Individual at Northallerton

THE MAN
In completing this brief report I have considered the documents provided to me by HMP
Northallerton and the information, including the post mortem report, provided by HM
Coroner.
Background
The man was born in 1987 in Sheffield. He was the eldest of three children. According to
reports he had no meaningful relationship with his natural father.
The man’s contact with Social Services began in 1991, initially following allegations of abuse
against him. As time progressed referrals came from his mother who struggled to manage
his challenging behaviour.
In January 2002, the man was accommodated under Section 20 of the Children Act 1989.
Sheffield Social Services placed him at Didsbury School, Manchester. It was during this
period of his life that he came to the attention of the courts. His offences were largely as a
result of frustration and inability to control his temper.
On 28 April 2003, the man received a twelve month Supervision Order. The man was
unable to comply fully with this order and in December 2003 re-appeared before the courts.
This time the man was given an Attendance Centre Order, but failed to complete it. In
August 2004 he was given an Action Plan Order. He successfully completed this.
Over the next nine months the man appeared in various Youth Courts. Following an
appearance on 12 April 2005, he was placed on a bed and breakfast basis in two separate
establishments. These placements did not work and on 14 June 2005 he was remanded
into custody. He was later released on bail, but committed further offences and found
himself once more remanded in custody.
In December 2005, his case was adjourned to allow him to have a four week bail
assessment period at an Approved Premises and to enable a Drug Rehabilitation
Requirement assessment to take place.
The man was later breached and returned to prison after he failed to return to the hostel and
when staff searched his room drug paraphernalia was found. The man was assessed as
unsuitable to return to such accommodation and was to be advised to report to the council
homeless section on release. The man was released on 11 May 2006.
13 June – 20 October 2006
The man was recalled to prison after unacceptable behaviour at the Probation Office, during
which he was seen to have a ‘gun’. This resulted in an armed response from the police and
his subsequent arrest.
The man was initially received at HMP/YOI Doncaster, but within ten days had transferred to
HMP Northallerton. HMP Northallerton takes young people aged 21 or under, serving two
years or less, or in the last three months of their sentence. The regime is centred around
preparation for release and job opportunities.
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On reception at HMP/YOI Doncaster he went through all the usual reception assessment
and screening processes. The man’s self-harming behaviour was recorded, along with his
drug use. The man’s recall papers were prepared and served on him. His sentence was
incorrectly calculated at this stage and he was given a sentence expiry date of 28 November
2006.
On 14 July, The man was seen by the mental health team, who could not find any treatable
mental illness. They attributed his challenging and impulsive behaviour to ‘learnt behaviour
patterns’.
The man threatened self-harm on 6 August. A suicide and self-harm support document
(F2052SH) was raised to support him through his crisis. The following day he transferred to
HMP Hull for a court appearance. The F2052SH accompanied him, but was closed 48
hours later, after a case review.
A further sentence calculation was undertaken, and still gave the man an incorrect release
date.
On 27 August, The man made minor cuts to his arms. The man was seen by healthcare and
a Suicide and Self-harm support package (ACCT) was put in place. This was closed on 1
September, following a case review.
On 29 September, The man made superficial cuts and a support package was put in place.
This was reviewed after 24 Hours and no longer felt necessary.
However, on 2 October, The man again self-harmed and so this once more triggered the
care of at risk prisoner’s process. The man was reviewed, assessed and involved in
planning his care.
The man transferred back to Northallerton on 16 October, following a Parole Board hearing
at which it was decided he should be released at this sentence expiry date. On 17 October,
the Custody Administration Officer realised the mistakes in the sentence calculation. The
man’s sentence expiry date was in fact 20 October.
The man was seen by healthcare and probation the day before his release. He was noted to
be fit for release and looking forward to going to his mothers.
The man was released on 20 October. His sentence has expired and he could therefore no
longer be held in custody. Furthermore, as his licence had expired he was not subject to
any supervision.
Conclusion
The man was treated sympathetically and sensitively whilst in custody with regard to his self-
harming behaviour. The man was appropriately engaged in the review process and in
planning his support.
It is of concern that the man’s sentence calculation was repeatedly wrong and the mistake
only discovered three days before he had to legally be released.
There is no documentary evidence to indicate what support the man was given prior to his
release, but it is evidenced that he was seen by probation and healthcare.
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I will share this brief summary of the man’s care with the relevant establishments to support
them in learning from significant events.
Emma Bradley MSt BSc RGN February 2007
Deputy Ombudsman
Head of Fatal Incident Investigation Team
Prisons and Probation Ombudsman
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