Individual at Morton Hall

INVESTIGATION INTO THE DEATH OF A WOMAN
ON 22 SEPTEMBER 2004
REPORT BY THE PRISON AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
JANUARY 2005
As well as being responsible for investigations of deaths of serving prisoners, I
also have the discretion to investigate deaths that occur soon after release
from custody. The tragic death of this woman falls into this category.
She had served five previous sentences at HMP New Hall and was released
from her final sentence on 17 September 2004. Comprehensive resettlement
arrangements had been made and she was to live with a specialist drug
rehabilitation provider for 12 months. Sadly, she was found dead some five
days later.
Because this is a discretionary inquiry, I have limited it to reviewing the
release arrangements and have contacted the prison, Nottinghamshire
Probation Service, the HDC monitoring company and Portland House, who
were to provide her accommodation. I have been assisted by the Suicide and
Self-Injury Prevention consultant with the Prison Service Women’s Team, who
has also audited the detoxification arrangements at the prison. A review of
the woman’s clinical care was carried out by my Deputy Ombudsman. The
final part of the inquiry has been for my Family Liaison Officer to make contact
with the woman’s family and solicitor to ensure that their concerns were also
considered. I would like to take this opportunity to add my condolences to
those already expressed.
I would like to thank the staff at all the organisations concerned who have
provided information to the investigators.
STEPHEN SHAW CBE
PRISON AND PROBATION OMBUDSMAN
2
CONTENTS
PAGE
Summary 4
Background 5
The woman’s sentence at HMP New Hall 6
After release from New Hall 9
Conclusions 11
Recommendations 12
3
SUMMARY
1 The young woman was 27 years when she died. She was adopted
soon after birth and grew up with her adoptive parents and brother in
the Mansfield area. She went to school there before working as a
secretary for several years. In 1988, she gave birth to a son who has
lived with her parents for the past few years.
2 Between 2000 and 2004 she was convicted of a number of offences, all
of which were related to her abuse of drugs and alcohol. The last
conviction was on 13 July 2004 and she was sentenced three weeks
later to eight months imprisonment for the offences of arson and
shoplifting. This was her sixth prison sentence and it was served at
HMP New Hall. She had already been held on remand and so her
release date was set for Friday 17 September.
3 She was identified as at risk of suicide at two points during this period
in custody, first on reception and secondly prior to sentence being
passed. She experienced further periods of depression and was
supported by the chaplaincy team. However, both the prison and her
mother described her as more motivated to stop reoffending during this
sentence than ever before.
4 Careful arrangements were made for her release from prison. The
CARATs drug rehabilitation team at New Hall referred her to Portland
House which provides accommodation and specialist treatment for
drug users and is located in Newark. A place was accepted and she
was released on Home Detention Curfew (HDC) licence, with a
condition to live there and, as is customary, with a travel warrant for her
journey. Drug tests prior to her release were negative.
5 She never arrived at Portland House. Premier Monitoring Ltd was the
company with the contract to monitor her curfew and they contacted
Portland House that evening and the following day. On Sunday 19
September, Premier notified the Home Office of her failure to arrive at
Portland House and her licence was revoked. Nottinghamshire Police
were notified, but as it was a report of revocation of licence, rather than
a report of a missing person, it received less priority and no action had
been taken by the time of her death.
6 During the five days between release and her death, she met a number
of her friends and telephoned her mother. She contacted her solicitor
for advice via a third party. On 22 September, she was found hanging
in woods in Mansfield and a syringe and drugs were found on her. The
Home Office pathologist has confirmed that the cause of death was
hanging and the police are satisfied that there were no suspicious
circumstances.
7 The inquest took place on 16 November and the verdict was suicide.
4
BACKGROUND
8 The woman was born on 11 April 1977 and came to live with her
adoptive parents some three weeks later, with her adoption becoming
legal when she was six months old. She attended local schools until
she was 16, leaving to take an office job. In the following year, she
experienced symptoms of depression and was a voluntary out-patient
at Mill Brook Hospital. Her family believe that her abuse of alcohol
began when she was 23, which is when she was first convicted for
driving with excess alcohol. They say that later she began to use
illegal drugs, took an overdose and was admitted as an in-patient. It
was at this point that her son came to live with his grandparents.
9 After her first conviction in 2000, she was convicted of 11 offences of
theft, one offence against the person and six Bail Act offences. She
was sentenced to several community penalties, but did not comply with
the conditions and each was revoked. Her offences were said to be
related to her drug habit. She served five prison sentences prior to the
last one – the first in January 2003 – and ranging in length from five
days to the last and longest of 88 days. When she was remanded in
custody for her last, and most serious offence she had only been
released three days earlier. Since her first prison sentence, the longest
period she had remained in the community was seven months between
November 2003 and June 2004.
10 A pre-sentence report was prepared for her last offence by
Nottinghamshire Probation Area. It recommended a further community
sentence, stating that she was motivated to become drug and alcohol
free. The assessment evaluated the woman’s risk to herself and said
that she was at no risk of suicide, but that her history of depression and
self-harm meant that she was assessed as at medium risk of self-harm.
5
THE WOMAN’S SENTENCE AT HMP NEW HALL
11 She was held in custody by the police on 20 June, charged with arson
and shoplifting. It was three days after her previous release from New
Hall. On arrest she was assessed as standard risk of self-harm but,
the following day, she cut her left wrist and was escorted to the prison
accompanied by a suicide and self-harm warning. She was remanded
in custody and returned to New Hall on 21 June 2004. The reception
procedures included health screening and the prison self-harm warning
(F2052SH) was opened. The form gave a detailed explanation of
events and her situation, but it did not set out standards for
observations or specify how other departments should be consulted.
12 She was assessed as fit for detoxification, and was located in the
detoxification wing where all the cells are single. An eight day
detoxification programme was completed successfully and drug tests
during her sentence were clear.
13 Whilst the F2052SH was open, observations of her were regular and
timely, but the records did not reflect the quality of interactions or
suggest any remedial action. Contact with other parts of the prison
was not always included, such as feedback from Visits after she had
been there. The Senior Officer checked the form, which was reviewed
and closed after 72 hours, with a detailed record of her current state of
mind, though it was not apparent that she had herself participated.
14 Soon afterwards she referred herself to the prison CARATs team,
requesting help with drug abuse through the Short Duration
Programme (SDP). This is a four week course which focuses on
stopping reoffending and reducing drug use. It aims to increase
awareness of harm minimisation and act as a gateway to further
treatment.
15 A second F2052SH was opened on 6 July following observations by
the workshop instructor who thought that she was worried about facing
a lengthy sentence. Anti-depressant medication was recommended
and a request for a psychiatric assessment made. Again the F2052SH
was closed after 72 hours, following a review which unfortunately did
not include multi-disciplinary staff who knew her, such as the
chaplaincy and CARATs team. It was closed nearly three weeks
before sentencing, fortunately without mishap. No actual incidents of
self-harm took place during sentence. She attended the psychiatric
clinic and was referred to a nurse who specialised in trauma and abuse
counselling.
The Governor should ensure that all staff working with a prisoner
are invited to F2052SH reviews. The prisoner herself should also
be involved.
6
16 On 3 August, she was sentenced to eight months imprisonment. The
SDP began the following week and was completed at the end of the
month. Reports from the programme are comprehensive and
demonstrate that she participated well and contributed effectively. The
assessment by the programme tutors was that she appeared highly
motivated to abstain from drugs, was willing to discuss personal
matters and could identify triggers to relapse.
17 She was upgraded to enhanced status on 22 August and moved to C
wing. Chaplaincy staff who knew the woman described her as a lovely
person to talk to. She complained of feeling low in mood at the end of
August and Healthcare staff commented she needed more time on the
medication.
18 As part of the woman’s preparations for release from New Hall, the
CARATs team referred her to Portland House, Newark, with the
intention that she would have secure accommodation and be able to
continue to treat her drug and alcohol use. Portland House Women’s
Service consists of self-contained flats for women who undertake a
therapeutic drug rehabilitation programme within the residential setting.
19 Her applications for accommodation and funding for specialist drug
rehabilitation were both successful. A multi-disciplinary assessment for
HDC at Portland House was carried out. It referred to her awareness
that she would need considerable support in the community to continue
her abstinence from drugs and alcohol. It was considered that the
short period on HDC licence would encourage a new structure to her
lifestyle. The prison probation officer interviewed her and said that she
was happy with the rules and regulations involved in HDC. Prisoners
should also complete an application but, on this occasion, she did not
herself complete or sign the form. (This is a housekeeping matter to
which I draw the Governor's attention.)
20 The HDC release board met on 16 September and confirmed that she
was fit for release and for tagging. She was seen by Healthcare as
part of this process and again found fit for release. There does not
appear to have been any medical advice regarding risks from drug use
after release back into the community. There is also no evidence of a
discharge letter to a GP, which would have been appropriate for a
woman with a history of substance misuse and depression who was
moving to a new area.
Prison Healthcare should contribute to discharge planning by
advising prisoners on the effects of drug use after a period of
abstinence and by providing a discharge letter to GPs.
21 Because her sentence was less than 12 months, she was not required
to be supervised by the probation service.
7
22 Throughout her sentence she received gifts of money and was
released with £140.44, including £80 she received anonymously on 13
September. It is prison policy that sums over £50 may only be passed
to prisoners if the donor is identified, but the policy was not
implemented on this occasion.
23 She was placed on HDC licence from 17 September 2004 to expire on
19 October. The address to which she was curfewed was Portland
House, between the hours of 19.00 each evening and 7.00 each
morning. The curfew times for the first day of release were different
and were from 15.00 on 17 September to 7.00 the following day. She
was released on 17 September, having first telephoned a long-standing
friend to arrange to meet her at Newark station.
8
AFTER RELEASE FROM HMP NEW HALL
24 The woman left New Hall in the morning with another prisoner and they
travelled together to Wakefield station. Instead of using the travel
warrant to go to Newark, it seems that she had a change of heart and
went instead to Mansfield. Both her mother and solicitor have
expressed concern about her travel arrangements and consider that
she would have benefited from transport being provided between the
prison and Portland House. Since this investigation began, Portland
House have decided that they will offer transport in similar situations.
25 Because she did not arrive at Portland House, and so did not sign her
tenancy agreement, the accommodation did not consider that their
missing person procedures were relevant. They use their treatment
provider’s operational procedure for clients missing from adult services
which refers to their reporting obligations and their duty to the client’s
safety. The procedure does not specifically refer to women who fail to
attend at all, but does say that the degree of risk should be assessed.
If the client is believed to be at significant risk of deliberate self-harm,
the police, next of kin, purchasing authority and any other interested
agencies should be notified immediately. No risk assessment was
carried out in this case and neither the next of kin nor relevant agencies
were notified by Portland House.
The Governor should ask Portland House to review their missing
person procedures to include action to be taken when someone
fails to attend and ensure that these are put into place.
26 Records from Portland House state that, when she did not arrive there,
about five unsuccessful attempts were made to notify the prison
CARATs team of her failure to report. The records do not include the
time or number of calls. Later in the day the same member of staff
reported that she had spoken to the prison and confirmed that the
woman had been released at 9.30 that day. She also recorded that the
HDC monitoring company, Premier Monitoring, had telephoned and
been told that she had not reported. Again the time of the calls was not
logged. The Portland House record of the telephone contact by
Premier is not consistent with Premier’s own record, which states that
they made one visit at 19.06 to perform her induction but no access
was gained to the premises and staff were advised that she was not
present.
The Governor should ask Portland House to log the time of
incoming and outgoing calls.
27 The Statement of Operational Requirement between Premier and the
Home Office states that if the curfewee is absent when the contractor
visits to install the equipment …the contractor must make at least one
9
further attempt to install it during the first curfew period. It is not
apparent that this requirement was complied with on this occasion.
Contractors are also required to complete installation within 24 hours of
the start of the first curfew period, which in this case was by 15.00 on
18 September. The records from neither Premier nor Portland House
indicate that a further visit was made before that time and it does not
appear that this requirement was complied with either.
28 A further requirement is that if the contractor fails to complete the
installation, it must be treated as an unauthorised absence violation of
curfew and either the original sentencing court or the Sentence
Enforcement Unit of the Home Office be notified. The Early Release
and Recall Section (ERRS) of the Home Office confirm that they were
not notified until two days after release on 19 September. On the same
day the woman’s recall was agreed and the revocation of licence was
signed on the grounds of inability to monitor.
The attention of the ERRS and the monitoring company should be
drawn to my comments on the company's failure to comply with
all their operational requirements.
29 Portland House staff recorded that the police attended their premises at
23.15 on 17 September. The ERRS notified Nottinghamshire Police of
her recall on 19 September, and referred them to Home Office Circular
1/1999 which states that the priority to be given to individual cases is
an operational matter for the local police, but that the Association of
Chief Police Officers Crime Committee has indicated their view that
HDC recalls should be treated as urgent action cases. Had she been
reported under the missing person procedures, the police investigation
would have received a higher priority. Nevertheless, the Mansfield
division did attempt to visit one of her previous addresses but could not
gain entry and the next and final information in the police log was when
her body was found.
10
CONCLUSIONS
HMP New Hall
30 During the woman’s sentence she was supported by staff throughout
the prison including the wing, workshop, chaplaincy and the CARATs
team. Risk of self-harm was appropriately identified and acted upon
and she successfully underwent a detoxification programme.
31 Staff are also to be commended for their comprehensive rehabilitation
plans for the woman. They responded to her request for support and
made detailed plans with her, which involved successful applications to
specialist community provision. Although no staff were formally
interviewed for the investigation, it was clear from those who were
spoken to that they felt a sense of disappointment that the plans were
not achieved. Had the prison been able to provide transport to
Portland House, it may be that she would have been able to achieve
her goals. Since this investigation commenced, Portland House have
changed their arrangements so that they will go to the prison and
provide transport for women in circumstances similar to hers. I
welcome this.
32 There were omissions to two aspects of the Healthcare contribution to
her discharge arrangements, in that there is no evidence in her records
of either advice on the risks of drug use after a period of withdrawal, or
of any letter for a GP at her new address.
Portland House
33 After her release, Portland House attempted to inform the prison
CARATs team that she had not arrived. Their missing person
procedure did not refer to circumstances such as these and it was not
implemented. The police and monitoring company became aware of
the woman’s absence when they made contact with the
accommodation, but her absence was treated as a breach of HDC
rather than as a missing person.
Premier Monitoring Services Ltd
34 The monitoring firm did not comply with three of its operational
requirements which meant that the woman’s recall was ordered a day
later than required.
11
RECOMMENDATIONS
Recommendation to HMP New Hall
1 The Governor should ensure that all staff working with a prisoner are
invited to the F2052SH reviews. The prisoner herself should also be
involved.
2 Prison Healthcare should contribute to discharge planning by advising
prisoners on the effects of drug use after a period of abstinence and by
providing a discharge letter fro GPs.
Recommendations to Portland House
3. The Governor should ask Portland House to review their missing
person procedures to include action to be taken when someone fails to
attend and ensure that these are put into place.
4. The Governor should ask Portland House to log the time of incoming
and outgoing calls.
Recommendations to Premier Monitoring Services Ltd
5 The attention of the ERRS and the monitoring company should be
drawn to my comments on the company's failure to comply with all their
operational requirements.
12