Individual at Leeds

Investigation into the circumstances surrounding the
death of a male prisoner
at HMP Leeds in May 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
January 2007
This is the report of an investigation into the circumstances surrounding the death of
a man who was a prisoner at HMP Leeds. His death occurred in May 2006. Shortly
after 7.10am one morning, the man at the centre of this report was found hanging in
his cell. Following a conviction 22 years earlier, he had been released on life licence
in 2005. He was recalled to prison two months before his death. A post mortem
examination conducted in May 2006 confirmed that death was caused by hanging.
The investigation was carried out by my two of my colleagues. They met with
members of the man’s family and I much appreciate the family’s willingness to
discuss his death so soon after their bereavement. I do not underestimate how
difficult this must have been for them. I offer the man’s family and friends my sincere
condolences for their loss.
I also commissioned a clinical review of the management of the man’s health needs
while he was in custody, and I am most grateful for the clinician’s assistance in doing
this. I must also thank the Governor, Deputy Governor, and staff at Leeds for their
ready help and co-operation during the investigation.
Over recent years, the number of prisoners on licence who are recalled to prison has
grown rapidly. Indeed, I understand that during the last five years there has been a
350 per cent increase in the number of offenders recalled for apparent breach of
their licence conditions. So-called ‘secondary imprisonment’ is an important
explanation for the current record size of the prison population as a whole. From a
number of my death in custody investigations, it has also become clear that those
recalled to prison are particularly at risk of suicide. Although I make no criticism of
the decision to recall the man, both prison and probation staff need to be aware of
the extent to which recall is a risk factor in relation to self harm/suicide.
My report includes five recommendations. One of these reflects my concerns about
communication between probation officers inside and outside the prison and is
addressed to the West Yorkshire Probation Area. One is concerned with awareness
of ACCT procedures in all parts of the criminal justice system and is addressed to
the NOMS Safer Custody Group. I am pleased to say that all these
recommendations have been accepted.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2007
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CONTENTS PAGE
Summary 4
The investigation process 5
HMP Leeds 6
Key events 8
Issues considered in the investigation 16
Conclusions 20
Recommendations 21
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SUMMARY
In August 1983, the man at the centre of this report was sentenced to life
imprisonment for murder. Although originally set a tariff of 15 years, he eventually
spent 22 years in 12 different establishments. He was released on life licence from
HMP Leyhill on 5 May 2005 to a hostel in Bradford. He had previously stayed there
three times as part of his resettlement plan. Soon afterwards he went to live with his
wife, but their relationship broke down and he later moved in with a new partner.
On 1 March 2006, the man was questioned by the police regarding threats to kill and
given police bail. During the same week, his probation officer was informed that the
police were also investigating allegations of sexual abuse/indecent assault. As a
result, his licence was revoked on 17 March 2006 and he was arrested. He spent
the night in police custody, before being transferred to HMP Leeds. He was not
charged, but the police continued to make further enquiries. On arrival at Leeds, the
man underwent the normal prison reception interviews and an induction programme.
No concerns were raised in his health screening or cell sharing risk assessment.
The man was assigned a personal officer and was soon described as settling back
well into prison regime. Staff spoke to him about his recall, and offered support and
advice. He subsequently submitted an appeal against the recall. He was visited by
his probation officer, whom he had known for many years, and who completed a
report as part of the appeal process. The report was based on an interview with the
man some four weeks before he took his life. It refers to him not coping in prison
and thinking about harming himself. The information was included in the probation
service computerised case record and the recall appeal report. However, it had not
been read by anyone by the time the man at the centre of this report had hanged
himself.
On that day he had been taken into police custody for questioning. Again he was not
charged, but was told that the Crown Prosecution Service (CPS) were to consider
whether any charges would be brought against him. On returning to HMP Leeds
later that day, staff thought that the man seemed fine, as did another prisoner who
spoke to him. He made three telephone calls to his partner after returning to prison.
On the morning of 10 May, although the roll check was considered completed, the
landing which contained the man’s cell appears not to have been checked until an
hour later when the cells were unlocked. He was then discovered by staff around
7.20am. He was hanging by a ligature in his cell. Officers, healthcare staff and
paramedics attempted cardio pulmonary resuscitation (CPR), but sadly were unable
to revive him.
My investigation into the man’s death started on 12 May. As part of my investigation,
I have looked into the concerns of his family about what might have led to him taking
his own life and whether more could have been done to prevent it.
I make five recommendations.
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THE INVESTIGATION PROCESS
1. The investigation at Leeds began on Friday 12 May 2006 when the investigation
team met the Governor, Deputy Governor, a representative of the local branch of
the Prison Officers’ Association (POA), and the Healthcare Manager. The lead
investigator explained the nature and scope of the investigation, and the report
handling process. He also spoke on the telephone with the Chair of the prison’s
Independent Monitoring Board (IMB).
2. On the same day, notices were issued to staff and to prisoners announcing the
investigation and inviting anyone with concerns or information relating to the man
at the centre of this report’s death, to make themselves known to the investigation
team. Only one prisoner came forward. The investigation team interviewed 18
members of staff who had contact with the man during his time in prison. They
also interviewed the man’s home probation officer.
3. My office also contacted the Coroner for West Yorkshire (Eastern), and the
investigating police representative. A copy of this report will be sent to the
Coroner to assist him with his enquiries.
4. On 20 June, my investigator and one of my Family Liaison Officers, visited
members of the man’s family. The family raised the following matters which are
addressed in the report:
The man’s niece said she had telephoned both the police station and the
prison to express concerns that the man might harm himself. Was any
information passed from the police to the prison about the man’s level of risk
to himself, and if so, why the prison did not put him on any sort of suicide or
self harm watch?
Was the man aware of all the allegations made against him at the time of his
death?
After visiting the cell, they thought the bars were very prominent and an
obvious ligature point.
Could it be determined how long the man had been dead when he was found?
Had a disagreement with his partner occurred shortly before his death? The
family believe the man had phoned her on the night before his death. They
have also seen a drawing in a puzzle book within his possessions that gives
rise to concern.
As he was a life sentence prisoner, were the usual precautions to look after
new prisoners ignored, and was he expected to be able to settle in and cope?
Did the man tell his probation officer who saw him in prison that the prison was
“doing his head in”, and that he was suicidal? If this was said, it is a major
concern and the family wish to know what was done with the information.
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HMP LEEDS
5. HMP Leeds is a category B local prison, dating from 1847. It accepts adult male
prisoners from courts in West Yorkshire and has 680 cells, plus rooms and wards
for 26 in the Healthcare Centre. A new gate complex opened in September 2002,
providing staff facilities and an improved entry point for all visitors and staff.
Leeds has an operational capacity (maximum crowded capacity) of 1,150
prisoners, and always functions at or near this figure. It expanded from four to six
wings in 1994. Leeds was last visited by HM Chief Inspector of Prisons in August
2005. She identified that the prison faced a number of difficult challenges
because of chronic overcrowding and a high turnover of prisoners.
6. There have been five apparently self-inflicted deaths at Leeds between March
and July 2006. Four of the prisoners who died had been recalled to prison.
Life sentence prisoners
7. Prisoners who are serving life sentences often have the option of a single cell.
Life sentence prisoners are also assigned a lifer manager, who keeps in regular
contact with them and deals with their sentence management for the duration of
their period in custody.
Recall process
8. A life sentence prisoner who is released has to abide by licence conditions.
Should there be a breach of any of these conditions, they are liable to be recalled
to prison. Leeds receives an estimated 120 licence recalls (including life licence
recalls) per year.
Personal Officer Scheme
9. All prisoners are assigned a personal officer. Their role is to meet with the
individual on a regular basis and to discuss any issues or concerns the prisoner
may have.
Roll check procedures
10. The roll check is the physical count of the number of prisoners within a prison.
Roll checks occur on a number of occasions during the day. Night Staff conduct
roll checks at the start of their duty and again at 6.30am. A running roll is
maintained by the prison. At each roll check, the Assistant Orderly Officer (Oscar
2) reconciles the roll by confirming the running roll at the Centre with that at the
Gate. The local instructions at Leeds for the conduct of roll checks state that:
“The first morning Roll Check is conducted at 6.30am by the night staff on that
wing/area; this is normally done in conjunction with the 'early start' day staff.
At 7am a full roll check is conducted with the roll being reported to the Senior
Officer (Oscar 2) in the 'Centre Office'.”
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Acct
11. Leeds has implemented the Assessment, Care in Custody and Teamwork
(ACCT) approach to helping and monitoring prisoners at risk of harming
themselves. The key aims of ACCT are to create a safe and caring environment,
to identify prisoners’ individual needs, and to offer individualised care and support
before, during and after a crisis.
Safer Cells
12. Leeds has a number of “safer cells”. These are specially designed to contain as
few ligature points as possible.
Probation Officer Contact
13. West Yorkshire Probation Area employs probation officers both within the
prison and outside in the community. All use the same computerised record of
their contact with offenders. If a concern is raised, the database can be
accessed for further information
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KEY EVENTS
Between 1 March 2006 and 17 March 2006
14. On 1 March 2006, the man at the centre of this report was questioned by the
police regarding allegations of threats to kill. He was not charged with any
offence as the police were continuing with their enquiries. During the same week,
his probation officer was informed that the police were also investigating
allegations of sexual abuse/indecent assault, alleged to have taken place the
previous month. A report was completed by the West Yorkshire Probation Area
and submitted to the Home Office’s Early Release and Recall Section. The report
recommended that, given the allegations and apparent increased risk, it was
appropriate for the man to be recalled to prison. His life licence was revoked on
17 March. He was arrested and taken to Bradford Bridewell police station.
18 March 2006
15. The man was not formally charged but spent the night in police custody. He was
transferred to HMP Leeds the following day, arriving around 11.28am. My
investigators were unable to trace the prison escort record (PER) relating to the
transfer from police custody to prison, and it has apparently been misplaced. It is
not known whether it included a reference to information about concerns for the
man’s safety, as reported by his family.
16. On arrival at Leeds, he was interviewed by staff as part of the prison’s reception
process. As he had been in prison previously, he was offered the choice of either
the full prison induction programme or the shorter version. He opted for the short
induction. This included a talk by a prison chaplain, and one on race relations, as
well as being seen by a Counselling, Advice, Referral and Throughcare (CARAT)
worker. A cell sharing risk assessment was completed which recorded “no
problems or risks” and noted that the man was a lifer recall prisoner. The first
reception healthcare screening, which also assessed any suicide risk factors, was
conducted by a nurse. No concerns were noted.
Between 19 March and 8 May 2006
17. The man completed his prison induction on 19 March. The next day he was
moved from the induction wing to B Wing, where he chose to occupy a single cell.
His cell was in reasonable condition and furnished with a bed, chair, cupboards,
table, television, sink and toilet. The man was assigned a personal officer. She
had an initial one to one meeting with the man to discuss his first day on the wing.
He said he was unhappy to have been recalled. He denied both allegations
against him (the first was that he had threatened to kill; the second was of a
sexual nature, which the man said he knew nothing about and was upset by). He
was positive that neither allegation would be proved. His personal officer said
that she was aware that the man was subsequently visited by his solicitor and
probation officer, but did not know the content of discussions between them.
18. About two days later, the man received a letter from the Home Office Release
and Recall Section which explained the reason for the recall and the process
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should he wish to appeal. On 23 March, the prison’s Lifer Manager and the
internal prison probation officer interviewed him. (This was a routine interview for
lifer prisoners, known as an immediate needs assessment interview.) The
internal probation officer told my investigators that the purpose of the meeting
was to discuss the circumstances of the recall and for the man to be able to raise
any other concerns. She said that he was aware of the reasons for his recall,
which he seemed relaxed about and was confident that the allegations were
untrue. He said that he knew nothing of the second allegation, and was upset
that such an accusation could be made about him. The internal probation officer
said she was not involved in the recall appeal process, and was unaware of a
report subsequently written by his field probation officer. She also said that
probation officers within the prison share the same computer system as those
who work in the community. She was unaware of the field probation officer’s
record of contact with the man and had no reason to access it.
19. The lifer manager told my investigators he knew the man, but only interviewed
him on the one occasion with the internal probation officer. Any further contact
would usually be instigated by the prisoner. The lifer manager said that the man
was informed of all sources of support in the prison. He also confirmed that the
man was aware of the allegations which led to his recall, and was angry that this
had happened to him. The lifer manager said that he too was unaware of the
field probation officer’s later report and had no reason to be informed of its
content. He said that reports include information gathered for the appeal and are
not usually reviewed until the hearing.
20. The man’s personal officer spoke with him again about his recall on 24 March.
Throughout March and April, all her meetings with him were recorded with
comments such as “no problems” in respect of his behaviour. They also show
that he got on well with other prisoners and staff, had settled back into the prison
regime and had soon applied for various jobs.
21. On 13 April, the field probation officer visited the man. The information he
gathered from their conversation was later recorded in the computerised case
record and included in a report to be used as part of the man’s appeal against
recall. The report included a section headed “Conduct in Prison” and made the
following comment about his wellbeing since being recalled:
“Since coming back into custody the man is unhappy and emotionally
negative to such an extent that he had contemplated self-harm/suicide”.
22. The field probation officer said that he was not concerned that the man was
currently at risk of harming himself, but did say that this was the only time he had
ever referred to self harming. Having built up a professional relationship with him
over the years, the field probation officer did not believe that the man’s
suggestion of self harm was a genuine statement of intent. He felt it was
something he had said off the top of his head and, indeed, during the course of
their conversation his mood changed. Based on his knowledge of the man, the
field probation officer did not draw the statement about contemplating self harm or
suicide to anyone else’s attention. The field probation officer said that the man’s
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mood lifted in the course of their meeting, and he had no anxieties about him
when he left.
23. My investigators asked the field probation officer if he was aware of the ACCT
procedures within prisons which help with the management and care of ‘at risk’
prisoners. He said he was unaware of them and that, had he known about the
procedures, he would have brought the reference to self harm to the attention of
prison staff.
24. On 19 April, the man’s personal officer told him that the oral hearing for his
appeal against recall was scheduled for 19 May. On 21 April, the field probation
officer submitted his report to the Lifer Release and Recall Section of the Home
Office. The report constituted a release risk assessment of the man and included
the information the field probation officer had gained from their meeting a week
earlier.
25. On 24 April, the man’s wing history sheet showed that his personal officer had
telephoned the prison’s police liaison officer to come and speak with him about
his recall. There were no records to show whether this actually took place.
26. The field probation officer visited the man again on 27 April in order to prepare for
the recall appeal hearing. On this occasion, no reference was made to the man
not coping with prison life or of harming himself. The same day, the man’s
personal officer also interviewed him for the Post-Recall Induction Interview. The
man told her that he was devastated at being recalled as he had started a new
life with a new partner and her children. His partner visited him on 6 May. (This
was not the first time she had visited him.)
9 May 2006
27. At around 9.20am on 9 May, the man was taken from the prison to Bradford
Central police station. The police wanted to question him about the allegations
which had led to his recall to prison. The accompanying escort form did not refer
to any problems, and recorded that the man was of “no known risk”. However the
police custody records indicate that he was assessed as having a “mental
condition or illness”. The officer who made the assessment described him in the
following words: “detained prisoner states he feels a little depressed at this time,
no med.” The man was questioned about the allegations made against him, but
was not charged. He was returned to prison at around 2.00pm that afternoon.
Again, the accompanying escort form did not refer to any problems. My
investigators found no documentation to suggest the man was interviewed in
prison reception on his return.
28. On returning to B wing, the man was allocated a new personal officer, who
introduced himself the same day. At interview, the new personal officer said that
although he had worked on B Wing previously he had had minimal contact with
the man up until this point. He could not recall their introductory conversation, but
said that he appeared fine, raised no concerns and did not mention his interview
with the police.
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29. The man made a number of telephone calls to his partner whilst in prison. In
particular, three calls were made on 9 May after he returned from the police
interview. The first call was at 2.26pm, the second at 2.48pm and the last at
7.30pm. The content of the telephone calls has been established from transcripts
of the recorded conversations, as they were not contemporaneously monitored by
prison staff. The conversations centred on the man’s police interviews. Although
he had not been charged, he was unhappy about the allegations against him. He
had been told that his case was to be referred to the CPS to decide whether or
not the matter was to be pursued. During the telephone conversations, the man’s
partner said that they might have to stop being partners, and just become friends
as it was possible that he might not be released very soon. On two occasions
within the conversations, he refers to his head as “choker, really really choker”.
30. The man’s friend occupied the cell next door to him. He told the investigation
team that he had known the man since his recall. On 9 May, the night before the
man died, he said they spoke briefly on the landing during association at around
7.20pm. The man had told him about his interview by the police, but they did not
discuss the detail. The man’s friend described him as being “OK” during their
conversations.
31. During the same evening, a wing landing officer said that she also had a general
chat with the man as he passed her on the landing during association at around
7.40pm. She described him as “fine, calm and in good spirits”. He mentioned
being interviewed by the police. The landing officer said that there was no
apparent worry in his voice. He also spoke about his partner and her children,
saying that he was happy and loved them. He said he was expecting and looking
forward to a visit from his partner the next morning. Their conversation lasted
around ten minutes and ended by the man saying that he would see the officer
the next day. The officer’s duty ended at 8.30pm that evening.
32. The evening roll checks of landings two, three and four on B wing were carried
out at around 8.00pm by the night duty officer when he began his night duty shift.
He checked that all prisoners were in their cells, that the exterior cell door bolts
were in place and made himself aware of the prisoners subject to an open ACCT.
During the night, the night duty officer assisted with an incident on A wing. The
man’s friend said that he was awake throughout parts of the night of 9 -10 May
and heard no sounds coming from the man’s cell next door.
Wednesday 10 May 2006
The morning roll check
33. Staff told the investigation team that the normal daily wing routine begins with an
officer conducting the morning roll check at approximately 6.00am. Each cell on
the landing is checked by an officer who looks through the cell door flap and puts
the cell night light on to physically check on prisoners. Staff coming on duty in the
morning, normally around 6.00am on contracted hours (also known as overtime
hours), would conduct the official roll checks and would then sign the wing sheet
records to this effect. The man’s friend (in the cell next door to the man) said that
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he did not recall the morning roll check being done on his cell. He said it was
normally carried out between 6.00am and 6.30am.
34. The night duty officer said that he believed that the morning roll check completed
by night staff was an un-audited roll check. As such, night staff were not
expected to sign the wing roll check. He said that he did his own check for his
own peace of mind at the end of his night shift, and thought that the official check
was done by staff arriving in the morning. At around 5.00am, he started his
morning roll check of the wing. He only completed the third landing, and did not
unlock the exterior bolts. (At the time he was unaware of the responsibility. He
was new to the establishment and, since starting night duties, no one had
informed him that unlocking the bolts was part of his duty.)
35. As he had some outstanding paperwork to conclude, the night duty officer went
downstairs to the movements office, leaving the second and fourth landing
unchecked. Two wing officers arrived soon after to start their morning shift. The
night duty officer said he briefed both officers on the night’s events, and the first
wing officer went to count the second landing. Other officers also started to arrive
for the beginning of their shifts. When the night duty officer went onto the landing,
he said he saw the senior officer checking the third landing and called to tell her
that he had already checked it. Before finishing his shift around 6.45am, the night
duty officer said he had heard a female member of staff shout “the numbers are
correct”.
36. The senior officer told my investigators that, being on contracted hours duty, she
started at 6.00am and her first task was to complete the B wing roll check. She
began her checks on the third landing. While in the midst of doing so, the night
duty officer called to say that he had already checked the cells on the wing. The
senior officer replied that he had not thrown the exterior bolts open, to which he
said he was unaware that he had to do this. She continued to unlock the bolts on
the doors on the rest of the landings, but did not look through any more
observation panels as she believed that they had all been checked.
37. The night duty officer only counted the third wing landing, and said that he
informed the senior officer of this. However, the senior officer believed that the
night duty officer had checked all the cells. This misunderstanding meant that the
roll check was incomplete when it was later signed off by a third wing officer. The
third wing officer also started his duty at 6.00am. He told my investigators that he
signed the roll check sheet to say that the count was correct although he had not
carried out the check himself. He could not recall which officer or officers had
actually carried out the roll count. When asked whether it was normal practice for
the roll check to be signed by an officer who had not carried it out, he said it was
customary for staff to undertake checks on behalf of others and for someone else
to sign the record.
After the morning roll check
38. Once the wing roll check is complete, staff begin unlocking the prisoners
attending workshops and court. The cell of the man’s friend was one of the first
to be unlocked at around 7.15am by a fourth wing officer, who then proceeded to
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the man’s cell next door. When the officer opened the man’s cell door, he found
him hanging off the back wall. He stood in shock and then immediately shouted
for staff whilst running into the cell to lift the man up. The man’s friend said that
he heard a shout for “staff”, and ran out to the landing to see what was
happening. No one was in sight. When he walked down the wing past the man’s
cell, he looked in and saw him hanging from the window bars at the back of the
cell. He was facing the back wall and the fourth officer was supporting his body
at the waist.
39. The man’s friend said that he stood startled, looking into the cell and the officer
shouted to him for help to support the man’s body. He ran into the cell to assist
the officer and, whilst doing so, the man’s body turned round and he saw a sock
in his mouth and quickly pulled it out. By now other officers had come to assist
and cut the ligature from the window bars.
40. A further officer who assisted came on duty at around 7.05am. At around 7.20am
he was on the B Wing fourth landing when he heard a shout. This assisting
officer quickly made his way in the direction that he saw other staff running.
When he arrived at the man’s cell, he saw the fourth officer supporting the man
hanging by ligature from the cell window bars. He assisted the officer until a
second assisting officer entered the cell and cut the ligature from the window bar.
The senior officer arrived and relieved first assisting officer who left the cell. The
first assisting officer said that other staff were present now, but he also noticed
the man’s friend who was standing at the back of the cell.
41. At around 7.10am, the second assisting officer, in his role as B Wing third floor
landing officer, began to turn on the lights in each cell on his landing for prisoners
scheduled to attend the workshops. At 7.20am, he heard a shout coming from
the landing above him, ran upstairs, and was directed to the man’s cell by a
prisoner on the landing. On entering the cell he saw the fourth officer supporting
the man’s body with his arms around him. The man’s friend was also in the cell
and assisting the fourth officer. The second assisting officer said he stood on a
chair and cut the ligature so that the man could be placed on the floor. Other staff
had by now arrived and commenced cardio pulmonary resuscitation (CPR).
42. The senior officer told the investigation team that she was on the third landing at
around 7.20am when she heard a call for assistance from the fourth officer on the
landing above. She ran up to the landing and, on arriving at the cell, saw the
fourth officer and the second assisting officer with the man’s friend bring the
man’s body down from the cell window bars to lay him on the floor. She noticed
the ligature around the man’s neck, and checked for a pulse but found none. The
man’s body was also very cold and stiff. She told staff to start CPR, but she
found it difficult to get air into his mouth because his jaw was so stiff. A further
officer, temporary senior officer, who was now also in the cell, commenced chest
compressions. The senior officer said that she cut the ligature from around the
man’s neck and then left the cell.
43. The wing landing officer from the previous evening returned to duty at 7.00am.
After being on duty for a very short time, she heard a shout for staff and made her
way in the direction of the shouting. She hit the general alarm button at some
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point between hearing the shout for assistance and arriving at the man’s cell.
The alarm button was recorded as being activated at 7.22am. On arriving at the
man’s cell, she looked in to see him hanging. The fourth officer was supporting
him from the top of the waist, and the man’s friend was assisting him.
44. The temporary senior officer had arrived on duty around 7.00am and carried out
staff checks. At around 7.20am, she was on B Wing second landing and heard a
shout for “staff”, coming from the fourth landing. She ran to the cell and saw the
fourth officer and the second assisting officer supporting the man. The man’s
friend was at the back of the cell. The temporary senior officer said that she
quickly removed the fourth officer’s knife from his belt and passed it to the second
assisting officer who cut the ligature from the bars. The temporary senior officer
assisted the fourth officer to support the man’s weight as he was laid down on to
the cell floor. The fourth officer and the second assisting officer left the cell and a
third assisting officer arrived. The senior officer had commenced mouth to mouth
resuscitation, and the temporary senior officer began chest compressions until
the third assisting officer took over. Nursing staff also arrived and, on the
instruction of one of them, the temporary senior officer removed the man’s socks.
Any signs of life were checked for whilst CPR continued, but none was apparent.
The temporary senior officer then left the cell.
45. The principal officer was the orderly officer for the day, which meant that he was
responsible for the routine management of the prison. His duty began at around
5.45am when he started to deploy staff to various roles. As there had been an
incident the night before, he also had to debrief a group of staff. The principal
officer told my investigators that he heard a loud scream at around 7.10am whilst
on B wing. He made his way in the direction of the scream and saw the man’s
friend standing outside the man’s cell. He saw staff inside carrying out CPR and
nursing staff just arriving. The principal officer said that he immediately used his
radio to contact the control room and call an ambulance. He arranged for security
screens and sealed the cell area. The paramedics arrived after approximately ten
minutes.
46. The first nurse arriving at the man’s cell came on duty at 6.30am. At around
7.15am, she heard an officer shout “blue call”. She told my investigators that she
ran to the cell where the shout had come from, taking her around a minute to get
there. The emergency equipment bag had been brought to the cell, and she saw
two female officers carrying out CPR. The nurse checked the man’s pupils and
observed that there were no signs of life, before taking over mouth to mouth
resuscitation from the senior officer. The nurse said that the senior officer used
her knife to remove the ligature from around the man’s neck. Despite its removal,
the nurse said it looked as if the breaths of air were not passing beyond the point
of his neck where the ligature had been situated. She also tried to enter an
airway into his mouth, but his jaw was locked and it proved impossible. CPR
continued for approximately ten minutes. A second nurse was now also present.
47. The paramedics arrived soon afterwards and confirmed that the man was dead.
Their report stated that the man was already dead when they arrived at the cell.
The paramedics recorded that the nursing staff had been attempting CPR, and
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that rigor mortis had set in, the man’s pupils were fixed and dilated, and staff were
unable to open an airway.
Other events
48. The duty governor began to implement the ‘death in custody’ contingency plans.
The Independent Monitoring Board was informed at 7.40am, as were the
Samaritans. A protective screen was put around the man’s cell door, and the cell
was sealed at around 7.55am. The police were also called. The first police
officers arrived at the prison at 9.45am followed by others throughout the day.
The coroner’s officer arrived around 8.15am.
49. The man’s partner was due to visit him that day. He had left a note for staff,
asking them to contact her before she left home. Unfortunately, she had already
left home by the time he was found, and she arrived at the prison at 9.30am. It
was therefore decided to meet her at the visitors centre to break the news of his
death. This was done jointly by the duty governor, a further governor and the
prison’s family liaison officer. The man’s partner told them that the only thing on
his mind which she was aware of concerned his recall to prison. She did not
believe these issues were serious enough for him to actually try to harm himself
or take his own life.
50. The man had named his sister as his next of kin, and the news of his death was
broken to her in person by prison staff at around 9.30am. The family were invited
to visit the cell, and did so at a later date using the opportunity to take flowers.
The prison offered assistance with the funeral costs.
51. All prisoners within the wing on open ACCTs were interviewed. A hot de-brief
meeting was held straight afterwards and staff talked through events of the
morning. A further de-brief was held some days later, although few staff
attended. The majority of staff were content with the level of support available,
although one of the senior members of staff felt that, because of their rank, they
were often expected to cope and not offered the same level of support as those
more junior. The man’s friend was offered support by way of a counsellor and the
prison’s GP.
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ISSUES CONSIDERED IN THE INVESTIGATION
The family’s information about the police and prison
52. The man’s niece said she telephoned both the police station and the prison to
express concerns that he might harm himself. He had told her that, if he ever
went back into prison, he would kill himself. She was reassured by the police that
he was being held in a camera cell. She could not recall whom she spoke to at
the prison and did not receive a call back to say if any action had been taken.
The family wanted to know if any information was passed from the police to the
prison expressing concerns about the man’s level of risk to himself, and if so why
the prison did not put him on suicide or self harm watch.
53. The investigation team contacted the prison’s police liaison officer to obtain a
copy of the custody record for the man on the day that he was arrested. They
also tried to obtain a copy of the escort records, which should have been
completed for the journey between the police station and prison. Neither record
could be located. My investigators were also unable to locate any prison
procedures for recording concerns raised by relatives via the telephone system.
As a result, I have not been able to answer this point for the man’s family. From
the information available there was no reason to put him on special monitoring for
self harm.
The Governor should implement a system to record any family concerns
received at the prison and the action taken to address them.
Was the man aware of all the allegations against him?
54. The man’s family said that the police interviewed him and he was apparently fine
during the interview. They enquired whether, at the time of his death, he was
aware of the allegations made against him. It was apparent from my investigation
that he told staff he was aware of all the allegations. There may have been
further details passed to him during his interview with the police. Some were
mentioned in the last telephone calls to his partner on 9 May, including that his
case was being referred to the CPS for a decision on whether he would be
charged.
Was there a disagreement with his partner?
55. The family wondered whether there had been a disagreement between the man
and his partner shortly before his death. They believe he telephoned her the
night before he died, and that the contents of the call might be relevant. They
have also seen a drawing in a puzzle book in his possessions. This includes a
picture of him and his partner on the beach, then with her figure crossed out. It
said “I can’t do it, I’m dead.”
56. My investigators have not seen the puzzle book, but have read the transcripts
and listened to the telephone calls which have been referred to earlier in this
report. The man was concerned about being recalled to prison, and being
interviewed by the police. He refers to his head as being “choker”. Although I
16
cannot categorically determine the meaning of the expression, it appears to have
been used in the sense that he was feeling stressed or perhaps confused about
events. Coupled with his partner’s concern that their relationship would have to
change if he was facing a further long period of custody, this may indicate
something of the man’s state of mind.
Clinical review
57. The clinical review was carried out by the Director of Public Health for Leeds
West Primary Care Trust. The review was compiled from the prison medical
record, security records and discussion with the Head of Healthcare. The report
makes no recommendations and considers that the man’s care was appropriate.
58. From the limited information available, the clinical reviewer says there was
nothing of note recorded during the man’s reception screening. The suicide risk
assessment score was two (a score of 10 or above would have indicated the
need for clinical intervention). He had little interaction with the healthcare team
whilst in Leeds.
59. When the man was found, the nursing staff arrived promptly and took over the
resuscitation and acted appropriately. (I defer to the clinical reviewer’s view, but
given the state of the man’s body when he was found it might be argued that he
was already beyond resuscitation. It is not respectful either to staff or to the
deceased person to conduct CPR when rigor mortis has already set in.)
Ligature points
60. Having visited the man’s cell, his family commented that the window bars were
very prominent and an obvious ligature point. As he was not thought to be at risk
of self harm, he was in a normal prison cell rather than a special cell with reduced
ligature points. He was also not monitored in the same way a prisoner known to
be at risk of self harm would be.
Time of death
61. The man’s family wondered whether it could be determined how long he had
been dead when he was found. My investigators explained that they would try to
determine when the man was last seen alive, and when he was discovered.
However, between these times they could not estimate a time of death which
would be a matter for a pathologist. My investigators found that the man was last
seen alive when his cell was locked on the evening of 9 May. He spoke to staff
and another prisoner during association but gave no indication of what he
intended to do.
Arrangements for life sentence prisoners
62. The man’s family wondered if, because he was a lifer, the usual precautions to
look after new people arriving in prison were ignored as he would be expected to
settle in and cope. However, all prisoners, whether it is their first time in custody
or not, go through a prison induction and health reception on the day of arrival.
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He had the option to complete a long or short induction programme. Having
previously spent a long period in prison, he opted for the short induction
programme which was completed. In addition, and like other Leeds prisoners, he
was assigned a personal officer and had the opportunity to raise any concerns.
In fact, as a life sentence prisoner, it is arguable that more safeguards were in
place for the man, as he was also interviewed by the Lifer Manager and probation
officer. By all accounts, the man appeared to have settled back into the prison
regime without giving any cause for concern.
Comments to the probation officer
63. The family believe the man told his field probation officer that prison was “doing
his head in” and that he was suicidal. They have asked what happened with the
information, whether it was passed to the prison and, if so, what action was taken.
My investigation confirmed that the man had known his probation officer for many
years, and that this was the only occasion that any reference was made to
thoughts of self harm. By the end of the conversation, which took place more
than a month before he took his life, the field probation officer was satisfied that
his mood had lifted. He recorded the conversation in the probation computerised
log, and referred to it in his report for the recall appeal hearing. However, he did
not draw the conversation to the attention of the prison, nor to his fellow probation
officer in the prison. The field probation officer was unaware of the prison’s
ACCT arrangements and said that, had he known of them, he would have been
more inclined to inform prison staff. The probation officer also said that he did not
know what action to take about other issues arising from his contact with
prisoners.
64. It seems that there was little communication between the prison and home
probation officers. Although the computerised log is shared, it was not clear
when one probation officer would become aware of the work of another. In the
man’s case, this appears to have resulted in them working in a disjointed manner
which did not encourage the sharing of important information. Although the
man’s reference to harming himself might not have appeared as a genuine
statement of intention, it should still have been passed to prison staff so that they
could decide what action was appropriate. An entry was made on the computer
case record, but it was not picked up because it was not drawn to the attention of
the prison probation officer who only checks the record if she is involved in the
case. Her work with the man had been completed before he met the field
probation officer and thus she had no occasion to access the record.
65. My investigators also contacted the Home Office Lifer Release and Recall
Section. They were told that comments such as those in the man’s report are
unfortunately quite common. The Lifer Release and Recall Section receives a
large number of reports. All are read, but staff do not routinely flag up issues
within them.
66. It would appear that the prison’s Lifer Clerk and the Parole Board itself are also
unlikely to draw specific attention to comments about self harm in a recall appeal
report.
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The Governor should liaise with the West Yorkshire Probation Area
regarding the procedures in place to respond to prisoners at risk of
harming themselves.
West Yorkshire Probation Area to remind staff of the importance of
adhering to its procedures for sharing important information with prison
staff.
The NOMS Safer Custody Group should consider the implications of
paragraphs 63-65 above with a view to improving awareness of ACCT
procedures elsewhere in the criminal justice system.
Roll check procedures
67. The local instructions for the conduct of roll checks state that the first morning roll
check is conducted at 6.30am by the night staff, and is normally done in
conjunction with the first day staff coming on duty. At 7.00am, a full roll check is
conducted, with the roll being reported to the Senior Officer (Oscar 2) in the
Centre Office.
68. The night duty officer was unable to do a full roll check at 7.00am, as per the
instruction, as his duty finished around 6.30am. The night of 9 May 2006 was the
first occasion he worked a night at Leeds. His night duties at his previous prison
differed from those at Leeds, but he was unaware of the difference until the end
of his shift. His instructions did not include all the necessary information, and the
senior officer that morning was not aware of this. The outcome was that the roll
check was only partially completed when it was signed off.
69. Although in interview all staff confirmed their awareness of their responsibilities
for roll checks, there were problems on this occasion. It appears to be the
custom that staff sign for tasks which they have not personally carried out. On 10
May, the record was signed without anyone realising that the check had not
actually been completed. I cannot say whether the man had already taken his life
when the roll check should have been conducted. However, had the procedures
been carried out correctly, he would have been found earlier and an attempt at
resuscitation would have been made sooner.
The Governor should urgently review the roll check procedures and remind
staff of their responsibility to follow the local instruction.
70. In the event, staff responded well and professionally when the man was found. I
also commend the actions of the man’s friend and would be grateful if the
Governor could arrange for those sentiments to be shared both with him and the
staff.
71. I also judge that the prison managed its family liaison responsibilities sensitively
and well.
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CONCLUSIONS
72. It is impossible to know what exactly was in the man’s mind on the night of 9-10
May. His niece says that he had told her that if he ever went back to prison he
would kill himself. The man had also told his field probation officer four weeks
earlier that he was not coping well since being recalled and found himself thinking
about ways to harm himself. However, he had given no other indication of such
intentions – either to staff or to fellow prisoners.
73. I cannot entirely explain what the man meant when he said during his last
telephone call that his “head was choker”. It was quite possible that he found it
difficult to accept the allegations made against him, and knew that they could
result in him remaining in prison. His partner did not report what he had said to
the prison, who remained unaware of the conversation until the calls were
transcribed for this investigation. To those around him, he seemed his usual self
the night before he died and appeared to be looking forward to a visit the
following morning.
74. Nevertheless, there was some information about the man’s risk of suicide or self-
harm sitting in a recall appeal report and in the Probation Service’s computerised
case record. His death therefore raises issues about awareness elsewhere in the
criminal justice system of the Prison Service’s policies to prevent suicide and self-
harm.
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RECOMMENDATIONS
HMP Leeds
1. The Governor should implement a system to record any family concerns
received at the prison and the action taken to address them.
2. The Governor should liaise with the West Yorkshire Probation Area
regarding the procedures in place to respond to prisoners at risk of
harming themselves.
3. The Governor should review the roll check procedures and remind staff
of their responsibility to follow the local instruction.
West Yorkshire Probation Area
4. West Yorkshire Probation Area to remind staff of the importance of
adhering to its procedures for sharing important information with prison
staff.
(This recommendation had been amended in light of consultation with
the West Yorkshire Probation Area)
NOMS
5. The NOMS Safer Custody Group should consider the implications of
paragraphs 63-65 above with a view to improving awareness of ACCT
procedures elsewhere in the criminal justice system.
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