Individual at Leicester

INVESTIGATION INTO THE CIRCUMSTANCES OF THE DEATH OF
A MAN AT HMP LEICESTER
IN OCTOBER 2004
PRISONS AND PROBATION OMBUDSMAN FOR ENGLAND AND WALES
FEBRUARY 2006
This is the report of an investigation into the death of a man who was found
hanging in his cell at HMP Leicester in October 2004.
This investigation was carried out under the terms of transitional
arrangements agreed with the Prison Service. An investigator was appointed
from within the Prison Service and she was supported by a colleague from my
office. I am grateful to them both. I am also grateful to the Governor and staff
of HMP Leicester for the assistance they received. I regret the delay in
completing this report.
It is not known who mourns for the memory of the man. It is likely that he
came from Kenya, although this is not certain and he himself claimed to come
from Swaziland. It is also probable that both his parents are alive. He had
made one phone call while he was in custody, but it is not known if this was to
a friend or a relative.
It is also not known what may have caused him to take his own life. The man
seems to have made no impression on the majority of staff who came in
contact with him. But while I am critical of the operation of the personal officer
scheme at Leicester prison, I have found nothing to suggest that what may
now reasonably be supposed to have been the man’s distress should have
come to the attention of staff.
Every death in custody is a human tragedy. All the more so as here, when
the man who died was thousands of miles from his home, family and friends
and when his motivation can only be guessed at.
This version of my report, published on my website, has been amended to
remove the name of the man who died and those of staff and prisoners
involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2006
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Contents
Summary
Conduct of the Investigation
HMP Leicester
Key Findings
The man’s location and movements
Events of 15 October
Issues considered in the Investigation
The Personal Officer Scheme
Immigration issues
Medical / Healthcare management
Conclusions
Recommendations
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Summary
1. This is a report of the inquiry into the circumstances surrounding the
death of a man Leicester prison in October 2004.
2. He was first placed in to prison custody in September 2004 after being
remanded from a Magistrates’ Court. He was charged with possession
of a false instrument and fraud. It is believed that these charges were
related to the man’s passport, which he had sent away with an
application for a United Kingdom driving licence.
3. On reception into prison, the man gave an address in Leicester, where
he said he had been living with an unnamed friend. He said that his
place of birth was Swaziland, although it later emerged that he was in
fact from Kenya. In his core prison record, under “next of kin” is written
“Nobody in this country”.
4. An Immigration Service form IS91 dated 21 September authorised the
man’s detention as “An illegal entrant…” the man would, therefore,
have been aware that he was likely to be subject to removal from the
United Kingdom.
5. On reception into Leicester prison, the man was seen by a duty nurse
who interviewed him and completed the First Reception Health Screen
and part of the Cell Sharing Risk Assessment form. The nurse
recorded that the man had no immediate medical or health problems,
did not suffer from any allergies and did not take drugs. On both
documents, it was recorded that the man had no thoughts of suicide or
of wanting to harm himself.
6. The nurse was one of the few staff able to recall having a meaningful
conversation with the man. He said that, during the reception process,
they discussed the fact that they both originated from African countries.
The man said he was from Swaziland and had left home about a year
before to pursue educational opportunities in the United Kingdom. He
said that he had lived in London before moving to Leicester because
he wanted to do a course at University. The man told the nurse that
his next of kin was a friend in London and that he had not informed
anyone back home that he was in prison because he wanted to deal
with the situation on his own. The nurse recalled that, although the
man was naturally concerned to be in prison for the first time, he did
not show any particular anxiety.
7. For his first two nights in prison, the man was located in Leicester’s
First Night Centre, where he would have undergone a basic induction
into the prison. There are no comments relating to the man’s stay on
the First Night Centre in the staff observation book and staff working
there could not recall him.
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8. After the first two nights the man was moved to L3 landing in the main
prison. L3 landing is used to house new remand prisoners and those
waiting to be allocated work. He returned to court on 29 September
and was remanded in custody until 27 October. On his return to the
prison he was located back on L3.
9. From 29 September until 14 October, the man was located on L3
landing and shared a cell with a prisoner. The prisoner was
interviewed but could recall nothing of the man. The L3 staff
observation book from 24 September to 14 October contains no entries
at all about the man. The only member of L3 staff who could
remember anything about his stay there was an officer. The officer
remembered the man because of his unusual name and that he had
used the prisoner telephone once, but was unable to recollect anything
further.
10. On 14 October, the man was moved from L3 to L4 landing. L4 landing
is used to house prisoners who have jobs in the prison, or those who
regularly go to education. There is no evidence to indicate whether the
man had been allocated a job, but staff interviewed assumed that he
would have been moved in preparation for work. The only entries
about the man in the L4 staff observation book are those relating to his
death the following day.
11. He was moved to cell L4-25 during the morning of 14 October. The
double cell already had one occupant, a fellow prisoner. The prisoner
left the cell during the afternoon and in this time the man was seen by a
landing officer. This was the last time he was seen alive.
12. At about 3:50pm, the prisoner returned from his visit, and the cell door
was unlocked by another landing officer. On opening the cell door, the
officer discovered that the man was hanging from the bars at the cell
window.
13. He was taken to hospital at 4:30pm and was pronounced dead at
4:50pm.
14. It has been almost impossible to construct a picture of the man’s time
in Leicester prison, because few of the staff interviewed recalled
anything significant about him and his wing history sheet has only a
few brief entries. The only remarks about him in any of the four staff
observation books relate to the discovery of his death. I have not,
therefore, been able to find out anything about any activity the man
might have engaged in, or any help or advice he may have been given
by staff other than that relating to health issues. It is not known
whether the man received any visits, but the prison did supply a
transcript of one telephone call with an unidentified person which took
place shortly after he was first remanded.
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15. By reporting sick for the first time, telling his cell mate that he had an
allergy, telling the landing officer that he had had stomach ache and a
healthcare officer that he had had a nose bleed, the man seems to
have been trying to draw attention to himself on 15 October.
Unfortunately, it would seem he did not make his distress clear enough
in order to receive the help he needed.
16. The man left a note which said, “When I die call my mum on this
number.”
17. I have uncovered no reason why the man should suddenly have had
such a significant dip in mood on 15 October to make him want to hang
himself.
18. This report makes three recommendations
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Conduct of the Investigation
19. This investigation was conducted under the terms of transitional
arrangements agreed between my office and the Prison Service that
applied between 1 April and 30 November 2004. In line with those
arrangements, I appointed a Prison Service Staff Officer, to conduct
the inquiry on my behalf. She was supported by a colleague from the
Ombudsman’s office.
20. The investigators met the Governor of Leicester prison and
representatives from staff associations.
21. They issued a notice to prisoners and staff, inviting anyone who might
have information relating to the man’s death to make themselves
known to the inquiry.
22. They interviewed prison staff and the two prisoners who had shared
cells with the man. Transcripts of the interviews are attached as
annexes of this report. They were also given statements supplied by
prison staff in the immediate aftermath of the man’s death.
23. A review of HMP Leicester’s Suicide Prevention policy and practice
was carried out by the Area Suicide Prevention Advisor.
24. The inquiry team received all due co-operation and assistance from
prison staff and prisoners.
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HMP Leicester
28. HMP Leicester is a local prison for adult men, built in 1825. With a
capacity of 385 prisoners, it is one of the smallest local prisons in the
country. The most recent report by Her Majesty’s Chief Inspector of
Prisons was in 2003. In 2004, the Independent Monitoring Board were
pleased to report that the installation of in cell electricity was due to be
completed in August 2005.
29. A report by the Area Suicide Prevention Advisor, is attached as an
annex to this report. He found that the strategy, policy and practice of
suicide prevention at Leicester is basically sound. The majority of staff
interviewed during his inquiry had had recent, up to date, training.
However, the advisor makes one telling comment:
“It appears that on the main residential unit of landing 3 and 4
that staff had only limited time to support prisoners beyond the
bare minimum. Prisoners talked of staff being too busy to listen
to them and that most of their requests had to be made by
written application.”
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Key Findings
The man’s location and movements in HMP Leicester
30. On his arrival at Leicester prison, the man went through the standard
reception process for prisoners. He was interviewed and
photographed, allocated a prison number and seen by a member of the
Healthcare team, a nurse, for a First Reception Health Screen. So far
as I can judge, the reception process was conducted appropriately and
was sufficient for the purpose of gathering initial information. In fact,
the most significant conversation the man had with staff during his time
in custody appears to have been during the reception process when he
was interviewed by the nurse. My investigator found the approach by
staff to new prisoners to be reassuring and respectful. However, as in
a number of older local prisons, physical surroundings in the Reception
area have a number of shortcomings.
31. After reception, the man was taken to the prison’s First Night Centre
where he remained for two nights. He would have gone through a
short induction process; this would have involved being interviewed
about his immediate needs and issued with a reception pack containing
tobacco and a £3 “credit” to enable him to make a telephone call. He
was also interviewed by staff from the Chaplaincy, Probation and
Resettlement departments but no information is available about the
content of these interviews. At the time of the man’s reception into
Leicester, it appears that there was no policy requiring staff to make
extra efforts to establish his needs as a foreign national.
32. Two days after reception, the man was moved to L3 landing. This is
the landing to which new prisoners who do not require detoxification
from drugs are allocated. The man should have been allocated a
Personal Officer on L3, who would have been responsible for ensuring
that his needs were met. There is more about the inadequacies of the
Personal Officer scheme later in this report.
33. The man went out to court for further remand on 29 September and
then returned to L3.
34. On 14 October, the man moved to L4 landing. Although there is no
evidence to corroborate this, staff have said that they assumed he was
moved there because he was about to be allocated work. He was
placed in cell L4-25 with a prisoner. It was in this cell that he died on
15 October.
35. The prisoner recalls that the man’s English was quite good, and that he
said he had come to England a couple of years earlier with his father.
The man told the prisoner that he had been arrested after sending his
passport away when applying for a driving licence. He said that the
man did not go down to collect the tea meal on the evening of 14
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October, which meant that he had no tea and did not collect his
breakfast pack for the following morning. He would have been issued
with a flask to collect hot water from the hot water boiler on the landing
recess so that he could make himself a drink
36. The prisoner says that, during the night of 14 /15 October, the man got
out of bed several times and walked over to the window. The prisoner
said that he gave the man a cigarette on a couple of occasions. During
the morning of 15 October, the prisoner says that the man pressed the
cell bell on a couple of occasions telling staff that he had an allergy and
needed to see a doctor. The prisoner says that staff warned him that, if
he continued to press the cell bell, he would be punished.
37. Staff did book the man “special sick” at 10:00am, through the special
sick book on the Centre. A healthcare officer (HCO) saw the man at
his cell door soon afterwards. He said that the man complained that
his nose had been bleeding, although it was not doing so at the time.
Further enquiry revealed that the man had had a cold and had been
blowing his nose vigorously. He agreed with the HCO that this was
probably the cause of the bleeding. He also told the HCO that he had
suffered with a stomach ulcer in the past. The HCO recalled a good
conversation and said that the man was showing no signs of stress or
of intending to harm himself, or attempting suicide. The HCO gave the
man advice about his nose, but did not give any medication or refer
him to the doctor.
38. The prisoner recalled that the man collected and ate his lunch and
“seemed okay”. He said that the man gave no indication that he was
contemplating harming himself. The prisoner left the cell at
approximately 1:45pm, because he had a visit with his solicitor that
afternoon.
39. The next and last person to see the man alive was a landing officer.
The officer answered the L4-25 cell call bell at about 2:30pm. In
interview, she said that she was not aware that he had rung the bell on
previous occasions and she did not say that he had been warned about
using his bell. She said that she opened the cell rather than speak to
the man through the door, because she was having difficulty
understanding his heavily accented English. The officer said that the
man asked if there was due to be kit change that afternoon. The officer
replied that she would check, but that if his landing was not due for a kit
change he would be in his cell all afternoon. The officer recalled that
the man told her that he had had stomach ache that morning, and had
been seen by someone. She says that, when she left the man, he
smiled at her and climbed under the duvet on his bed.
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Events of 15 October
40. An officer opened the man’s cell door at 3:50pm to let the prisoner
back into cell L4-25. The officer saw that the man was hanging from
the window bars. The ligature was made of a bed sheet.
41. The officer immediately called for assistance from other staff. He was
followed into the cell by a second officer, who assisted the first officer
in cutting the man down from the window. They placed the man on
one of the beds in the cell and were joined by a third officer, who
assisted in cutting the rest of the ligature from the man’s neck. The
radio was not used to summon assistance and the staff who assisted
were alerted by the first officer’s shout. He checked for vital signs and,
being unable to find a pulse, decided that the man should be placed on
the floor so that staff could begin to attempt to resuscitate The man.
The staff immediately began to attempt to resuscitate the man through
artificial respiration and cardio pulmonary resuscitation (CPR).
42. The landing officer was present as well as the other officers. She did
not have a radio and so telephoned the healthcare centre for
assistance. At about 3:55pm, a HCO entered the cell. He asked for an
ambulance to be called and tried to use the prison defibrillator to see if
he could detect signs of life. The battery on the defibrillator was flat
and so the HCO and the first officer continued manual CPR and
artificial respiration.
43. Paramedics arrived at the scene at about 4:00pm. They continued to
work on the man and their defibrillator showed that there were some
signs of life. They made the decision to move the man to hospital. He
was strapped into a chair and taken to the ambulance which left the
prison at 4:30pm. Sadly, the man was pronounced dead at the hospital
at 4:50pm.
44. The immediate response by the staff who found the man was speedy,
professional and entirely compassionate. The ambulance was at the
prison within three minutes of being called and paramedics were at the
scene within ten minutes of him being discovered.
45. All staff and prisoners at Leicester were informed of the man’s death as
soon as practicable after the prison received the news. Staff involved
were de-briefed and offered the services of the prison’s Post Incident
Care Team. No member of staff interviewed expressed dissatisfaction
with the way they were treated after the man’s death was discovered.
46. The man’s cell mate was immediately located with another prisoner for
company, and later with a friend in the prison. He told my investigator
he was satisfied with the way he was treated by staff.
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47. All prisoners subject to F2052SH procedures (for those considered to
be at risk of self harm or suicide) were immediately reviewed and
reassured.
48. All relevant agencies were informed of the man’s death and the
Governor attempted to contact the man’s mother through the Kenyan
Embassy.
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Issues Considered in the Investigation
The Personal Officer Scheme
49. At the time of the man’s death, Leicester’s Personal Officer Scheme
was under review. The Personal Officer Scheme is meant to ensure
that prisoners have an identified member of staff to whom they can turn
for help or advice. The member of staff should see the prisoner
regularly, deal with any needs or problems, and record the prisoner’s
progress in their wing history sheet. In addition, any other member of
staff may record their observations about a prisoner in the history sheet
or the wing observation book.
50. The system current during the man’s time at Leicester was the
following:
• Two officers on a landing would be allocated a bank of cells for
personal officer duties. The officers would be responsible for
prisoners housed in those cells. (Because Leicester is a local
prison where the turnover of prisoners is frequent and rapid,
prisoners are often not in the same cell for very long.)
• Officers were allocated personal officer time as and when
staffing levels allowed. If there was a shortage of staff through
sickness or operational requirements elsewhere in the prison,
there would be no time to be allocated for such duties.
51. The man’s history sheet shows only four entries on September 22 and
23, and no further entries before his death on 15 October. None of the
entries was made by landing staff, and my investigators could not find
any member of staff who considered themselves to be the man’s
personal officer. It was clear to the investigation team that landing staff
knew nothing at all about the man.
Immigration Issues
52. The man was arrested and charged with possession of a false
instrument (his passport). It appears that discrepancies had come to
light when he sent the passport away, as proof of identity, when
applying for a United Kingdom driving licence.
53. The man stated to the authorities that he was a Swaziland national, but
the contact number he left for his mother was in Kenya and it is
believed that he was in fact Kenyan. He told his cellmate that he had
entered the United Kingdom two years previously with his father, but
did not say where his father was at the time of his arrest. He stated
that his next of kin was “No one in this country.”
54. The Immigration Service had issued a form IS91 against the man,
which required him to be held as a detainee. He would probably have
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been aware that he would be subject to removal from the United
Kingdom. His status was that of detainee and he told his cellmate that
his case was due for review on 27 October, which was the date he was
due back in court.
Medical and Healthcare management
55. The man’s prison medical record and First Reception Health Screen
state that he had no medical or healthcare problems, was not a drug
user and was not considered to be at risk of self harm or suicide. His
prescription chart does show that he was prescribed Ibuprofen on 22
September, but there is no indication of the reason for this.
56. It may be significant that, on the day he died, the man asked to see a
doctor and gave his cell mate and two members of staff three different
reasons for feeling unwell. However, there is nothing to indicate that
he was showing signs of distress. He appears to have been given
appropriate advice by the HCO for the symptoms he
presented at the time.
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Conclusions
57. It is impossible to tell what might have been the trigger for the man to
hang himself. He appeared to have no medical or mental health
problems, was not a drug user and did not seem to have any problems
with staff or other prisoners. There were no significant events due to
take place (his next court appearance was almost two weeks away).
He had changed cells the day before he died, but did not have a close
relationship with his previous cell mate. In addition, a lack of any
significant information about the man’s time in prison makes it
impossible to do more than guess at his motivation.
58. The Personal Officer scheme at Leicester at the time was poor. Staff
appeared not to know anything about the man, despite the fact that he
had been in custody for more than three weeks.
59. After finding the man, staff acted promptly and professionally and made
every effort to resuscitate him. It is worthy of note that paramedics
were with the man within ten minutes of the ambulance being called.
60. Leicester’s contingency plans were good and were followed
appropriately. Staff and prisoners were appropriately supported in the
aftermath of the man’s death.
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Recommendations
1. The Governor of Leicester should review the Personal Officer scheme
to ensure that staff are given enough time, on a regular basis, to
ensure meaningful contact with prisoners and that all observations are
recorded.
2. There should be regular testing of emergency medical equipment held
at the prison to ensure that it is in working order.
3. Staff involved in attempting to save the man’s life should be formally
recognised for their swift, professional and compassionate response.
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