Individual at Moorland Closed

Investigation into the circumstances surrounding the
death of a man at HMP & YOI Moorland
in August 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2008
This young man was just 20 years old when he died on in his cell at HMP & YOI
Moorland. He was found hanging by staff carrying out a routine morning roll check.
It is tragic when someone so young apparently decides that they have nothing more
to live for. My investigator and I offer our sincere condolences to the man’s family
and friends for their sad loss.
I wish to thank the Governor of Moorland, for making the necessary facilities and
information available to my investigator, and for the assistance of the Liaison Officer.
In the course of the investigation, I also asked for a clinical review to be carried out
into the care and treatment the man received in custody. I am grateful to the clinical
reviewer for this.
The man had been given a life sentence with a minimum term of 12 years
imprisonment. There was also evidence that he had felt bullied by other prisoners,
albeit the most recent incident was a month before his death. However, he gave no
indication to prison staff that he was feeling suicidal. In fact, the opposite appears to
have been the case.
My report makes one recommendation for the prison and identifies one example of
good practice. This version of the report has been anonymised for publication on the
PPO website.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2008
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CONTENTS
Summary 4
The Investigation Process 5
HMP & YOI Moorland 8
Key Findings 11
Issues 18
Conclusions 20
Recommendation and Good Practice 21
3
SUMMARY
The man was sentenced to life imprisonment at Newcastle Crown Court on 20
January 2006. The judge said he should serve a minimum of 12 years in prison.
Once he had been sentenced, the man returned to HMYOI Castington where he had
been held on remand. After his needs had been assessed, he was allocated to HMP
& YOI Moorland and transferred there on 27 June 2006.
The man appeared to settle in well to his new surroundings and participated in a
course designed to meet the needs of life sentence prisoners. However, there are
two recorded incidents of him complaining to prison staff that he was being bullied by
other prisoners. The complaints were properly investigated and appropriate action
taken.
In order to improve his key skills, the man had joined an education class and would
eagerly remind prison staff to unlock him for his class. Additionally, he was
progressing well in his workplace and appeared keen to please his instructor. In the
afternoon of the day before he died, the man had arranged with the instructor to do
cleaning work in the workshop at the end of the week.
During a routine roll check during the night of 21/22 August 2007, the night patrol
looked into the man’s cell at about 5.00am and saw him hanging from the light fitting.
She summoned assistance from an officer who was also in the area and at the same
time asked for medical help using her prison radio. Sadly, when prison staff and a
nurse entered the cell, it was obvious to them that the man had died and
resuscitation was not possible.
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THE INVESTIGATION PROCESS
1. Once my office had been notified of the man’s death by the Prison Service,
the investigation was allocated to a member of my staff. He contacted the
Duty Governor the same day and agreed with him to meet and open the
investigation at the prison two days later (24 August 2007).
2. My investigator was met at the prison by the Liaison Officer and taken to meet
the Governor in the prison boardroom. The meeting was well attended and,
as well as those previously mentioned, included an Independent Monitoring
Board member, the Prison Officers’ Association member, a senior manager at
the prison, the Residential Manager, and Head of Risk Offender
Management. In addition, and at the request of my investigator, I am pleased
that two members of Doncaster Primary Care Trust were able to be present.
They were Head of Strategic Commissioning with responsibility for prison
healthcare, and Assistant Director of Clinical Effectiveness (Clinical
Reviewer). Their presence has undoubtedly assisted the preparation of their
review and the timeliness of my report.
3. The Governor gave my investigator an overview of what had occurred, after
which the investigator and the representatives from Doncaster PCT visited the
cell where the man had been found. Before leaving the prison, the
investigator gave them the man’s medical record for their consideration.
Additionally, he identified those members of staff he wished to speak to. He
arranged to return to the prison to begin his interviews the next month on 27
September. The following staff contributed towards my investigation,
although they were not all interviewed using tape recording facilities:
• A prison officer for over 13 years. Prior to joining Moorland in September
2004, he had been employed for ten years as a prison custody officer at
HMP Doncaster. This prison officer is a member of Houseblock (HB) 4
staff, which is where he has worked since transferring to Moorland. This
officer locked the man up for the night on 21 August.
• A Senior Officer (SO) has been employed by the Prison Service for 17
years. He has worked at Moorland for 15 years and prior to this was an
officer at HMP The Mount. This Senior Officer has been an SO for six
years and was the night manager on 21 August.
• A Operational Support Grade (OSG) has been employed by the Prison
Service for two years. Her duties include working every four weeks as
night patrol. This OSG was the night patrol on HB 4 on 21 August, and
found the man hanging.
• This second prison officer has been employed by the Prison Service for
five years. He has been an officer for three years and prior to this was an
OSG at HMP Lindholme. This second officer has been employed at
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Moorland since February 2006. He was in HB 4 when the man was
discovered, and was the first person to respond to the OSG request for
assistance.
• A Healthcare Officer (HCO) has been employed as a nurse by the Prison
Service for five years. She has a B.Med/science honours degree in
nursing as well as a first level nursing qualification. Prior to joining the
Prison Service, the Healthcare officer was a nurse at a local hospital.
• A third prison officer has been a prison officer for three years. She
currently works on HB 4 but had previously worked on HB 3. This Officer
has provided background information about the man.
• An Officer Instructor (OI) has been employed by the Prison Service for
over 16 years. Before transferring to Moorland in 1998 he worked at HMP
Bullingdon and HMP Bellmarsh. He is currently employed as an instructor
in a production workshop preparing breakfast packs for the two Moorland
sites. This Officer Instructor was the man’s workshop supervisor and has
provided background information about the man.
• A fourth Prison Officer has been employed by the Prison Service for 18
years. He was originally based at HMYOI Feltham until he transferred to
Moorland in 2000. This Officer is currently employed in the prison’s
Offender Management Unit and is one of four officers responsible for
writing lifer reports. This Officer has provided background information
relating to the man.
• A Probation Officer that has seconded to Moorland. She qualified as a
probation officer in 2003 and prior to this worked as a trainee probation
officer for two years. The probation officer interviewed the man as part of
his life sentence review two weeks before he died.
4. One of my family liaison officers, telephoned the man’s mother, in September
2007. The family liaison officer explained my role and offered the man’s
family the opportunity to meet her and the investigator. The purpose of the
meeting was for the man’s family to contribute towards my report and ask any
questions they would like me to examine. The man’s mother decided that she
did not require a visit. However, she did want to know if the man had asked to
see one of the prison’s Listeners the day before he died. My investigator has
confirmed with the prison liaison officer that the man did not ask to see a
Listener. Additionally,the man’s mother asked that my report should reflect
how grateful she was for the support she received from the prison. I am
pleased to recognise that fact here.
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HMP & YOI MOORLAND
5. Moorland prison is a large and complex institution divided between two sites
known as Moorland Open and Moorland Closed. Moorland Closed is a
training prison for both adults and young offenders. Moorland Open is a few
miles away.
Code red and code blue
6. In the event of urgent medical assistance being required, the prison has a
radio code system to alert medical staff to the emergency situation. Code red
informs medical staff that the patient is bleeding. Code blue alerts them that
the patient is in breathing difficulty. The system ensures that medical staff
take the correct emergency equipment with them and helps provide the
necessary care as quickly as possible.
Her Majesty’s Chief Inspector of Prisons
7. In December 2005, Her Majesty’s Chief Inspector of Prisons, made an
announced inspection of the prison. The inspection found that Moorland was
generally delivering a safe, purposeful and resettlement orientated regime.
The Chief Inspector added that this was commendable, given the mix of types
and ages of prisoners, the range of needs that they presented and the variety
of accommodation in which they were held.
Independent Monitoring Board (IMB)
8. Each prison has its own IMB made up of volunteers from the community. The
Board’s role is to ensure that the prison is properly run and that prisoners are
treated decently. Each Board produces an annual report for the Secretary of
State.
9. In its most recent annual report (2006), the Moorland Board concluded their
summary by saying that the prison was well established and high performing.
They added that the prison provides a safe, secure and aesthetically pleasing
environment for prisoners, with ample provision for education, purposeful
activity and work.
Life Sentenced Prisoner Induction Group
10. The induction programme is aimed at newly sentenced lifer prisoners and
provides support by involving other lifers. The prisoners assisting do so by
offering their experience and explaining the life sentence process. The
induction group is run by the Probation Service and is a question and answer
course. Occasionally, there is participation from guest speakers, including
former life sentence prisoners who describe what life is like after release.
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Listeners
11. Moorland has a Listener scheme (a system where the Samaritans train
selected prisoners to be the first contact for any prisoner who is feeling
vulnerable and at risk). The scheme is confidential and any prisoner can ask
to speak to a Listener at any time of the day or night. Prisoners can access a
Listener easily by speaking to a member of staff who will then make the
arrangements. During the hours that prisoners are locked in their cells,
anyone wishing to speak to a Listener can ask the night staff to arrange it.
The Night Orderly Officer has the authority to unlock a Listener and to escort
him to the cell of the prisoner who is requesting assistance.
Night state 10.00pm – 6.00am
12. Night state is when the prison is fully locked up for the night and staffing levels
are at a minimum. The role of those staff on duty is to monitor the security of
the wing and the prisoners held there.
13. At night time, as well as officers and Operational Support Grades (OSGs),
there is a Senior Officer (SO) on duty. The SO is responsible for the prison
and, in the event of an incident, staff will refer to the SO for advice and
instructions. If necessary, the SO in turn will refer to the on call Duty
Governor for advice.
14. During night state, it is not normal to unlock a cell unless the night manager
has sufficient staff in place to deal with any situation. Night patrol officers do
not carry security keys and are therefore unable to move freely around the
prison. However, they do carry a cell door key in a sealed pouch secured to
their uniform belt. If it is felt necessary to enter a cell in the event of a life
threatening situation, the night patrol officer breaks the pouch seal to obtain
the key. However, in the first instance, the officer must summon assistance
and should only enter a cell on their own, if it is safe to do so.
15. Unlike the night patrol officers, the night manager does carry security keys
and is able to move freely about the prison. The manager will usually visit
each of the wings during the night and check on the welfare of the staff and
ensure they are carrying out their duties correctly
Police investigations of deaths in custody
16. With all deaths in prison custody, the police are notified by the prison as soon
as the death has been discovered. In the first instance, the police treat the
area where the person is found as a potential crime scene and, as part of their
investigation, note the names of everyone involved and those who have been
in contact with the body. Additionally, they note the identity of all those
entering and leaving the cordoned area. It is only when the police are
satisfied that the death is not suspicious that my investigators may begin their
own investigations.
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Prison Service Orders (PSOs)
17. Prison Service Orders are long term mandatory instructions that are intended
to last for an indefinite period. Any mandatory instructions to Governors or
Directors of contracted prisons are written in italics. Each PSO is given a title
and unique reference number.
Previous deaths at Moorland
18. Since 1 April 2004, my office has been responsible for investigating all deaths
in custody. Moorland has had one other death during this period, that of a
man who died of natural causes.
9
KEY FINDINGS
19. On 24 March 2005, the man was remanded into custody to HMYOI
Castington. He had been charged with murder. As part of the normal
procedure for admitting prisoners into custody, a health screen assessment is
carried out by a member of the prison healthcare staff. The clinical review
annexed to this report notes that the man was given a detailed health screen
and, other than minor medical treatment, he had no significant medical
history. The clinical reviewer has considered the man’s mental health and
concludes that he had no identified mental health problems or known
psychiatric history. The man originally told the nurse assessing him that he
did not use drugs. However, he later admitted to what is described in the
clinical review as recreational drug use. The drugs mentioned in the review
include cannabis, amphetamines and ecstasy.
20. The clinical review notes that, whilst at Castington, the man’s physical and
mental health was regularly monitored. Shortly before his trial, the man was
experiencing difficulty in sleeping. A Community Psychiatric Nurse (CPN)
assessed him and concluded that he had no mental health problems and that
his anxiety was associated with the trial. At the point when the man was due
to return to court for sentencing, he was relocated into healthcare for
observation. This is normal Prison Service procedure for anyone charged
with murder.
21. The man remained at Castington on remand until his trial. He was found
guilty on 20 January 2006 and sentenced to life imprisonment. When passing
sentence, the trial judge said that the man should serve a minimum of 12
years in prison. This meant that his minimum period of imprisonment would
have taken him to 21 April 2017.
22. Following the trial, the man was taken back to Castington. Once again, as is
normal Prison Service policy, he went back into healthcare pending a health
assessment which was scheduled for the following day. After the assessment
the man was discharged from healthcare and so returned to his normal wing
cell.
23. As a life sentenced prisoner, the man could only be held at a prison suitable
to meet the needs of his age and type of sentence. The most appropriate
prison available for him at the time was Moorland. Five months after being
sentenced he transferred there on 27 June 2006.
24. After arriving at Moorland and going through the normal reception procedures,
the man was allocated to HB 3. The third prison officer worked on HB 3 and
knew the man well. She told my investigator that the man was polite and
respectful, adding that he did not cause any problems. The officer described
the man as someone who was neither happy nor outgoing. During one of her
conversations with the man, he told the officer that he was no longer with his
girlfriend, but did not expand on this. This prison officer left HB 3 in January
2007 and did not meet the man again until he moved to HB 4 later in the year.
10
25. The fourth prison officer works in the prison’s Offender Management Unit. He
told my investigator that, between 14 March 2007 and 11 April, the man joined
the Life Sentenced Prisoner Induction Group and apparently participated well.
26. However, at the end of March, the man complained to an officer that three
prisoners were threatening him and taking his tobacco whenever he went to
his workplace. In line with the prison’s anti-bullying strategy, the man was
interviewed by a wing manager the same day (30 March 2007). He told the
manager that he did not know the names of the prisoners bullying him. After
assessing the information and speaking to the man’s workshop instructor, it
was decided to change his place of work with immediate effect. He was re-
employed in one of the prison’s production workshops. The workshop is
responsible for packing breakfast packs for the prison and its sister site,
Moorland Open. The man was content with the outcome. He was advised to
speak to staff if he had any further concerns and the file was then closed.
27. Unfortunately, on 22 July 2007, the man had cause to complain once again
that he was being threatened for his tobacco. This time, the man told staff the
names of the prisoners responsible. As with the previous event, the man was
seen the same day by one of the wing managers. The manager’s
recommendation was for staff to monitor the man whenever he went to the
prison shop, and for the two prisoners named by the man to be monitored and
assessed. The file was closed two days later (24 July). As a result of the
allegations, and to help the man, he moved from HB 3 to HB 4.
28. The third prison officer, who had previously known the man when he was on
HB 3, met him again on HB 4. She told my investigator that the man was
quieter than he had been on HB 3 and did not mix with other prisoners. The
prison officer said he kept himself to himself, but was liked by other prisoners.
She remembered how he would remind prison staff to unlock him so that he
would not miss his education classes. This officer said there was never
anything to suggest that the man was planning to harm himself.
29. A prison officer had recently taken over as the man’s personal officer.
Although he had not had the opportunity to meet the man formally, he
described him as someone who blended in and did not bring attention to
himself. The man’s personal officer confirmed that he had no reason to be
concerned about the man’s safety.
30. In the meantime, the probation department was preparing an annual review of
the man’s life sentence plan. The man’s probation officer met him for about
one hour at the beginning of August 2007, after which she returned to her
office to write her report, completing it on 17 August. The probation officer
said the man was very polite, chirpy and motivated to change and address his
offending behaviour. She said that the man told her that he deserved his
sentence and accepted it, although he said he was not the person responsible
for the victim’s death. The probation officer said that the man did not appear
suicidal.
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31. My investigator met the Officer Instructor (OI) who is responsible for the
breakfast pack production workshop where the man was employed. He
described the man as polite and responsive, and said he would do what was
asked of him. He added that the man was not a control problem and, as well
as doing his own work, the man would assist him to clean the workshop. The
officer instructor said the man always spent time with him at the end of the
work period and they would chat about everyday issues, such as what was in
the news. He said that, as well as the work he was doing in the workshop, the
man was undertaking part time education classes designed to assist his
reading and writing skills.
32. The officer Instructor said that on the day before he died (i.e. 21 August
2007), the man worked as normal in the workshop. The officer instructor told
my investigator that he was planning to give the workshop an extra clean on
the following Friday. The man was aware of this and asked him if he could
assist, offering to scrub the floors, which the officer instructor agreed to. The
officer instructor said that at no time did the man give any indication that he
was planning to harm himself, nor did he ever say anything about being
bullied. He last saw the man at 4.30pm, which was the end of the work
period.
33. During the evening, prisoners are allowed out of their cells to associate with
one another. The third prison officer remembered seeing the man that
evening. She told my investigator that he was laughing and joking. With
hindsight, she said this was out of character.
34. A prison officer was on duty in HB 4 that evening. He told my investigator that
the man was a polite young man who caused no problems to wing staff. This
prison officer said that during the evening the man had been mixing with other
prisoners in the wing. At about 7.55pm, the evening association period came
to an end and prisoners returned to their cells for the night.
35. The prison officer described how, once prisoners are locked into their cells, he
carries out a roll check and accounts for all of the prisoners on his landing.
He said that he looks into the cell through the observation panel in the cell
door and satisfies himself that the prisoner is in the cell. Once he has
accounted for all his prisoners he then goes to the wing office to enter the
number on a lock up sheet and sign for his roll.
36. After the total wing rolls are collated and agree with the prison roll, the
majority of staff on duty leave the prison. One officer remains behind in each
Houseblock pending the arrival of the night staff who take over. The officer
who remained in HB 4 that evening was another prison officer.
37. The second prison officer arrived for duty at about 8.00pm. He went to HB 4
and took over from the other officer. The second prison officer had arrived
early for his night duty to enable the other officer to leave earlier than would
otherwise be expected. Before leaving the Houseblock, the other officer
handed over to the second prison officer, but did not pass anything on relating
12
to the man. Although not the night patrol for HB 4, the second prison officer
assisted the Operation Support Grade (OSG) assigned to HB 4 by counting
the roll.
38. The second prison officer told my investigator that in order to carry out a roll
check he opens the door observation panel and looks for the prisoner. He
said that he remembered seeing the man sitting on his bed watching
television. The prison officer said the man was in a double cell, on his own
and using the lower bunk. He told the investigator that neither he nor the man
spoke to each other. The officer confirmed to the prison’s communication
room that his roll was correct.
39. A OSG arrived at the prison at about 8.15pm. She was allocated as the night
patrol on HB 4. When she arrived onto HB 4 she spoke to the second officer
who told her that the roll check had been completed.
40. My investigator asked the OSG if she had been given any specific instructions
about the man, and she said not. As she had not been given any instructions
to monitor the man outside the normal roll checks, there was no expectation
that she would see him again until the next check scheduled to take place
about 5.00am. Between them, the second prison officer and the OSG carried
out the HB 4 patrol checks during the night. Other than a routine
management check by the Senior Officer (SO), the night was uneventful.
41. The Senior officer started work at about 8.45pm. He was given a handover by
the Orderly Officer who had been on duty during the day. The senior officer
confirmed that he was not given any information relating to the man. He said
he was given a list of the names of all prisoners who were being monitored
under the Prison Service suicide and self harm support procedures, and
confirmed that the man was not on the list.
42. The Senior officer said that at about 9.00pm he received confirmation from the
communications room that the prison roll was correct. He said that for staff to
confirm the roll, they have to get a response from the prisoner. Even if they
are underneath a blanket, staff are required to see some movement.
43. During the night, the SO carried out his management checks and visited the
Houseblocks. He confirmed at interview that he had been to HB 4 and
completed his checks.
22 August 2007
44. When it came to the time to complete the morning roll check at 5.00am, the
second prison officer and the OSG divided the Houseblock up between them
and shared the work. The OSG went to the third landing, whilst the second
Officer started at landing one. At interview, the OSG said that, in order to see
into the cells at night, she has to switch on the light. That is what she did
when she arrived at the man’s cell and looked through the observation panel.
When she looked into the cell she saw the man hanging from the light fitting.
She described how he had a ligature around his neck. It had been fashioned
13
from a prison issue bed sheet. The OSG said the man was facing the bed.
From her position, this was on the right hand side of the cell. She said his
body looked lifeless, not moving and that his eyes were open. The OSG
added that the man’s head was tilted to the right, and his body fully
suspended off the ground. The OSG remembered seeing a chair to one side
of the man’s body, but could not recall which side.
45. The OSG shouted to the second prison officer who was still on the lower
landing. As he was running up the stairs, the OSG used her prison radio to
request assistance by calling a “code blue” emergency.
46. The OSG removed the leather pouch containing a cell key from her belt and
handed it to the prison officer. She said they waited for other assistance to
arrive and, as soon as they had sufficient staff there, the cell door was
unlocked. The second prison officer said that three prison officers arrived,
along with the Healthcare Officer and the Night Orderly Officer, the senior
officer. The OSG could not recall who opened the door, but believed it was
the second officer. This officer confirmed that he took the pouch from the
OSG. However, he had difficulty breaking the pouch seal and it was another
Officer who managed to break it and remove the key. The cell was then
unlocked and the officers went in.
47. The OSG said that when the cell was unlocked she stood outside the cell
looking at the man. She heard one officer say he could tell from the man’s
appearance that he was dead. Another officer arrived and, seeing that the
OSG was distressed, took her to an office.
48. My investigator asked the OSG if either she or the second prison officer had
considered entering the cell. Although the OSG believed that the man was
dead, she said they had not thought of entering as she understood that cells
should not be entered unless three or four staff were present. The OSG could
not recall who had given her this instruction, but it was something that she
believed to be the case.
49. The second prison officer said staff were instructed not to enter a cell until
other staff were present. He added that this was so the officers had
witnesses if anything were to happen. My investigator asked him if he would
have felt confident to enter the cell, and he confirmed that he would.
50. The second prison officer described at interview how two of the officers took
the weight of the man’s body, whilst he cut the ligature at the point it was
connected to the light fitting. They then placed the man onto his back on the
cell floor. The officer said the man’s tongue was sticking out and was
discoloured. His skin was blotchy and his body motionless. The second
prison officer thought that the man’s neck was broken. He recalled seeing a
chair next to the man’s body and believes he used it to stand on before
hanging himself. The second officer said the Healthcare Officer told them
that, out of respect for the man, she was not going to attempt resuscitation.
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51. The second prison officer added that, soon after entering the cell, paramedics
arrived. After carrying out their own checks, they confirmed that the man had
died. The second prison officer asked one of the paramedics if they should
have attempted resuscitation and was told that it would have been ineffective.
52. The Healthcare Officer (HCO) told my investigator that she did not know the
man and had not met him prior to responding to the code blue call. At the
time she received the call she was working in the prison’s healthcare centre.
The nurse was assisted by an OSG night patrol who was looking after 12
prisoners.
53. As soon as the code blue call was received, the HCO grabbed an emergency
response bag containing the necessary equipment for someone experiencing
breathing difficulties. The nurse told my investigator that the bag contains
oxygen, mask, aspirator suction equipment, defibrillator, airways and an
Ambu bag, which is used to push air into the patient.
54. The Healthcare Officer said that, after collecting the bag, it took her no longer
than one and half minutes to arrive at the man’s cell. When she arrived, she
saw the three Officers cutting the man down and laying him on the floor. The
Healthcare officer said it was obvious to her that the man had been dead for
some time. She described his arms as mottling, his face as bloated and his
tongue extremely swollen and blocking his airway. She checked for any
respiratory signs but could not find any. She added that the man’s body was
cold to the touch.
55. My investigator asked the Healthcare officer if she had carried out Cardio
Pulmonary Respiration (CPR) and was told not. She said that, due to the
man’s tongue being so swollen, she could not have performed CPR. The
Healthcare Officer added that the officers did not perform CPR either, as they
were still cutting him down when she arrived. She went on to say that,
although she is not medically qualified to certify a death, her nursing
experience allows her to verify that someone is dead. In the man’s case she
believed that it would have been inappropriate and undignified to start CPR.
56. The Healthcare Officer said she was still at the cell when paramedics arrived.
She said they connected an Electrocardiograph (ECG) machine to the man’s
body. ECG equipment monitors the activity of the heart. Sadly it did not
detect any signal and the man had died. The HCO said she spoke to the
paramedics about CPR and they told her that they would not perform CPR. It
was their opinion that the man had been dead between three to five hours.
57. The clinical review describes the man’s condition as cyanosed (a blue tinge to
the skin) with signs of mottling and being cold to the touch. The man’s airway
was obstructed by his tongue and no respiration or pulse was detectable.
58. Because of the nature of the man’s death, the paramedics asked for the
police to be called.
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59. The Senior Officer was in his office when he heard that the OSG had asked
for code blue medical assistance on HB 4. He described the office as being
approximately 150 yards from the houseblock.
60. He said that, when he arrived at the cell followed by the Healthcare Officer, he
saw a number of staff about to open the cell door. He added that he got to
the cell just as the officers were opening the door. The Senior Officer saw the
staff enter the cell and begin to cut the man down. He immediately contacted
the communications room and asked for an ambulance, after which he went
back to the cell. When he arrived at the cell, the Healthcare Officer had
already decided that the man was dead and confirmed that CPR had not been
carried out. The SO contacted the communications room and asked the
operator to telephone the on call Duty Governor, and (in line with Prison
Service instructions) the police. The Senior Officer said that paramedics
arrived at about 5.45am, followed ten minutes later by police officers.
61. The Senior Officer followed the prison contingency plans and sealed the area
where the man had died, treating it as a potential crime scene. Once the
police had completed their enquiries, and were satisfied that the man did not
die in suspicious circumstances, they released the cell back to the prison and
allowed the man’s body to be taken by undertakers to the mortuary.
After the man’s death
62. Following the young man’s death, his next of kin details were obtained from
his prison record. The recorded address was some considerable distance
from Moorland and, in order to inform his family at the earliest opportunity, the
Duty Governor asked a manager at a prison more local to his mother’s
address to break the news on his behalf. Once the man’s mother had been
told, Moorland’s own family liaison officer and a prison chaplain travelled to
her home to offer condolences and to provide more information about what
had happened.
63. In the meantime, prison management reviewed all prisoners who were being
monitored under the Prison Service’s suicide and self harm procedures.
Additionally, Listeners were asked to assist staff by supporting prisoners who
might be affected by the man’s death.
64. The prison’s care team was asked to support staff. In general, this appears to
have worked well. However, one member of healthcare staff felt that the care
team support had been less than satisfactory. In contrast, the OSG said the
care team support was good. Unfortunately, she said she could not say the
same about her support from prison management.
65. Following any death in custody, the Governor should follow the instructions
contained in PSO 2710 and hold a de-brief meeting with those staff involved
as soon as possible. The practice is known as a “hot de-brief”. It would
appear from the staff interviewed that this was not done following the man’s
death.
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ISSUES
Clinical Review
66. The clinical review notes that the man’s health and mental health needs were
assessed appropriately during his time in prison. His healthcare needs were
assessed and, when required, further investigation was carried out. A
psychiatric review carried out at Moorland concluded that the man did not
require any on-going supervision or treatment. There were no recorded
changes in his mood, behaviour or emotional state that might have indicated a
change in his healthcare. The reviewer is satisfied that the man’s mental
health assessments were properly managed.
67. She further notes that between June 2006 and August 2007 the man was
treated in healthcare on just one occasion. The reason for seeing healthcare
was that he complained of coughing, chest pain, vomiting blood and
abdominal pain. An x-ray taken at the time was reportedly normal, with no
other medical evidence found to explain his symptoms. The clinical review
confirms that there were no documented reports in the man’s medical record
of any change in mood or emotional state.
68. As part of the clinical review, it was considered what type of medical
equipment was available to the nurse. The clinical reviewer concludes that
the appropriate medical equipment was quickly available.
69. The clinical reviewer recommends that prison staff should be commended for
their support to the man, especially at the time of his trial, sentence and
transfer to Moorland. Although I make no formal recommendation on this, the
Governor may wish to share the views of the clinical reviewer with the
Governor of Castington and his own staff.
Unlocking a cell at night
70. The OSG was not sure about the circumstances that would allow staff to enter
a cell at night. She was accompanied at interview by her husband, who is
also an OSG. He too was uncertain and told my investigator that he had
asked Senior Officers for guidance, but had not been given a clear answer.
He described it as a grey area. Clearly there is some confusion about
unlocking a cell door at night. I am satisfied that the small delay in unlocking
the man’s cell made no difference whatsoever to the outcome. However, in
another emergency, it might well have been vital to have entered the cell
immediately and administered emergency aid if resuscitation was to have any
effect. The Governor may wish to consider issuing guidance on entering cells
at night.
Resuscitation
71. I am satisfied from the descriptions given by those staff who found the man
that CPR was not possible. Like the healthcare nurse who attended the man
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that morning, I believe that it would not have been decent or appropriate to
have attempted resuscitation.
Staff support
72. At interview, the OSG, who at the time of her interview was off duty as a result
of the man’s death, said it was approximately seven days before anyone from
a managerial position contacted her. She said her colleagues had supported
her, as had the prison care team. However, she felt let down by
management.
73. The Healthcare Officer said that she had been supported by her own
colleagues. Although she did not wish to say anything on tape, she added
that she felt let down by the local prison care team. I am not aware to what
she was referring but the Governor may wish to review the arrangements for
supporting staff.
Debrief
74. PSO 2710 explains that following a death in custody a hot de-brief should
take place. It adds that a senior member of staff should lead the de-brief and
a member of the care team must attend. It would appear from those staff
interviewed that no hot de-brief was carried out.
The Governor should ensure that hot de-briefs are carried out in line
with the instructions contained in PSO 2710.
Suicide and Self Harm monitoring
75. My investigator was impressed to see displayed at the entrance to the prison
a notice board showing the names and location of all prisoners who were
being monitored. The system is updated as necessary and tells all staff at a
glance the current situation. I regard this as good practice.
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CONCLUSIONS
76. This young man had a chaotic background. He had been convicted of
murder and was serving a life sentence. At a minimum, he had no prospect of
release until he was over thirty years old. Whether this had any bearing on
his decision to end his life cannot be known, but it has to be a possibility.
77. A further possibility is the implied by the fact that he had complained of being
bullied, with the most recent recorded event taking place approximately one
month prior to his death. Whether this was actually a factor is once again
unknowable. What I can say is that I am satisfied that prison staff treated
what the man told them seriously and dealt with the complaints appropriately.
78. The man appeared to have settled well into Moorland. He had engaged with
the education department, wanting to improve his key skills and would remind
prison officers to unlock him so that he could go to his class. Only a few
hours before he died, the man had planned with his instructor the
arrangements for cleaning the workshop a few days later. Sadly, it seems
certain he had other things on his mind that he did not share with anyone
else.
79. I am satisfied that the man kept his true intentions close to his chest and that
neither prisoners nor prison staff had any inclination about what it was he was
planning to do. Additionally, I am satisfied that the systems were in place to
support the man, had he shared his suicidal thoughts with staff.
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RECOMMENDATION AND GOOD PRACTICE
The Governor should ensure that hot de-briefs are carried out in line with the
instructions contained in PSO 2710.
The Governor has accepted the recommendation and intends to implement the
change by 15 March 2008
The display board showing the names and locations of all prisoners being monitored
for suicide or self harm is good practice. It informs every member of staff arriving for
duty the name and location of those prisoners deemed to be vulnerable.
The Governor acknowledged the recognition of good practice and said the system
has worked well.
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