Individual at Lincoln

Investigation into the circumstances surrounding the
death of a man
at HMP Lincoln in November 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2007
This is the report of an investigation into the circumstances of the death of a man at
HMP Lincoln in 10 November 2006. The man was found hanging in his cell in E
wing. He was 31 years old.
I extend my sincere condolences to the man’s family and friends for their loss.
The investigation was carried out by two of my colleagues. Lincolnshire Primary
Care Trust agreed to carry out a review of the man’s clinical care and treatment
while at Lincoln. I am grateful to them for completing this review.
I would also like to thank the Governor of Lincoln, and her staff for their help and
assistance during the course of this investigation.
The man was accustomed to prison life and nothing arose during the investigation to
indicate that he was considering harming himself. There is some evidence that he
felt under threat from other prisoners and he made repeated efforts to contact his
girlfriend on the morning of his death. Beyond that, there are no clues to his
intentions. His death came as a surprise to prison staff, fellow prisoners, and his
own family.
Whilst having no bearing on the man’s death, I have made one recommendation in
this report. I also make two housekeeping points that arise from the clinical review.
In addition I have noted one area of good practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2007
2
CONTENTS
Summary 4
The Investigation Process 6
HMP Lincoln 7
Key Events 8
Events leading up to the man’s death 8
Events following the man’s death 12
Main Findings from Clinical Review 14
Conclusions 15
Recommendations 17
Good Practice 17
Housekeeping 17
3
SUMMARY
The man was 31 years old when he died and he was well used to prison life. He
was also known to HMP Lincoln, having served sentences in there in the past. The
man had been a drug user for many years and a lot of his crimes were linked to his
drug usage. When the man apparently took his own life on Friday 10 November
2006, he had just four months to serve of his latest sentence.
The man’s final sentence had commenced on 6 June 2006. It was an 18 month
sentence with a conditional release date of 6 March 2007. He man spent the first
week of the sentence in HMP Nottingham before being transferred to Lincoln. Seven
weeks later, he was transferred to HMP North Sea Camp. The man absconded from
North Sea Camp after a few days but was soon re-arrested. On 11 August, he was
returned to Lincoln. As with his earlier spell in Lincoln, the man asked to be located
in the Vulnerable Prisoners Unit, which is in E wing. His reason for asking for
protection was that he was fearful of attack from other prisoners. It seems that these
prisoners were friends of people from whom the man had stolen property.
Upon his return to Lincoln, the man quickly settled in. He obtained a job as a wing
cleaner and gained enhanced status1. The entries made by staff in the man’s
records report positively on his attitude. The man was described as keeping himself
to himself and as someone who gave nothing away about his deeper feelings. Nor
did he speak about his girlfriend. This was confirmed by the man’s cousin who was
in E wing at the same time.
Apart from his work as a cleaner, the man’s other main occupation was visiting the
gym. From their interviews with staff and prisoners, my investigators found that the
man’s commitment to work and his interest in the gym did not waver. He gave no
hints from these aspects of his life or from any other that there was anything
troubling him.
The man’s telephone records at Lincoln show that the majority of his calls were to his
girlfriend. Between 10.05am and 11.05am on 10 November, the man rang his
girlfriend’s mobile telephone four times. She did not answer any of the calls. Also
that morning, the man separately asked two officers about visits. He asked the first
whether he was due a visit that afternoon. Later on in the morning, he asked
another officer whether he was due a visit at the weekend. The man was told that no
visits had been booked for 10 November but the weekend visits list would not be
available until later on in the day. The man did not mention to either officer who he
was hoping might visit. Neither officer noticed anything unusual or untoward about
the man’s demeanour.
One of the other prisoners said that he and the man spoke at about 11.30am. The
man asked him for his sausage roll. When the prisoner passed it to him, the man
smiled and said thanks.
1 Prisoners on enhanced status are entitled to more privileges than prisoners on basic or standard
regime. A prisoner achieves enhanced status by working hard or going to education and through
general good behaviour.
4
The First Officer was the last person to see the man alive when he locked him into
his cell at midday. They each said to the other ‘see you later’. As with everyone
else who encountered the man that morning, this officer also said that he seemed his
usual self.
When staff unlocked prisoners after lunch the man was found hanging from a
ligature tied to the window frame. A Code One alarm was issued to signal a medical
emergency, staff entered the cell and cut the ligature. Healthcare staff arrived and
attempted to resuscitate the man. They continued with their efforts until relieved by
ambulance paramedics who took the man to outside hospital. Unfortunately all
efforts proved unsuccessful and the man was pronounced dead at 2.17pm.
The man’s death was a shock to all the staff and prisoners who knew him. None of
them thought that he seemed someone who would do such a thing and none noticed
any change in his demeanour or behaviour. The man’s father told my staff that he
would not have believed that his son would take his life.
My investigators followed up two reports recording information from prisoners
suggesting that the man might have been at risk. One was about the background to
the man asking to be in E wing. When my investigators spoke to the prisoner
responsible for this information, he was able to add little to what they already knew.
The other report suggested that on the morning of his death the man told staff that
he was feeling suicidal. This proved to be an unfounded rumour.
5
THE INVESTIGATION PROCESS
The investigation was opened on 17 November 2006 when one of my colleagues
visited Lincoln and met a number of prison staff, including the Deputy Governor, the
prison’s family liaison officer and a representative from the Prison Officers’
Association. My investigator also met the chair and vice chair of the Independent
Monitoring Board (IMB). My investigator informed all those he met of the nature and
scope of the investigation. Notices were issued to staff and prisoners notifying them
of the investigation.
Eight members of staff and five prisoners were interviewed. No additional prisoners
came forward to give evidence directly in response to the published notices.
Lincolnshire Primary Care Trust agreed to carry out a review of the man’s clinical
care and treatment while at Lincoln.
One of my Family Liaison Officers (FLO) contacted the man’s father. The FLO and
one of my investigators visited the man’s father and grandmother. The man’s father
said that he would never have believed that his son would have taken his own life.
And it seemed strange that he had eaten lunch shortly before his death. The man’s
father had wondered at first whether a third party had been involved. However, he
had come to accept that was unlikely because his son was so strong physically it
would have taken a number of men to subdue him.
To try to understand whether his son had been planning to take his life, his father
wondered whether he had submitted a canteen order in the week of his death and
whether he had charged up his telephone credit account. Another thing that he
wondered was whether his son had spoken with the prison chaplain.
My investigator obtained copies of the man’s last three canteen orders. Monday is
the day for submitting orders and the man submitted an order on the Monday before
his death as usual. He ordered similar items as previously, including a telephone
credit. My investigator found that the prison chaplains had no record or recollection
of any contact with the man.
The man’s father mentioned vulnerable prisoner status. He was aware that his son
had made a number of enemies through his drug use. He wondered if his son had
felt in fear for his life and whether this fear of reprisals had been weighing heavily on
his mind. After the man’s death, his father found a number of letters from his son’s
girlfriend. He had studied the letters intently, but was unable to pick up any clues as
to his son’s state of mind.
The man’s father said that the way Lincoln handled matters after his son’s death had
been very good.
6
HMP LINCOLN
HMP Lincoln opened in 1872. It is a local prison holding just under 500 remand and
convicted prisoners. Lincoln comprises four residential units. E wing is a modern
wing housing the Vulnerable Prisoners Unit (VPU).
The facilities at Lincoln include production workshops, laundry, education, and
vocational training courses. The prison also has charity workshops.
Lincoln has a healthcare centre with in-patient accommodation. Detoxification
provision is available in C wing with separate detoxification arrangements for
vulnerable prisoners in E wing.
The last inspection of Lincoln by Her Majesty’s Chief Inspector of Prisons (HMCIP)
was an unannounced inspection in September 2005. Appendix III of the Chief
Inspector’s report related the findings from prisoner focus groups. Comments from
prisoners from E wing included:
“Officers engage with prisoners during association; some officers play pool
with prisoners.”
“[There are] no staff bullying issues, but staff can frustrate or goad prisoners.”
“Feel safe [from other prisoners] on wing ...”
“[Problem is] mainly frustration with [other prisoners] not bullying.”
“[There is] good access to [the] chaplain.”
“Cleaners were out of cell all day working and they also had daily association,
unlike the rest of prisoners on the wing.”
“Not comfortable [with] mixed wing visits – get shouted at by other prisoners.”
7
KEY EVENTS
Events leading up to the man’s death
The man’s time in Lincoln
On 6 June 2006, the man was convicted on a number of driving offences and was
initially received into HMP Nottingham. During a first reception health screening
interview, the man said that he had never harmed himself in the past and had no
thoughts of doing so now. After spending just over a week in Nottingham, the man
was transferred to Lincoln. By the time of his transfer, the man had successfully
completed a detoxification programme for heroin and cocaine/crack cocaine.
On arrival at Lincoln on 15 June, the man said that there were prisoners in both B
and C wings with whom he would have problems if located in either of those wings.
The man asked for protection and he was located on E wing (E wing is Lincoln’s
vulnerable prisoners wing).
On 31 July, the man was re-categorised and transferred from Lincoln to North Sea
Camp (a category D open prison). While in the reception area at North Sea Camp,
the man was struck in the face by another prisoner. He absconded two days later.
The man was re-arrested on 11 August and taken back to Lincoln. Upon his arrival
at Lincoln, the man was taken though a standard first reception health screening
interview. He was asked whether he had ever tried to harm himself in the past and
he said that he had not done so. The man was also asked whether he had any
present thoughts of self-harm and he replied that he had no such thoughts. He did
report, however, that he had been assaulted at North Sea Camp and said that he
had fears for his safety. He applied for protection under Prison Rule 45. As with his
previous time in Lincoln, the man was located on E wing in a single cell.
The man had been using illicit drugs while out of prison so he was prescribed an
opiate detoxification programme which was completed on 18 August. He later
declined services offered by the CARATS (Counselling Assessment Referral Advice
Throughcare) team, saying that he did not consider drugs to be a problem for him.
On 5 September, the man started work as a cleaner and he quickly proved himself to
be a good worker. An officer recommended the man for enhanced status on 15
September recording that: ‘[The man] has proven himself to be a good and able
cleaner. He is polite and applies himself with enthusiasm to any job given to him.’
Another officer wrote a similar endorsement of the man’s work and behaviour on 19
September. The man’s records contain very few other entries after these two.
The First Officer told my investigators that the man was very quiet and polite. He
had a fairly small circle of friends, mainly the other cleaners, and he would have a
laugh and a joke with them. Outside of that group, the First Officer thought that the
man had friendly but superficial relationships with most of the other prisoners. The
First Officer said the man was the sort of person who would speak to officers if he
had concerns. For instance, he told officers that he was worried about going to
North Sea Camp before he was sent there. The First Officer understood that the
8
man had had a relationship with the girlfriend of a prisoner at North Sea Camp, and
that had led to him being assaulted when he went there. The First Officer knew that
the man was fearful of prisoners in B and C wings at Lincoln, but he was unaware of
the background to these fears. The First Officer said that he never noticed anything
about the man’s demeanour to give him any cause for concern for his safety.
In his interview, the Second Officer described the man in similar terms. The Second
Officer said that the man kept himself to himself. He ‘gave away’ nothing about his
feelings and whether he had any troubles. The Second Officer said that although the
man did not say a lot, he would speak when he needed something. The Second
Officer confirmed that the man was a good worker who got on well with the other
cleaners. The Second Officer said that he would exchange banter with the man
about him lifting two mattresses at a time. Like the other officers, the Second Officer
was very shocked that the man had apparently taken his own life.
In his interview, the Third Officer said that the man was a man who kept himself to
himself, a man who never spoke about having any worries. The Third Officer
described the man as someone who got on with other prisoners and who did not
bother staff with issues unless he needed something. The Third Officer said that the
man came across as not caring what other people thought. He was a big chap who
would be able to ‘hold his own’ if necessary. As with his fellow officers, the Third
Officer never had any fears for the man’s safety. Similar evidence was given by the
Fourth Officer.
The Senior Officer (SO) told the investigators that he had only known the man from
the time of his return to Lincoln after he had been in North Sea Camp. Even from
that brief contact, the SO described the man as one of the best behaved prisoners
he had encountered.
Another SO also referred to the man keeping himself to himself, adding that neither
he nor any of the other officers ever had any concerns for the man’s safety. After the
man’s death, the other cleaners told him that the night before he died the man had
been laughing and joking with them.
The man’s records show that he was issued with a written warning on 9 November
for blocking his window with a jumper. The Officer Support Grade (OSG) who issued
the warning told the investigators that what the man had done was something that is
common practice among prisoners at Lincoln – he had tied his jumper to his cell
window to form a makeshift curtain. The OSG said this is forbidden as it prevents
night staff from seeing whether or not the window bars have been tampered with.
The OSG said that he had first spoken to the man about blocking his window on the
evening of 7 November. He told the man to remove the jumper and the man said
that he would do so. When the OSG carried out his morning check at 5.30am on 8
November, the man’s jumper was still blocking the window. The OSG said that he
would not wake a prisoner in those circumstances, but would inform the on-coming
day staff about the incident. On the evening of 8 November, the OSG found that the
man had again blocked his window with his jumper. The OSG once more asked the
man to remove the jumper and the man again said that he would do so. The jumper
was still in the same position on the morning of 9 November and it was then that the
OSG filled out the warning form. The OSG said that a single warning of this type
9
would not have resulted in any punishment – a prisoner will only suffer loss of
privileges if they have received three such warnings within a three month period.
The OSG said that the man had not been argumentative on the evenings of 7 and 8
November. He agreed each time that he would remove his jumper and had been
unperturbed about it.
The man’s cousin was also in E wing in Lincoln at the time. The cousin said that he
and the man were good mates. They last saw each other on the night of Thursday 9
November and they had had a great laugh. The cousin said that there was nothing
to suggest that the man was becoming despondent and he carried on with his usual
activities like going to the gym. The cousin added, though, that the man never spoke
about his real ‘feelings’ and he never spoke about his girlfriend. The cousin said that
the man had been battling to get off drugs for a long time. He would go through
detoxification each time he came into prison, but would start using again when out
resulting in further crimes. The cousin also said that the man was becoming
institutionalised and was effectively homeless when out of prison. The cousin added
that both the prisoners and the staff in E wing are nice people.
The day of the man’s death
The SO said that at about 10.30am on Friday 10 November, the man approached
him to ask if he was due to have a visit that afternoon. The SO telephoned the visits
unit and was told that no visit had been booked. The SO said that, when he told the
man he was not due a visit, he did not seem concerned.
The computerised telephone records show that between 10.05am and 11.05am that
morning the man made four attempts to contact his girlfriend on her mobile
telephone. She did not answer any of the calls.
The Second Officer also had a conversation with the man about visits. At around
11.30am, the man asked if any visits had been booked for him for the weekend.
When the Second Officer checked, he found that the weekend visits list was not yet
available. The Second Officer told the man that the weekend visits list would be
available that evening. The Second Officer said that the man seemed fine. That
was the last time the two of them spoke. The Second Officer’s shift finished at
12.30pm.
The Third Officer recalled speaking with the man that morning. The man was sitting
at the servery talking with another prisoner. The Third Officer asked them to move
away from the servery and to continue their conversation on the landing. The Third
Officer said that the man appeared his usual self.
Another of the prisoners at Lincoln knew the man from going to the gym. He said
that the only time the man ever missed going to the gym was when he was aching
from the previous day. The prisoner said that he last saw the man at about 11.30am
on 10 November. As the prisoner does not like prison food, the man asked him for
his sausage roll. The prisoner gave it to him and the man smiled and said thanks.
The prisoner said that the man seemed fine. The prisoner also told the investigators
that the man did not seem the sort of person who would take his own life.
10
The First Officer said that just after 12.00 noon he was helping to lock up prisoners
after lunch. He asked the man if he had finished his lunch and the man said that he
had2. The First Officer said ‘see you later’ and the man replied, ‘thank you very
much … see you later.’
The discovery of the man’s death
At about 1.40pm, the Fourth Officer began helping to unlock prisoners for the
afternoon. When the Fourth Officer reached the man’s cell (on the 4’s landing), he
saw him hanging from a ligature tied to the cell window. The Fourth Officer shouted
to an officer who was across the landing and asked him to call a Code One alarm (a
Code One alarm indicates a medical emergency). The Fourth Officer entered the
cell. He held the man around the waist with one arm and used his anti-ligature knife
to cut the ligature. The man slid to the floor and the Fourth Officer started to check
for a pulse. The Fifth Officer then arrived followed by healthcare staff.
The Fifth Officer said that he was on the 3’s landing when he heard the shout of a
Code One. The Fifth Officer ran up to the 4’s landing to assist. He said that when
he arrived, The Fourth Officer had already cut the ligature and the man was on the
floor. the Fifth Officer removed some furniture so there would be more room in the
cell and then checked the man’s neck for a pulse. The Fifth Officer said that he
thought he detected a faint pulse. He also thought that the man might have been
breathing as there were some mucous bubbles coming from his nose. The Fifth
Officer asked the Fourth Officer if he could feel a pulse from the man’s wrist but he
replied that he was unable to. The Fifth Officer said that he asked another officer to
get a nurse, but nurses were already on their way. A nurse then came into the cell
and began attempts to try to resuscitate the man.
In a formal statement about her involvement, the Nurse wrote that she was in the E
wing treatment room on the 2’s landing when a call was made for a nurse. She was
told that there was a Code One incident on the 4’s landing. The Nurse went to the
man’s cell taking with her the emergency resuscitation bag. The man was on the
floor lying on his side. With the help of one of the officers she turned the man onto
his back. The man was not breathing, he had no pulse and he was unresponsive.
The Nurse gave the man two emergency breathes and checked again for a pulse.
The Nurse wrote that other nurses arrived at this point and attempts were made to
try to resuscitate the man. A defibrillator was attached but it indicated that no shock
should be given. The nurses continued in their efforts to try to resuscitate the man
until ambulance paramedics arrived (ambulance service records show that they
reached the man at 2.00pm). Unfortunately, all attempts to try to resuscitate the
man proved unsuccessful and he was pronounced dead at 2.17pm.
2 During the post mortem examination the man’s stomach was found to contain a large amount of
semi-digested food from having taken a recent meal.
11
Events following the man’s death
Family and staff support
Lincoln’s family liaison officer (FLO) told my investigator that because of a situation
that had arisen following a previous death in custody, Lincoln asked the police for a
risk assessment of the man’s next-of-kin (his father). It was almost 5.00pm before
the police contacted Lincoln to say that there was nothing to indicate that there
would be any problems with visiting the man’s father. Due to the time it would then
have taken to travel to the father’s home in Mansfield, Lincoln’s FLO contacted
Nottingham prison to ask if their staff could make the visit to break the news of the
man’s death. Unfortunately, Nottingham’s FLO had already gone home so Lincoln
asked Nottingham police to break the news and to ask the father to telephone
Lincoln. The father did so and he spoke that evening both with Lincoln’s FLO and
with Lincoln’s acting Governor. Arrangements were made for the father to visit
Lincoln the following day along with his mother (the man’s grandmother). The family
was able to visit the cell and to speak to staff.
Lincoln paid the man’s funeral expenses and Lincoln’s FLO and acting Governor
attended the funeral. Lincoln sent flowers for the funeral and the prisoners at Lincoln
also contributed a wreath after collecting £112.
The vice-chair of the IMB was in Lincoln at the time of the man’s death. She spent
several hours that afternoon speaking to staff and she also spoke to the man’s
cousin. He told her that the man was not the sort of person who would discuss
significant personal matters with others.
A staff debrief was held on the afternoon of the man’s death and the staff on duty at
the time were offered the opportunity to speak to the local care team. Prisoners in E
wing were told on an individual basis about the man’s death.
The report that the man was at risk from other prisoners
On 12 November, a security information report was completed that a prisoner who
worked in reception told staff that he was not surprised at the man’s death. The
reception prisoner was reported as saying that the man was a ‘dead man walking’ as
there were a number of contracts out on him from various drugs dealers. He also
said that another ex-prisoner had ‘put a price’ on the man for assaulting his girlfriend.
The reception prisoner told my investigators that he had known the man for around
15 years. He said that in the last six years the man had begun to take a lot of drugs,
and he was committing a lot of crime when on the outside to fund his habit. The
reception prisoner said that many of the man’s victims had prisoner friends in Lincoln
and that was why the man was in E wing. He said that he had also heard a rumour
that the man had assaulted the girlfriend of another prisoner and that he was also
aiming to get back at him. The reception prisoner said that these people would have
waited for the man to come out of prison before doing anything.
12
The last time that the reception prisoner saw the man was about a week before his
death when he was putting some property into storage. The man seemed fine and
did not say anything to indicate that he might be thinking of harming himself.
The suggestion that the man told staff that he was feeling suicidal
One of my investigators spoke to the police about their investigation into the man’s
death. The police investigation included interviews with prisoners. The prisoner who
knew the man from the gym told the police that two other prisoners had overheard
the man telling staff on the morning of his death that he was feeling suicidal.
However, the officers had not taken any action.
My investigators spoke to all three prisoners. The prisoner from the gym said that
the man did not seem the sort of person who would have taken his life. However, on
the evening of 10 November he overheard two other prisoners talking about what
had happened that day. They were saying that they had heard a rumour that the
man told staff in the morning that he was depressed but the staff did nothing about it.
The first of the two prisoners told my investigators that he heard a rumour that
officers knew that the man was in a depressed mood on 10 November but they had
not taken any action. This prisoner did not know the source of the rumour. He said
that he did not know how much truth there was in the rumour, but his experience of
officers in E wing was that if they have any inkling that a prisoner might be at risk of
self-harm, they take appropriate action without delay. This prisoner added that he
knew the man from inside and outside of prison and it was totally out of character for
him to harm himself.
The second of the two prisoners said that although he had sold cigarettes to the
man, they did not really know one another. On the evening of the man’s death,
prisoners were talking about the fact that he was seen using the telephone in the
morning.
13
MAIN FINDINGS FROM CLINICAL REVIEW
• The man had the standard reception screening for a prisoner transferred from
another prison. He did not have a secondary screen as this is only completed
for new prisoners. The man was assessed regularly in his first few days as he
was on the detoxification regime. The screening process identified that he had
substance misuse problems. There was nothing to suggest a risk of self harm.
• Drug detoxification is a potentially risky treatment. I was impressed with the
degree of monitoring of the man while undergoing detoxification at Lincoln in
August 2006. The nursing care plan meticulously documents what needed to
be done and the nursing notes record that he was assessed very carefully.
• The man had significant knee pain and a history of a serious knee injury. He
was X-rayed on 23 August 2006. His notes record that the X-ray was chased in
September and November, but there is no entry in his notes of the result. The
decision to carry out an X-ray should never be taken lightly, and in this case
there was clear justification for the test. However, no action was taken because
the result was unknown. There should always be a clear trail from
investigation, to result, to action.
• The man was at high risk of contracting Hepatitis B and was correctly
commenced on a course of Hepatitis B vaccinations. However, he was given
the third dose too soon after the second and this might have reduced the
vaccine efficacy. Nursing staff said that at times of staff shortages as was
apparently the case in the latter part of 2006, Hepatitis B vaccination is
accorded a low priority. I was informed that additional staff have recently been
trained to give this vaccination and that vaccination now conforms more to the
recommended schedule.
• The man’s risk of self harm/suicide was assessed on transfer to Lincoln on 11
August. At the reception medical he denied any past history of self harming
and he answered “no” when asked if he considered harming himself. A nurse
who knew him from a previous period of imprisonment, and spoke to him
regularly during this sentence, told me she was shocked that he had killed
himself as he had given no indication to her at any time of any distress or desire
to self harm.
• All three nurses who attempted to resuscitate the man were of the opinion that
he had been dead for some time before his body was discovered and there was
no sign of life at any stage during the resuscitation attempt. All three had
received training in CPR, and all equipment was in working order. I was
satisfied that resuscitation would not have been successful.
• Although there was an immediate debrief following the man’s death, none of the
three nurses directly involved in trying to resuscitate the man received ongoing
support or counselling.
I recommend that a protocol be developed to ensure that healthcare staff are
offered ongoing appropriate support following a significant untoward incident.
14
CONCLUSIONS
The man had become accustomed to serving periodic sentences in prison custody.
His final period in custody commenced on 6 June 2006. He spent his first week at
Nottingham before being transferred to Lincoln. On arriving in Lincoln, the man
asked to be located into the vulnerable prisoners’ wing (E wing) as he was
concerned for his own safety. It seems likely his concerns were mainly about other
prisoners in Lincoln with friends who were victims of crimes he had committed.
Having spent six weeks in Lincoln, the man was transferred to open conditions.
While in the reception area of North Sea Camp, the man was struck in the face by
another prisoner. He was in North Sea Camp for just two days before he absconded
but remained at liberty for just a week. He was re-arrested on 11 August and taken
back to Lincoln. On returning to Lincoln, the man again asked to be located on E
wing for his own protection.
The fact that the man had absconded from North Sea Camp did not prevent him
from obtaining a job as a wing cleaner and he proved to be a good worker. This is
both what officers said when interviewed and is reflected in entries made in his
records. He was recommended for enhanced status on 15 September and that was
approved soon afterwards.
Beyond the fact that the man asked to be located in E wing for his own protection,
his records at Lincoln contain nothing to indicate other concerns. Apart from his
work as a wing cleaner, the man’s main interest was the prison gym and he was a
physically powerful man who was neither timid nor frightened. Although the man
was said to have had fairly superficial relationships with most prisoners, he
apparently got on well with the other cleaners, and his cousin was in E wing at the
same time. The cousin said that he was laughing and joking with the man on 9
November, the evening before his death. The cousin also said that the man was not
the sort of person to speak about his deeper feelings.
In hindsight, it is possible to look upon events that occurred on the morning of 10
November as indicating that the man might have been anxious about his girlfriend.
At about 10.30am, he asked the SO whether he was due a visit that afternoon. After
checking with the visits unit, the SO told the man that no visit was booked. At about
11.30am, the man asked the Second Officer if he had any visits booked for the
weekend. The Second Officer checked and then told the man that the weekend
visits list would not be available until the evening. Although the man did not mention
to either officer who he was hoping might visit, we know that from 10.05am to
11.05am he rang his girlfriend’s mobile telephone four times but she did not answer.
Neither the SO nor the Second Officer thought that the man seemed concerned
when they spoke to him. Two other officers spoke to the man that morning, including
the First Officer who locked the man into his cell after lunch. All four officers thought
that the man seemed his usual self. That view was shared by the prisoner who knew
the man from the gym. He said that the man asked him for his sausage roll at about
11.30am. The prisoner gave the sausage roll to the man who thanked him and
smiled.
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When the man’s cell was unlocked after lunch he was discovered hanging from a
ligature tied to the window frame. Staff responded and attempted resuscitation.
Unfortunately, all attempts proved unsuccessful and the man was pronounced dead
at 2.17pm. The clinical reviewer interviewed the three nurses who were involved in
the attempts to try to resuscitate the man. All three thought that by the time he was
found, he had been dead for some time.
Following the man’s death, the reception prisoner reported to an officer that he was
not surprised at what had happened, describing the man as a ‘dead man walking’.
The reception prisoner told my investigators that there were a number of people who
were aiming to get the man because of things he had done in the past. The
reception prisoner added, however, that these people would have waited for the man
to come out of prison before trying to get their revenge.
Another issue that was explored by the investigators was a rumour that, on the
morning of his death, prisoners overheard the man telling staff that he was feeling
depressed. The investigators spoke to the three prisoners who potentially knew
most about the rumour. None of them personally witnessed the supposed incident
and none could give a lead about anyone else who might have done. Moreover, as
already mentioned, my investigators interviewed four officers and a prisoner who
spoke with the man that morning. All said that the man seemed his usual self.
As is often the case in deaths I investigate, I have been unable to identify any
obvious trigger for what occurred. The man gave no clues that might have alerted
staff or other prisoners to the possibility that he was at risk, and nor did he leave
behind a note of explanation. Everyone to whom my investigators spoke, including
the man’s father and his cousin, consistently expressed their surprise that the man
should take his own life. The man’s father told my staff that he had closely studied
his son’s letters searching for clues, but had found nothing.
Whilst not having any direct bearing on the outcome, I am making one
recommendation concerning staff support and two housekeeping points to improve
healthcare services for prisoners. Finally, I should report that I consider that the
manner in which other prisoners in E wing were told of the man’s death is an
example of good practice.
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RECOMMENDATION
1. I recommend that the prison health partnership should develop a protocol to
ensure that healthcare staff are offered ongoing appropriate support following a
significant untoward incident.
The Prison Service has accepted this recommendation saying: Support is
available (to staff) from a range of sources through both the prison and the
PCT. A comprehensive protocol needs to be in place to ensure that staff are
aware of the services on offer and how to access which service best suits
their individual needs. The Prison Service set a target date of August 2007
for completion.
GOOD PRACTICE
1. It is commendable that the other prisoners in E wing were told of the man’s death
on an individual basis.
HOUSEKEEPING
The following two housekeeping issues were identified by the clinical reviewer and I
urge the prison health partnership to address them:
1. The Head of Healthcare should review the process for ensuring that
investigations such as X-rays and blood tests, ordered by medical and nursing staff
are actually carried out. The process must ensure that the results are read by the
clinician who requested them, recorded appropriately, and actioned.
The Prison Service has accepted this recommendation saying: A review of
current practice with regard to the follow up of investigations will be carried
out and the local protocol developed.
2. The Head of Healthcare should review the process of ensuring that all patients at
high risk are offered Hepatitis B vaccination, and that the correct (“Green Book”)
schedule is followed.
The Prison Service has accepted this recommendation saying: A rolling
programme of training is now in progress. Since the death of Mr Roberts, a
nurse manager is now in post and responsible for the Hep B vaccination
programme.
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