tested positive for
benzodiazepine and opiates.)
The healthcare officer told The Assistant Ombudsman that staff would have been
advised verbally that the man was on a detoxification programme, as this would have
imposed restrictions on the patient, such as limited access to gym and sport. Details
of a prisoner commencing detoxification would also be included on the Healthcare
Daily Report, which was available to all staff. He said prisoners undergoing
detoxification for alcohol were placed on observations, due to the potential physical
dangers of withdrawing from alcohol, but these dangers were not present in opiate
and benzodiazepine withdrawal. Those on substances detoxification were therefore
not placed on special observations.
According to his incident report form, a senior officer who escorted the man from
reception to his cell. In his police statement, the senior officer said this happened at
between 4:00 and 4:30 pm (the reception officer’s statement said it was between
3:00 - 4:00 pm), and that the man was quiet and had asked if people on the wing had
been talking about his return. The senior officer said he gave the man a meal and
subsequently went back to give him a phone call to his mother. The man had to
leave a message, and the senior officer promised he could try again later. The
senior officer then went to get the man a tea pack. The man apparently asked for
water, and the officer told him there would be an opportunity to get some later. He
added:
“[The man] had given me no cause for concern at any time, I was very
shocked when I came back to find out what had happened. I am not aware of
any self-harm or attempt to take his own life previously. Although [the man]
was quiet on arrival, this struck me as being because he was worried about his
reception with other inmates, but he hadn’t been popular before he left last
time round …”
29
In his statement to the police, an officer said there was nothing on the VPU board
about any special requirements for the man (for example, extra observations for
detoxification). He said he saw him to speak to at about 3:30 pm when he opened
his cell for showers and to get ready for tea. He said he could not remember the
man saying anything to him and that the door was pushed or kicked closed from the
inside.
The officer spoke again to the man later on when the latter rang his bell. The officer
told him he could come and go as he pleased, but the man told him that he did not
feel comfortable with some of the other prisoners on E wing because of previous
incidents when he was last in prison. The officer reassured him that there would
always be an officer on the landing when the cells were unlocked. (The Unit
Manager confirmed to The Assistant Ombudsman that he insisted that his staff
maintained a presence in the corridors at all times.) He said he knew the man well
and that what he said caused him no concern.
The officer offered the man the opportunity to collect his tea from the dinner tray at
about 4:20 - 4.25 pm, but he declined because he did not want to come out of his
cell. The officer explained to the police that, “Dinners are not taken to prisoners who
refuse to collect them, so [the man] went without.” The officer said the man rang his
bell a couple of times during the evening, but he (the officer) could remember nothing
more particular.
At about 5:00 pm, a healthcare officer gave the man his medication.
The prisoner in the neighbouring cell said he heard the man talking to himself at
about 6:30 pm.
An officer said in his police statement that he was aware that the man did not want to
associate with any other prisoners and that he was frightened of reprisals. At about
7:15 pm, he collected him from his cell to facilitate the phonecall to his mother. They
initially tried the pinphone in the segregation unit as “[the man] was frightened to use
the pinphones next to gate 8 or on the landing of E2.” However, the phone did not
work and so the officer allowed him to use the office phone. The man asked his
mother to collect the keys to his flat and remove his possessions as he did not expect
to get bail. (The man’s mother said in her police statement that she thought her
son’s speech was “quite slurred” but that he did not express any intent to harm
himself. She told me that what he said was quite muddled.)
The healthcare officer from reception spoke again to the man at 8:00 pm18 when
administering his medication. He also provided a ventolin inhaler.
An officer said that, later that evening, the man was “clearly frightened and paranoid
of other prisoners,” although he did leave his cell briefly to get some hot water.
The prisoner next door told the police that he and the man chatted through the doors
at around 10:00 pm. He said the man sounded really paranoid, saying that “people
were out to get him”. The prisoner said the man was upset about coming back into
18 7.45 pm in his police statement.
30
the prison “and his head was fucked”. However, a short time later he sounded a lot
calmer. The prisoner said they spoke for about half an hour and then fell asleep.
An officer saw the man lying on his bed, apparently asleep, during roll count at 8:00
am the next day. He said he knew the man felt threatened by prisoners on the main
wing and that he had no friends on E wing either.
Another officer said the breakfast trolley was parked about 14 feet from the man’s
cell door. He said the man said he would like breakfast, “but basically he wanted it
delivered. He refused to come out and as such did not have breakfast.”
At about 8:15 - 8:30 am, the man asked an officer if the gate separating his cell from
the others could be locked so that he could shower. The officer explained that he
could not be given special treatment, and assured him that he and another officer
would remain on the landing whilst the man showered. The man did not take a
shower and re-secured his door. The officer said, “He was clearly frightened of
coming out while other inmates were unlocked.” He added, “At no time did [the man]
show any signs of self-harm or suicidal tendencies … The only thing I picked up …
was his paranoia and fear of other inmates.”
The Assistant Ombudsman asked why the gate was not closed off, given the man’s
fears. She was told that the area in which he was located was not closed off from
access by other prisoners as at least one other prisoner was housed there. It was
the practice that prisoners were able to access the accommodation, landings and
cells when unlocked for work and recreation. However, the man was seen by the
duty Unit Manager and healthcare officer in order to address his concerns. In
addition, the residential staff were very familiar with the issues the man had with
other prisoners located on both C and E wings.
Staff could not recall whether any prisoners hung round the man’s cell, and could
only say that during unlock for work and recreation prisoners were able to move
freely in the accommodation areas.
The healthcare officer who had seen the man on reception spoke to him at about
8:45 am. He said, “He had no complaints about the withdrawals, but asked when he
would receive his next dose [around 1:00 pm] … On both these occasions … I at no
point saw any indication that he was low in mood or preoccupied in any way.”
The prisoner next door said he and the man chatted for about half an hour at about
9:00 am. He told the police that the man was saying things such as, “Tell my parents
that I’m sorry for everything I have done and also that I love them.” He also said he
was sorry for everything he had said and done to the prisoner. The prisoner said
these comments made him think the man was unstable. He said the man said he
was “pissed off” with the world. The man stopped speaking when there were officers
around and waited until they had gone to start speaking again. (Self-evidently I have
no way of verifying this man’s account and it is possible he may have mis-
remembered what was said.)
An officer spoke to the man at about 9:30 am, when the latter rang his cell bell and
asked the officer to get him some hot water so he could make himself some tea. The
31
officer said in his police statement that he refused to do this, “as I wouldn’t wait on
him but I offered to escort him to get water if he wanted.” The officer said he
suspected the man did not want to get any verbal abuse. The man told the officer
that he did not want to see anybody, but eventually accompanied him to the kitchen
area. On the way, the man spoke to another prisoner (the prisoner’s police
statement revealed nothing of note). On his return to his cell, the man asked the
officer if he could go into the segregation part of the VPU, but was told he could not.
The officer unlocked the man with all the other prisoners at about 10:00 am. He said
the man pulled the door shut again straightaway. (The observation hatch was clear
at this point.)
At about 11:20 am, the officer went to the man’s cell to tell him that lunch was being
served. He said the man told him that he did not want to see anyone, and asked the
officer to get it for him. The officer said in his police statement that he:
“would not be manipulated by [the man] to be at his beck and call, so told him I
wouldn’t. I explained three staff were on hand should he be intimidated or
threatened in any way. He refused to come out. He [name], Head of Security,
had told him his meals would be brought to him. He then shut the cell door
again.”
This was the last time the man was seen alive.
The officer told the police that, “Today I found [the man] to be quite quiet. If he had
been under threat genuinely, he would have asked. He had never complained about
being threatened whilst he had been in prison on this occasion. He didn’t want to be
in E wing, he wanted to go on C wing, as the inmates are quieter and more timid …
There was no indication to me that he was suicidal.”
32
The discovery of the man hanging
The healthcare officer who saw the man on reception recorded in an incident report
form that he was administering the lunch-time medication at 1:15 pm. He said he
went to the man’s cell, noticed a “cloth/towel” obscuring the observation glass,
entered the cell and found the man hanging from a pipe that traversed the cell
ceiling. He said he immediately summoned help from an officer who was in the
corridor at the time. He said he instructed him to get an ambulance and to summon
an officer from Healthcare. The healthcare officer said the officer who had first seen
the man in reception arrived and he (the healthcare officer) instructed him to take the
man’s weight, whilst he cut through the belt that the man had used as a ligature. The
healthcare officer reported that the man was placed on the bed and that he could not
observe any breathing or pulse. He said he began CPR and was joined by another
healthcare officer who had brought the emergency equipment. He added, “From the
point of opening his cell to commencement of CPR, I would suggest was no more
than one minute.” The healthcare officer said they continued to perform CPR until
the paramedics arrived and that they continued to do so under the paramedics’
direction until the man was transferred to hospital.
The healthcare officer’s account in his police statement differed slightly, although
probably not significantly. In his police statement, he said the bed had been moved
out from the wall at an angle and it was apparent the man had used it in hanging
himself. The healthcare officer said he hit his personal alarm and asked an officer,
who was between the man’s cell and the corridor to the main VPU, for his scissors.
He said that, at this point, another officer arrived and he instructed the first officer to
get an ambulance and another healthcare officer. He said he cut the man down
whilst the officer supported him and that they laid the man on the bed and started
CPR. The healthcare officer could not recall whether the gate separating the man’s
cell from the rest of the corridor was open or closed when he arrived.
According to the officer near-by’s incident report, he saw the healthcare officer open
the man’s cell at approximately 1:14 pm. After he opened the cell, the healthcare
officer shouted to him to push his alarm. The healthcare officer asked a second
officer to assist him while the first officer secured all prisoners on E1 and E2 landings
behind their doors. (The officer confirmed in his police statement that the gate
capable of dividing the man’s cell from the rest of the unit was open at the time that
the healthcare officer arrived at the cell.)
According to the second officer to arrive, he was on duty on E2 landing when he
responded to the first officer’s alarm. He thought, but was not sure, that the gate
between the man’s cell and the rest of the wing was closed. The officer said when
he entered the cell he saw the man hanging from the ceiling by his belt. He said he
jumped on the bed, drawing his cut down scissors, but the healthcare officer told him
to support the man’s weight and he (the healthcare officer) would cut him down.
When the belt was cut, the officer laid the man on the bed and removed the ligature
from around his neck. “I could see [the man] had no colour and wasn’t breathing.”
(In his police statement, the officer said the man’s lips were blue (cyanosed).) He
said he started breathing for the man while the healthcare officer started chest
compressions. Thereafter, with the second healthcare officer, they continued CPR,
rotating the roles. The officer timed the departure of the ambulance as 1:54pm.
33
The second healthcare officer said in her incident report that her personal alarm
sounded at approximately 1:15 pm. She immediately attended cell 4 on E1 landing
and found “approx 3” officers outside the cell. The man was on his bed “very pale
and appeared unconscious.” She ran back to healthcare to collect the emergency
equipment, shouting for someone to call an ambulance.19 She returned to the cell
with an officer and took over the airway and ventilations while the first healthcare
officer and the other officer took turns with the cardiac massage. The paramedics
arrived at approximately 13:25. (I judge this was more likely 13:30, as the
ambulance service recorded the time of arrival as 13:29.) The officers continued with
CPR while the paramedics attached a defibrillator, cannulated, intubated and
administered drugs. The healthcare officer said in her police statement that she
knew the man and was surprised he had taken his life. She said she could not recall
ever dealing with him for self-harm issues.
In his incident report, an officer said that at 1:15 pm, he attended an alarm bell raised
by the officer nearest the man’s cell. On entering the man’s cell, he saw an officer
cutting the belt from around the man’s neck. The healthcare officer and another
officer helped place the man on the bed. The officer said he asked staff to inform the
second healthcare officer to bring an oxygen bottle and mask (this is a slightly
different account from that of the healthcare officer herself). According to the officer,
the first healthcare officer commenced CPR and an officer used his oxygen mask to
do the breathings. The officer then left the cell.
Another officer said in his incident report that he attended following the nearby
officer’s alarm bell. He entered the cell to assist but left once CPR was commenced.
Another officer timed his arrival at the cell at 1:05 pm (I think this must be in error)
and recorded the healthcare officer as taking charge and ordering everyone but the
officer assisting him out of the cell. The officer then ran with yet another officer to the
gate to help with the arrival of the ambulance and the locking mechanism was over-
ridden to ensure easy access for the ambulance.
Another officer said he had run to the cell at approximately 1:16 pm. He said, “I
asked [the healthcare officer] if he needed a hand to put [the man] on the floor,
instead of on the bed he said he was fine where he was.” He says it was he who
radioed for an ambulance at 1:19 pm.
The Unit Manager said he responded to a personal alarm from the healthcare officer
(I think he might be mistaken in this). He said he told all but four officers (including
the two administering CPR) to return to their posts. He briefed another Unit Manager
and asked him to check the arrangements for the ambulance. The second Unit
Manager said he would supervise the incident from now on.
According to the police statement of one of the paramedics, when he arrived the man
appeared cyanosed and was not breathing. His heart rhythm was asystole (a
straight line). Attempts to cannulate him were also unsuccessful and atropine and
19 According to the police statement of the paramedic, for some reason the ambulance crew initially
understood that they were attending an assault.
34
adrenaline were eventually administered via endotracheal intubation (directly into the
airways). Further adrenaline was administered en route to the hospital. The man
was transferred to the ambulance and taken to Jersey General Hospital at 1:50 pm.
Another officer’s incident report adds that he assisted with the medical equipment,
started an event log (at the request of the second Unit Manager) and accompanied
the man on the ambulance (where he also assisted the paramedic with CPR).
The second Unit Manager’s own incident report adds a little more detail. He said
Officer Blake called a Code Red20 at 1:19 pm and that two officers maintained a log
after the first record keeper left the prison. The Unit Manager secured the man’s cell
with a device (colloquially known as a boot) and padlock. He said the Scenes of
Crime Officer attended at 3:40 pm.
The logs maintained at the man’s cell referred to a number of items discovered and
removed by the police. They were a piece of elastic, a small broken brown plastic
bottle, and a piece of cling-film found in the man’s slop bucket. Police records show
in addition one white bottle top and a piece of cling-film. The suspicion must be that
these items were drugs paraphernalia of some kind although I see little merit in
speculating upon how they came into the man’s possession, how they came into the
prison, or their purpose. In the event, the toxicology report found nothing of
significance.21
After his arrival at hospital at 2:07 pm (2:05 pm according to the ambulance records
and 2:08 pm according to the attending doctor), staff in the Accident and Emergency
Department continued resuscitation attempts until 2:28 pm. The doctor’s report said
that the man was in cardio respiratory arrest on arrival and that his pupils were fixed
and dilated. He said, “he had ETT, IV access and neck collar was placed. CPR as
per ALS protocol for asystole was continued for a further 20 minutes. At 14:28 [the
man] was pronounced dead.”
Contingency plans
The paperwork I have seen indicates that the contingency plans for a death in
custody were put into effect very well. Comprehensive logs were maintained, all
those who needed to be informed were contacted very speedily, and the cell was
sealed as a potential crime scene. The police were in the prison just 80 minutes after
the man was found. I judge this to have been very professionally handled and I
would wish the Governor to share that sentiment with all concerned.
20 Code Red requires all designated staff to respond immediately.
21 The man’s blood was found to contain only 1.2 micrograms per millilitre of dihydrocodeine and 0.16
micrograms per millilitre of diazepam. The blood had been further screened for the presence of other
drugs and pharmaceuticals but nothing of significance was detected. The blood concentration of
diazepam was within the range generally accepted as being therapeutic while the blood concentration
of dihydrocodeine was greater than would be expected for analgesic use but was, I understand, within
the range that would be readily accepted by somebody with opiate tolerance.
35
Post mortem
The post mortem found no evidence of significant injuries beyond those consistent
with hanging and nothing to indicate that the man had been forcibly restrained or
involved in a struggle. The cause of death was given as hanging.
As noted above, the toxicology report identified small amounts of dihydrocodeine and
diazepam but nothing of significance in relation to other drugs or pharmaceuticals.
No alcohol was detected.
Multiple linear scars consistent with previous self-inflicted injuries were noted on the
front of the man’s left forearm. A small volume of partially digested food was
discovered in his stomach (suggesting that he had eaten not too long before his
death).
Family liaison
Following the discovery of the man hanging, the Senior Unit Manager telephoned his
parents so that they could attend the hospital. While there they met the chaplain.
The Governor told me that he had met the man’s father following the death of his
son. The family had been offered the chance to visit the cell where the man had
died, but had declined.
The Senior Unit Manager, along with the Deputy Governor, the reception officer who
helped with the resuscitation (who had been separately texted by the man’s brother),
and the drugs counesllor (who had been invited by the man’s mother), all attended
the funeral on 13 September.
The Governor has since written to the man’s parents to offer assistance with the
funeral expenses.
I judge that family liaison was handled well and was an example of good practice.
The follow-up within the prison was also managed well. The six staff directly
concerned were offered independent counselling. They also received an e-mailed
message of thanks and offered further support a week later.
Prisoners were assessed for risk following the man’s death. A couple of days
afterwards, arrangements were made to ensure all prisoners now have in-cell
television on their first night in custody.
The Governor told me that he would have arranged a memorial service at the prison
had one been requested, but none was. He also said he had heard that both staff
and prisoners had made inappropriate comments following the man’s death. He was
not certain this was the case, but nevertheless took prompt steps to address staff on
the matter.
36
Examination of the issues
Resettlement
Like HM Chief Inspector of Prisons, I am struck by the absence of effective
resettlement and aftercare services in Jersey. Despite substantial intervention and
support by the Probation Service and some drug counselling work, nothing appears
to have been effective in addressing the man’s offending behaviour or his re-
settlement needs, leading to successive periods of imprisonment.
I understand that voluntary aftercare has been bolstered since 1 July 2006 by the
provision of funds to enable a Probation Officer to be allocated at the point of
sentencing. This makes it more likely that prisoners will elect to continue the
relationship after release. This is to be welcomed (although it falls some way short of
a structured system of post custodial supervision). In addition, I understand that
progress is being made on facilitating prisoner re-settlement with the setting up of a
sentence management unit. This too is to be welcomed. Nevertheless, work on
resettlement needs to be driven forward and effective joint working is the key to
effective resettlement.
I recommend that the Governor at La Moye works closely with the Probation
Service in setting up offending behaviour and resettlement programmes for
prisoners.22
In addition, and notwithstanding progress currently underway:
I also recommend that the States of Jersey should review resettlement,
aftercare and offender management services for released prisoners.
I was initially surprised to learn that the Prison and Probation Services are not
currently brigaded together under the Home Affairs Department. (I am aware that the
then Chief Inspector of Prisons made a formal recommendation on this issue in the
report of his 2001 inspection.) I understand that the Probation Service itself
considers that it is best placed where it is, but I believe this is a matter that should
receive continuing attention.
I recommend that the States of Jersey considers what structures would best
facilitate consistent and seamless offender management.23
F2052SH
The man was not considered to be at risk of suicide or self-harm during his final stay
at La Moye, but I have nevertheless reviewed the prison’s response to previous
instances where he was considered to be at risk.
22 I understand that, following two one-day workshop reviews by prison and probation staff, a review is
planned for July 2007.
23 Commenting on my draft report, the Chief probation Officer disagreed with this recommendation.
He said the matter of where the Probation Service rested had only recently been considered and that
good progress was being made towards consistent and seamless prisoner management.
37
The first time was on 8 August 2005. On that occasion, I have discovered that the
F2052SH paperwork was not completed satisfactorily. It is not clear when the form
was closed, either the doctor or the unit manager did not complete the closing report,
the observations were limited in scope and the special watch sheets included entries
for 22 May 2005 that I do not understand.
I recommend that the Governor should review a selection of F2052SH booklets
to satisfy himself that they are being completed to a satisfactory standard.
It would appear that the man was placed on the F2052SH at 5:00 pm on 8 August
2005 because he cut his chest with a razor blade after being moved to the
segregation unit, a move he considered unjust. The officer responsible also
recorded, “… stated that he would [word unclear - ? swallow] the blade. Informed
him that he would have to do so and we would deal with the situation afterwards.” If
this was a fair description of the conversation, the Governor may wish to draw my
concern about its contents to the officer concerned.
The healthcare officer’s contribution to the Healthcare Assessment recorded that the
man told the doctor, “he has recently had fleeting ideas of suicide/self-harming and
he feels victimised by the wing staff; says he has had enough.” The doctor’s own
note recorded that the man would not discuss the reasons for his actions and the
words “Feeling suicidal” appear in quotation marks.
The man was placed on two observations an hour. He was due to be reviewed on 12
August and it seems probable he formally came off the monitoring at that stage,
although there are no observations after 3:50 pm on 9 August. The closing report
(which, as noted, has been completed only by one hand) reads:
“Adjudicated, given suspended sentence and warning, given his job back and
clear parameters and returned to his cell (11:00 - 09.08.05). The trigger for his
self-harm has now been removed, I do not consider him to be at risk.”
I think this was a fair judgement.
The second time a F2052SH form was opened was on 3 April 2006. A healthcare
officer opened the form at 3:40 pm. The man was again held in the segregation
block. The healthcare officer recorded her concerns as follows:
“[The man] has self-harmed, superficial cuts to chest and cut to left side of
head; has previous history of self-harm.”
“[The man] feels unable to cope, he is out in 13 weeks and doesn’t feel strong
enough to resist drugs. Also states he feels under threat both within the
prison and outside.”
The doctor’s assessment was similar:
“Self-harmed with superficial cuts. Anxious about discharge from prison in
13/52 [thirteen weeks]. Main problem appears to be bullying and threats from
others. Grandfather very ill.”
38
This time the paperwork does show that the F2052SH was closed the following day.
It is not clear if the man himself attended the review. There are references to the
man’s anxiety about his release – and his hope to be accepted by Silkworth Lodge –
and to his being bullied by a named prisoner. The support plan was to email the
drugs counsellor and someone at ADS and to discuss the bullying issue with the
Deputy Governor. I consider that this too was an appropriate response. Since both
the drugs counsellor and the person from ADS were involved in the RAMAS meeting
on 2 May which formulated a strategy for the man’s release, it also seems the plan
was properly followed through.
In England and Wales, the F2052SH is in the process of being replaced by a strategy
known as ACCT (Assessment, Care in Custody and Teamwork). In the view of my
office, ACCT is a significant step forward on F2052SH and is helping to save lives,
but proper staff training is undoubtedly key to its success. The Governor at La Moye
told me he would only want to introduce ACCT if he had adequate resources, and I
understand his caution. I note from the minutes of a Suicide Awareness Group
meeting on 4 October 2006 that sufficient resources for implementation had now
been identified. I welcome this development and recommend:
The Governor personally drives forward arrangements for implementing ACCT
prison-wide.
Alleged bullying by staff
The man’s parents told me that, since their son’s death, they had read the diaries
and notes he made during his last sentence. These talked of bullying by prison staff.
An example they gave was regarding their son’s work footwear. He complained that
he had been given boots a size too small and, when he complained to staff, they told
him to use Vaseline to squeeze his feet in. This resulted in him not being able to go
to work. The man’s mother described the diaries as upsetting to read. She and her
husband were clearly very concerned by the allegations of staff bullying and gave
copies of the diaries to the police.24
I have reduced the length of what follows compared to my draft report in light of a
suggestion that it was disproportionate to the conclusions I reach. However, I should
stress that, when speaking to my Family Liaison Officer about the draft, the man’s
mother continued to attach considerable importance to this issue and remained
concerned that she had received, unprompted, two separate accounts of her son
being bullied by staff.
I have examined what documentary evidence there is relating to the man’s complaint
about staff’s attitudes over his boots. An investigation was conducted, during which
24 I have seen a copy of a letter the man’s mother wrote to the Minister for Home Affairs following her
son’s death. She said her son telephoned her often during his previous imprisonment, “despairing of
his unfair treatment and bullying.” She said the treatment he received had destroyed his confidence
and self-esteem and that he had been close to suicide then because of this bullying. The man’s
mother added that another prisoner had told her that her son was bullied often and treated unfairly.
Someone else had reported that he was “bullied unmercifully”.
39
The man and three prisoners he named as witnesses were interviewed. One of the
prisoners confirmed that the officers picked on the man, but added that he brought a
lot of it on himself. The second said the man should not speak to the officers the way
he did and that, if he did, he had to be prepared to take the consequences. The third
said the officers were “quite petty with him; they seem to go out their way to be on his
case.”
When The Assistant Ombudsman asked the Unit Manager about this episode, he
said the man was given the size of boots he had asked for. Of course, if these
turned out to be too small, they should have been changed even so – but
contemporaneous prison records do not suggest that the man raised this as an issue
with staff.
I suspect this is a case of six of one and half a dozen of the other. I find telling the
measured response of the prisoners who were interviewed. I consider it likely that
staff did not cut the man any slack where they might have done with other prisoners,
but that this was because his reputation preceded him. It is clear from his history
sheets that he was a challenging young man and that he was often ‘up to something’.
Nevertheless, I was concerned to find amongst the investigation papers a note from
the investigating officer, setting out details of a complaint by a prisoner about the
man bullying. The man was re-interviewed on 12 July and this time he was asked if
he had been bullying other prisoners and to account for the “43 entries on his wing
history sheet between the 18th of April 2005 up to date and not one of them being
positive.” He subsequently dropped his complaint.
I am very concerned about the way the man’s legitimate complaint was apparently
deflected by allegations of bullying against him. The two issues should have been
kept entirely separate. As it is, the prison response has every appearance of trying
to intimidate the man into withdrawing his complaint – which he did. Whether staff
merely applied the rules (albeit rigorously in the man’s case) or over-stepped the
mark was therefore not established. This is of concern in itself, but may also have
led the man to believe he could expect little support from them during his final period
at La Moye.
I recommend that the Governor personally supervises the investigation of all
complaints about members of staff and that the prisoner is given a finding one
way or the other.
I found only one other complaint of bullying by staff. In a note to the Deputy
Governor dated 14 February 2006, the man accused two named officers of “bullying”.
Much of the letter relates to the officers’ attitude towards other (named) prisoners, but
the man complained about an officer locking up the wing up early and making him go
straight to work from gym without first having a drink. The man also referred to
having spent three months in segregation for bullying other prisoners. He said he
thought events had been exaggerated due to staff resentment of him and felt he had
been dealt with very unfairly.
It is not clear what action, if any, was taken about this complaint.
40
The Assistant Ombudsman asked the Unit Manager about the man’s complaints of
bullying. The Unit Manager advised that, “because that was quite a long sentence,
we had verbal complaints against every member of staff including myself on
occasions. Basically, if he couldn’t get what he wanted, he would play up a member
of staff.” He said he told the man to put his complaints in writing (policy was to
investigate only written complaints about staff) but he never did so. Instead, he
withdrew his complaints after a couple of days and turned his attention to someone
else. The Unit Manager was certain he had been firm but fair with the man and that
his staff had been the same.
I have not identified any specific instances of bullying behaviour that warrant
independent investigation. It seems to me that staff might have been harder with the
man who died in some respects, but that this was as much a response to his own
behaviour, which staff found demanding and sometimes arrogant. The staff at La
Moye whom we and the police have interviewed advised that they related well with
him. They said he could sometimes be very trying, but that he was always dealt with
professionally.
Discharge from Silkworth Lodge
I commend prison and Probation Service staff for the way the man’s release in July
2006 was planned. Despite the fact that he was apparently clean and sober in
prison, the plan recognised the need for him to address his drug misuse. A
placement for him at Silkworth Lodge was duly set up, and he was to go afterwards
to sheltered accommodation to ease himself fully back into the community. He was
also given the support of ‘voluntary probation’ which ensured regular ongoing contact
with the Probation Service.
Successful completion of the Silkworth Lodge programme was the gateway to
addressing all the man’s post custody care. Unfortunately, the plan fell apart very
early, when he failed to comply and was discharged. His parents are very critical of
the way this was handled.
The man went to probation on the day he was discharged. He said he felt he was
victimised at Silkworth Lodge as he was the only drug user – all the others were
alcohol users. He did not consider he was getting the same service as everybody
else. Probation Service staff suggested that it was possible that he was simply too
articulate for the staff there to deal with when he challenged them. They said there
had been a lot of staff changes at the Lodge – those there at the time had not had so
much training and some were not long out of rehab themselves.
The counsellor at Silkworth Lodge said that staff challenged the man repeatedly
about his failure to conform. He explained that adherence to the rules and regime of
the Lodge was a key element of the programme itself, since it served to establish
discipline and a structured life-style. Hence, failure to conform undermined what they
were trying to achieve. In addition, the other people on the programme had tired of
the man’s non-conforming behaviour. The counsellor said staff were trained in
handling people such as the man and that, notwithstanding the absence on sick
leave of the Director, everything was done as it normally would be.
41
The Probation Service took the view that the key issue was the lack of an exit
strategy from Silkworth Lodge. They said there had been no attempt to address
practical issues, such as finding somewhere for the man to stay, or the emotional
difficulties he would have experienced as a result of being rejected yet again when
he was not even using drugs. The man’s needs were complex and Silkworth Lodge
should have appreciated that they could not act in isolation. Anything they did would
have far-reaching ramifications.
The Assistant Ombudsman asked the counsellor about this. He said that copies of
the discharge summary had been sent on the day of the man’s departure to the
Probation Service, the drugs counsellor at the prison and the ADS, so all the relevant
agencies were alerted to what had happened. In addition, he said it had been
arranged that the man would be discharged to his mother’s address.25
The man’s probation officer told The Assistant Ombudsman she did not consider this
was sufficient. Although she received a telephone call from an administration worker
at the Lodge, she considered that any discharge should have been preceded by a
meeting between Silkworth and the Probation Service in order to consider whether
discharge was inevitable and, if so, to allow alternative arrangements to be put in
place.
It is of course simply not possible to know what, if any, difference such an approach
would have made. It is also important to bear in mind that Silkworth Lodge is not part
of the criminal justice community and that its responsibilities are quite different. Apart
from any moral duty it had towards the man, it also had a responsibility to safeguard
the interests of the other residents, whose own recovery programmes were liable to
disruption due to his challenging behaviour. I think Silkworth Lodge could have taken
a different approach with the man and that other organisations charged with his care
might have stuck with him for longer. But that is probably to apply the wrong
parameters.
Nevertheless, I hope the Director at the Lodge will consider carefully whether there
are any lessons to be learned from the man’s death.
The man’s missed appointment with the Probation Service
In light of the man’s relatively fragile state and the recognition that this further
rejection would have had an emotional impact on him, I was surprised to note that no
immediate action appears to have been taken when he missed his first probation
appointment. Instead, it was one week before a letter was sent to him asking him to
attend at a later date. I appreciate that the contact was purely voluntary, and that the
Probation Service had no formal responsibility for him at that time, but it is difficult to
avoid speculating whether earlier intervention would have prevented or curtailed his
relapse.26
25 The man told his probation officer that he could not stay at his mother’s address.
26 Commenting on my draft report, the Chief Probation Officer emphasised the substantial contact the
Probation Service had had with the man following his release. He believed they had provided him with
an “excellent service” and that the probation officer in particular had provided considerable assistance
to him. He continued:
42
ADS
The man’s parents have expressed their concern that their son was not able to get
an earlier appointment with ADS following his discharge from Silkworth Lodge.
Commenting on the draft of this report, the Director of ADS advised that they were a
small community based service that operated Monday to Friday. They were not in a
position to provide an emergency prescribing service. He accepted, however, that
the response time of one month in this case was unusually long and explained that it
was due to pressures and staff shortages at the time of the referral. He said ADS
was normally able to offer an appointment within 1 – 3 weeks (which was within
national treatment guidelines).
The man who died might not have benefited long term from his contact with ADS27,
but early contact and, importantly, a prescription for subutex might have alleviated
some of his immediate problems and certainly removed the driver for him to engage
in acquisitive crime. In short, it might have helped to keep him safe. Given his
recent rejection by Silkworth Lodge, it is not difficult to see that he might have felt that
his life was spiralling back out of control and that, notwithstanding the support he was
receiving from the Probation Service, there was no-one to whom he could turn for
help. The Probation Service contact log for 30 August reported that the man said he
had tried everywhere to get help with his heroin addiction but no-one wanted to
know.
I have not engaged with ADS during the course of this investigation (other than to
disclose extracts from my draft report), but I hope a copy of my report will be passed
to them. I also hope that, in light of my observations on this matter, they consider
how they might better - and more quickly - respond to those seeking their help.
I was struck by the large percentage of Jersey’s prison population who have been
convicted of drugs offences or whose offences were drugs related. The drugs
counsellor told The Assistant Ombudsman that she discovered through one-to-one
interviews the previous year that some 70 per cent of prisoners had problems with
alcohol or drugs. She described the prison’s attempts to address the issue:
“Whilst the comment about the missed appointment is perhaps justified by hindsight, it could equally
have been argued that a swift failure to report letter could have been counter productive. It could be
stated with equal justification that ‘despite [the man] failing to keep his appointment, and being
encouraged to keep in contact verbally, a further written appointment was given to him which he
kept.’”
The Chief Probation Officer added that the probation officer knew from the Assistant Chief Probation
Officer’s chance encounter with the man that he was apparently doing okay.
27 The Director of ADS helpfully outlined the man’s contact with ADS over the years. He said:
“He was first seen in July 1999 and commenced a treatment programme for opiate addiction. During
that episode of treatment, he failed to attend six of fifteen appointments. He subsequently had in-put
from the service for each of the years between July 1999 and August 2006 with the exception of 2004
when he was seeing [name] (Court Officer) on condition of a Treatment Order. I can confirm that
during his contact with the ADS, [the man] commenced a number of detoxifications from both alcohol
and opiates.”
43
“The prison practises only detoxification. It is an eight day programme with a
choice of two medications. We do not have the resources for maintenance
programmes.
I provide one-to-one counselling. I am self-employed and used to be part-time
but am now full time.
We provide education into the harm caused by substance abuse. We also
provide group work, including an awareness course that lasts three months.
We deliver it to a different wing each day. We also provide detox acupuncture
and the AA visits on Thursdays. We also ran a course on relapse prevention
and another course for drug importers. This was discontinued, however, due
to lack of resources. Drug and alcohol advisers from the community come into
the prison once a week and spend about three hours here. They help with the
process of feeding people back into the community. Our links with doctors etc.
are good and we ensure that relevant links are made and appointments set up
before people are released ...
Unfortunately the quickest way to get a referral is in prison. Detox is also
easier in prison because there are more constraints and people are away from
their usual influences. It is not uncommon for people who decide that they
need to clean up for a while to engineer a return to prison. They commit
crimes right by the police station or their families set them up, because they
will not comply with detox programmes at home. [The man who died] used
prison in this way.
Jersey has been reluctant to admit to any problem with drugs, but is now
beginning to get to grips. There were previously no rehabilitation or treatment
programmes available in the community. Now both of these are as good as
resources allow. There is still under-funding, however.”
I am pleased to note the links that have been developed between the prison and the
community in addressing substance misuse and that the prison has increased its
own activity in this respect. In light of the scale of the problem, however, I question
whether it is yet enough. This man’s death suggests that it is not.28
A States of Jersey Official Scrutiny panel review, Responding to Drug Use, was
completed in 2004. The panel made 21 recommendations aimed at improving the
States’ response to drug misuse and said it would seek to review the implementation
and outcome of its recommendations in a year’s time. I have been unable to
ascertain whether any further action was indeed taken. At any rate,
I recommend that the States of Jersey reviews the current position with regard
to addressing drugs misuse to determine what further work needs to be done.
28 During this investigation, I learned that another young man, released at about the same time as the
subject of this report in July 2006, had died on 13 January 2007. The cause of death was thought to
be a drugs overdose.
44
Sharing of information
The police knew (because the man told them) that the man had attempted suicide in
2001 by carbon monoxide poisoning. (The man told the police FME, however, that
he had never self-harmed.) The Probation Service knew about the 2001 attempt and
that he had made a number of attempts to take his own life during 2004. The prison
knew about the two incidents of self-harm during his previous period of custody. But
none of the organisations had all the information.29
Indeed, the Police National Computer record for the man has no marker for
suicide/self-harm. This is despite his 2001 attempt (about which they were aware).
I understand that information from the police to the prison about risk of self-harm is
communicated via an Exceptional Risk Form or sometimes on the court committal.
No other procedure exists for other agencies, but work is ongoing to introduce a
system similar to the Prisoner Escort Record (PER) form used in England and Wales.
This is to be welcomed.
I recommend that a system for sharing information about risk, akin to the PER
form, is introduced as a matter of urgency.
There are currently a number of initiatives to share information between the
Probation Service and the Prison Service, but these do not yet represent a
comprehensive system.
I recommend the Governor of La Moye jointly reviews with the States of Jersey
Police and the Jersey Probation and Aftercare Service mechanisms for
exchanging information on self-harm.
I also recommend that he ensures all staff are trained to access that
information and actively encourages them to do so.
Reception at La Moye
Despite the fact that he was well known to staff, the man underwent the full reception
procedure at La Moye – that is, he was seen first by the reception officer, who dealt
appropriately with his desire to be segregated, and immediately afterwards by a
healthcare officer to assess his physical and mental health. (I would say, however,
that given the low intake of prisoners - I understand the prison receives only a
handful a week - I am surprised the reception process took as long as it did. From
the times given in police statements, it seems the man was received at the prison at
about 1:00 pm but was not taken to a wing until some time between 3:00 and 4:30
pm (the timings given vary). Swift entry into prison can help to reduce levels of
29 Commenting on the draft of this report, the Chief Probation Officer said the man had been ‘red-
flagged’ on their IT system before 2004, including for self-harm. In addition, the 2002 Probation
reports referred to self-harm attempts. He said the Governor had always received Probation reports
that resulted in custody and had had full access to their IT system since 2003. He said the prison
would therefore have had the relevant information before August 2005. He added that the prison, on
the other hand, had not told Probation about the self-harm in custody in August 2005. He said the
Probation Service had worked hard to share information, particularly risk information, with other
agencies.
45
anxiety, particularly amongst those going into custody for the first time. Although it
was by no means his first time in custody, the man was anxious about the reception
he would get from other prisoners. The delay can only have served to exacerbate
this. The Governor might wish to consider this further.)
Given that the man had twice before harmed himself whilst at the prison, it might be
questioned why his belt (with which he was to hang himself) was returned to him by
the reception officer. The officer specifically addressed this point in his statement to
the police. He said that, given that the man was not accompanied by an Exceptional
Risk Form, there was no reason for him to withhold the belt. I consider this was
reasonable, notwithstanding subsequent events. Episodes of suicidal ideation can
be short lived and the fact that someone has self-harmed in the past does not mean
that he or she remains at risk indefinitely. The officer who assessed the man for risk
of self-harm was experienced and knowledgeable. I have no reason to question his
judgement. It is also important that prisoners – and perhaps particularly those who
are most vulnerable – should be treated humanely and with dignity. Allowing them to
dress normally is one way this can be achieved.
However, I am concerned that prison files appear only partially to be joined up –
returning prisoners are given new prison numbers and a new record is opened each
time. There is thus a lack of continuity of information from one sentence to the next.
This has implications not just for the reception process, but also for the prisoner’s
management on the wings. This problem should to a large extent be overcome by
the new IT systems. In the meantime, I consider that it should be possible in a prison
the size of La Moye, with its limited turnover of prisoners, to establish systems that
create greater continuity between separate periods of custody.
I recommend that the Governor considers how information about an individual
might be joined up in a way that is readily accessible to staff.
The man’s mother explained that she thought the prison would have automatically
kept a closer eye on her son, as last time he was in the prison he had cut himself and
had refused to let them treat the cuts. However, as noted above, whilst previous
incidents of self-harm might point to a heightened risk of self-harm, it does not mean
that such a risk necessarily exists. In this man’s case, and given the particulars of
the two incidents, it would not have been unreasonable for the prison to conclude
that his ideation related exclusively to the particular circumstances that obtained at
the time (though, as suggested earlier, knowledge of the two previous incidents might
have influenced their judgement).
Nevertheless, I am concerned that the man was not placed under increased
observations as a result of his being on a detox regime. I understand that policy at
La Moye is for those withdrawing from alcohol to be placed on special observations,
but the same policy does not apply to drugs withdrawal. The physical dangers of
withdrawal from drugs are not the same as those for withdrawing from alcohol, but it
is an unpleasant experience and many will find it difficult to bear. It is also likely that
46
the withdrawal will have some effect on the person’s mental state and that this could
heighten risk of self-harm.30
I recommend that all those withdrawing from any substance are placed on
special observations.
Detox
La Moye operates abstinence rather than maintenance programmes for drug users
and uses dihydrocodeine to reduce the severity of withdrawal symptoms. The
current Chief Inspector of Prisons commented on this in her report:
“While the current prescribing regime for opiate users was neither in line with
the island-wide drug strategy nor the English/Welsh clinical management
guidelines, it would be difficult for controlled drugs such as methadone and
subutex to be introduced safely as the standard treatment, given the lack of
resources and unsuitability of the environment.”
She went on to say:
“Specialist advice should be sought before there are changes to the clinical
management of opiate users, as current healthcare resources are insufficient
to introduce the prescribing of controlled drugs safely.”
I do not dissent from the value of specialist advice, but my own view is that urgent
consideration should be given to introducing more appropriate detox medications and
other treatments. In her clinical review, the Deputy Ombudsman makes a similar
recommendation.
I recommend that consideration is given to introducing more appropriate detox
medications and other treatments.
First night arrangements
No first night arrangements – whereby prisoners newly received into the jail are
placed in an area of the prison specifically designated for new arrivals and where
they can be monitored more closely – exist at La Moye. The first few days in custody
are the time when prisoners are at their most vulnerable. Statistics show that the
most likely time for prisoners to kill themselves is in the first days or weeks after
arrival. Ensuring that newcomers are given additional support, are monitored and
are provided with a full induction into the prison are therefore of vital importance. For
this reason, I welcome plans to establish a First Night Assessment Unit at the prison.
I understand that even those such as the man who died, who have spent previous
periods at the prison, will be accommodated on the Unit for the first night at least, “so
that any changes to their circumstances can be identified and managed”. This is a
significant and important development.
30 Given the agitation that can be caused by withdrawal, I am concerned that practice at La Moye is to
put prisoners who are withdrawing in shared cells with those who are not. This must be extremely
unpleasant and distressing for both parties.
47
However, I have some concerns about the Unit designated for this purpose. In the
first place, there is no office space either for interviewing prisoners or for storing
records. In the second, and more directly relevant here, the design of the cells is
potentially unsafe. The cells are new and well appointed, but each one has its own
toilet and shower area, which is entirely closed off from the rest of the cell, with the
door facing away from the main cell door. This is of particular concern, given the
heightened risk of self-harm amongst those newly received into prison.
I recommend that the Governor reviews the configuration of the cells in the
new induction unit to ensure they facilitate easy observation of prisoners.
Few of the other cells at La Moye have integral sanitation.31 While I fully appreciate
the resource constraints, this is simply not acceptable in the 21st Century. It is not
decent for either prisoners or staff.
I recommend that the States of Jersey allocate funds to providing in-cell
sanitation at the earliest opportunity.
The man’s cell
On my initial visit to La Moye, I visited the cell the man had occupied (cell 4 on E
wing). I noted that it was comparatively large by English standards, with a high
ceiling. I also saw that it contains many potential ligature points, including pipework
and the window and frame. Most strikingly, a pipe containing electrical fittings
snakes across the ceiling. This is a frankly ludicrous weakness in the cell’s design. It
was from this pipe that the man attached the ligature, using his bed to climb up to
attach it. I recommend:
In any future refurbishment of cells at La Moye, the pipes containing electrical
fittings should be removed and the wires chased into the walls and ceiling.
I also recommend that any other measures to reduce the ready availability of
potential ligature points are taken as soon as possible.
As part of the Prison Improvement Plan, funds have been found for the conversion of
some cells to what are known as 'safer cells'. At the time of this man’s death, the
prison had no such cells. The Governor hopes that this work will be completed in
early 2007 so that La Moye will have at least one safer cell for each part of our
population. I welcome this news.
The man’s cell contained no television or radio and it would appear he had no
newspaper. Save for a selection of magazines that were on the floor when he was
found, he had no other source of stimulation. On my initial visit to La Moye, I was
particularly concerned that the man had spent his first night in custody without a
television. (I understand that one would normally have been provided, but was not
because he arrived just before the weekend.) The Deputy Governor had separately
arranged that in future no prisoner should spend his first night without a television –
31 Some cells on the VPU do have their own toilets, but the design is such that it is not decent to use it
when the cells hold two prisoners.
48
whatever day he arrived – and I commend his initiative in do so. Nevertheless, I
recommend:
The Governor should ensure arrangements are in place that every prisoner has
access to a television and radio on his or her first night in custody.
A white towel had been used by the man to cover the spyhole in his cell door and this
prevented him being seen. He had attached it with sticking tape – presumably
provided innocently by a member of staff for some other purpose. Obscuring the
spyhole is a mainstream part of prisoner culture, and it is not hard to understand the
desire for privacy. However, it inevitably raises concerns about security, control and
safety, and staff must not condone the practice, even implicitly. One officer referred
in his police statement to staff noticing that the man’s spy hole was covered but being
unconcerned because he was not considered to be ‘at risk’.
I was concerned on my visit to La Moye that staff might, on occasions, be turning a
blind eye to the obscuring of spyholes – I understand the use of disciplinary
sanctions to discourage the practice is very rare. I was told this was not the case.
I recommend the Governor should remind staff that all objects used to obscure
the spyholes should be immediately removed, and repeat offenders should be
charged under the Prison Rules.
Food
I have also considered whether staff should have been more concerned about the
man not eating. Although he was given a tea pack on the Friday evening, it seems
probable he took little further food until his death. This is quite remarkable in a man
whose history sheets refer repeatedly to cadging food off other prisoners. (He was
also apparently told at Silkworth Lodge that he ate too much.) Food refusal can be
an indicator of possible self-harm ideation (it can suggest either that the prisoner
does not consider it worth eating or can itself be a form of self-harming behaviour),
but nobody seems to have been alert to this, even though a number of officers and
the Unit Manager were apparently aware of the situation. The Unit Manager told The
Assistant Ombudsman that he would have been concerned about the man if he had
been on duty.
In any investigation into a death in custody, it is easy to be seduced into identifying
missed opportunities that could have changed the course of events and it is
important that I maintain balance and perspective in drawing conclusions. For that
reason, I do not make too much of the man’s food refusal as an indicator in itself of
possible self-harm. However, this was a man who normally ate a lot but who could
not be enticed out of his cell for three meals. I consider that his behaviour provided a
clear indication of the strength of his fear of repercussions from other prisoners. I
think it likely that staff interpreted his behaviour as manipulative (some police
statements corroborate this view) and that the more sinister interpretation of his
behaviour was overlooked as a consequence.
49
I recommend the Governor reminds staff of the importance of identifying
prisoners’ behaviours, such as food refusal, that may indicate their state of
mind.
Anti-bullying
The man had spent a considerable portion of his various times at La Moye
segregated at his own request for his own protection. He appears to have feared
different prisoners at different times and for different reasons. It is clear that he upset
a number of people by his behaviour and made himself unpopular with some other
prisoners. To some extent, therefore, the prison authorities may have become inured
to this aspect of his behaviour and may have taken it on this occasion largely with a
pinch of salt. (The Unit Manager was convinced when he spoke to The Assistant
Ombudsman that the man would be able to talk his way out of his predicament.) I
cannot say whether the man’s behaviour on 1 and 2 September 2006 differed in any
way from what prison staff were already long accustomed to and therefore whether
they should have reacted differently. But staff reports of his refusal to come out of
his cell suggest that he was genuinely scared for his own safety. I have to ask
therefore – and even accepting the limited space available in the prison – why he
was placed on the same landing as three of the four prisoners he specifically named
when requesting segregation. The decision makes little sense to me, regardless of
how well staff could protect him either by their presence on the wing, or by the ability
to close the gate thereby separating the man’s cell from the others. I do not doubt
that managers were confident of their ability to protect him, but he may not have
shared their confidence and the close proximity of those from whom he feared
repercussions must have been unnerving for him.
More generally, I am concerned by the apparent inability of the prison to get to grips
with bullying behaviour. The man himself was on different occasions both the victim
and the aggressor, but no action appears to have been taken either against him or
those who were allegedly bullying him. The Unit Manager told The Assistant
Ombudsman that on occasion groups of prisoners were called into the office for a
talking to, but no formal action appears to have been taken. Instead, the prison
appears to have relied on separating the people involved (in itself a difficult task
given the size of La Moye). This did nothing in the long run to resolve issues and to
send messages to other prisoners that any form of bullying is unacceptable. I note
that HM Chief Inspector of Prisons was also critical on this point. I am pleased to
note therefore that the prison introduced a new Violence Reduction Policy in
September 2006.
I recommend that the Governor monitors carefully the application and impact
of the Violence Reduction Policy and quickly makes any necessary
adjustments. I also recommend that he ensures adequate resources are
provided to train staff.
The man’s mother wondered whether there was any evidence of other prisoners
making her son’s life hard. She mentioned a prisoner whom he used to wind up and
then back off just before he reached breaking point. She said it was like a game to
her son.
50
After the man’s death, a prisoner told a senior officer that he had heard two named
prisoners make verbal threats to the man whilst he was in his cell the night before.
The prisoner said the other prisoners told the man that if he went on the wing they
were going to get him and if he stayed in his cell, they would burn him out. Asked if
he was sure this is what he had heard, the prisoner said, “Pretty much so.”
The Assistant Ombudsman interviewed the two prisoners referred to. She also
interviewed a third mentioned by the man when he asked to be segregated from the
main prison. Unfortunately, all three decided (one on the spot and two subsequently)
that they did not wish to be involved with my investigation. For that reason, I am
unable to refer to the notes of those meetings. Suffice to say that none of them was
able to shed any light on this allegation and, as noted above, staff were not aware of
prisoners hanging round the man’s cell.
CPR
No criticism is intended here of the healthcare officer, who acted with speed,
compassion and professionalism when the man was found hanging. However, good
quality CPR should always be delivered on a firm surface, and it is not generally
good practice do so on a bed. My Deputy Ombudsman has advised that the bed was
in fact “an appropriate hard surface”. Nevertheless, it would be wise for the Governor
to remind staff of what is best practice.
I recommend the Governor reminds staff that CPR should generally be
delivered on a firm surface and not on a bed.
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Conclusions
The man at the heart of this report was a prolific offender who appears to have
become caught in a cycle of drug use and stealing to fund his drug use. By the time
of his death at age 29 he had been in prison 29 times. Self-evidently, none of his
many engagements with the criminal justice system had any impact at all on his drug
using and offending behaviour or set him back on the right path.
It is clear that his death came as a surprise to those who had dealings with him
during the previous three days following his arrest. However, it is also clear that no
one person or agency was aware of the extent of his previous self-harming
behaviour. Nor was any person or agency aware of the extent of his drug taking, and
the likely pains of withdrawal given an unsatisfactory approach to detoxification.
Finally, the prison was not aware of any specific threats against the man – although it
seems likely that some were made.
It is also clear that the man had left La Moye in July 2006 with high hopes of ending
the cycle of drug use and offending. Sadly, those hopes ended in failure within a
matter of weeks. It may also have been that he had not anticipated being remanded
into custody when he appeared at court on 1 September (although, given his record,
I cannot see how any other outcome was likely).
This investigation and report has gone wider than many others I have completed.
However, it seems to me that this man’s death was not the product of a single rash
moment in September 2006, but the culmination of many years of drug use and
offending behaviour to support that abuse. In learning lessons from his death,
therefore, it is necessary to look at these wider issues to identify what might be done
differently to prevent another such tragedy.
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Recommendations
1. The States of Jersey should consider what arrangements are in
place to review deaths in custody from natural causes.
2. I recommend that the Governor at La Moye works closely with the
Probation Service in setting up offending behaviour and
resettlement programmes for prisoners.
3. I also recommend that the States of Jersey should review
resettlement, aftercare and offender management services for
released prisoners.
4. I recommend that the States of Jersey considers what structures
would best facilitate consistent and seamless offender
management.
5. I recommend that the Governor should review a selection of
F2052SH booklets to satisfy himself that they are being completed
to a satisfactory standard.
6. The Governor personally drives forward arrangements for
implementing ACCT prison-wide.
7. I recommend that the Governor personally supervises the
investigation of all complaints about members of staff and that the
prisoner is given a finding one way or the other.
8. I recommend that the States of Jersey reviews the current position
with regard to addressing drugs misuse to determine what further
work needs to be done.
9. I recommend that a system for sharing information about risk, akin
to the PER form, is introduced as a matter of urgency.
10. I recommend the Governor of La Moye jointly reviews with the
States of Jersey Police and the Jersey Probation and Aftercare
Service mechanisms for exchanging information on self-harm.
11. I also recommend that he ensures all staff are trained to access
that information and actively encourages them to do so.
12. I recommend that the Governor considers how information about
an individual might be joined up in a way that is readily accessible
to staff.
13. I recommend that all those withdrawing from any substance are
placed on special observations.
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14. I recommend that consideration is given to introducing more
appropriate detox medications and other treatments.
15. I recommend that the Governor reviews the configuration of the
cells in the new induction unit to ensure they facilitate easy
observation of prisoners.
16. I recommend that the States of Jersey allocate funds to providing
in-cell sanitation at the earliest opportunity.
17. In any future refurbishment of cells at La Moye, the pipes
containing electrical fittings should be removed and the wires
chased into the walls and ceiling.
18. I also recommend that any other measures to reduce the ready
availability of potential ligature points are taken as soon as
possible.
19. The Governor should ensure arrangements are in place that every
prisoner has access to a television and radio on his or her first
night in custody.
20. I recommend the Governor should remind staff that all objects
used to obscure the spyholes should be immediately removed,
and repeat offenders should be charged under the Prison Rules.
21. I recommend the Governor reminds staff of the importance of
identifying prisoners’ behaviours, such as food refusal, that may
indicate their state of mind.
22. I recommend that the Governor monitors very carefully its
application and impact and quickly makes any necessary
adjustments. I also recommend that he ensures adequate
resources are provided to train staff.
23. I recommend the Governor reminds staff that CPR should
generally be delivered on a firm surface and not on a bed.
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