Individual at Pentonville

CIRCUMSTANCES SURROUNDING THE DEATH OF A MAN AT HMP
PENTONVILLE IN JUNE 2005
REPORT BY THE PRISONS AND PROBATION OMBUDSMAN FOR
ENGLAND AND WALES
February 2005
This is the report of an investigation into the death of a man, who died whilst a
prisoner at HMP Pentonville in June 2005. The man was found hanging in his
cell at 5:45am. He was 31 years of age. The toxicology report shows that he
had alcohol in his blood.
I wish to offer my sincere sympathy and condolences to the man’s family and
friends for their sad loss. I know the staff and prisoners at Pentonville who knew
him share those sentiments.
Two of my colleagues undertook the investigation, and have been assisted by
one of my Family Liaison Officers.
I wish to extend my thanks to the Governor and his staff for their help and
cooperation during the investigation. Particular thanks go to the Senior Officer
who acted as the local liaison officer. I am also grateful to the Camden Primary
Care Trust for instigating a clinical review and the Reviewer for carrying out the
review.
The man’s death was the second of two such deaths to have occurred at
Pentonville within days. The consumption of alcohol is a common feature. The
police investigation did not find alcohol in the man’s cell. In his case, he was
charged with serious offences and was the subject of a probation licence recall.
He had been returned to custody on 27 May 2005. He was alone in his cell for
the first time on the night of his death.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN FEBRUARY 2005
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Contents Page
Summary 5
Investigation Methodology 6
The man 7
HMP Pentonville 8
Events prior to the man’s death 10
Events after the man’s death 14
Clinical review 14
Conclusion 17
Recommendations 18
Good practice 18
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Summary
1. At 5:45am on a Wednesday in June, the man was discovered hanging in his
cell during the early morning roll check at HMP Pentonville. He was alone
in a double occupancy cell, and a ligature made from a bedsheet was
attached to the window. At the time of his death, the man had been in
Pentonville for 20 days.
2. The man was first sentenced to 14 years imprisonment on 27 September
1997. His sentence was varied on appeal to 12 years imprisonment. He
was released on licence from HMP Maidstone on 17 May 2004. His licence
was due to expire on 17 May 2008.
3. The man appeared at Highbury Corner Magistrates’ Court in May 2005
charged with two offences, and was remanded into custody. The Probation
Service reported that he had breached the conditions of his licence, and
requested that it be revoked.
4. The man went through Pentonville’s reception process and was not
identified as at immediate risk of self harm. Owing to the nature of his
alleged offence, he was correctly identified as a Vulnerable Prisoner and
placed on C wing.
5. Staff and prisoners who knew the man stated that he gave no outward
indication that he intended to take his life. However, my investigators
established from prisoners whom they interviewed that he was fearful of the
prospect of a further substantial term of imprisonment.
6. The post mortem toxicology report found the man had a large quantity of
alcohol in his blood.
7. This report makes three recommendations.
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Investigation Methodology
8. The investigation was opened at the prison on 17 June by my two
colleagues. The Governor and his staff produced the man’s core file and a
number of other documents for examination. The records had been
secured after his death.
9. Notices were issued to staff and prisoners informing them of my
investigation.
10. Meetings were held with representatives of the Prison Officers’ Association
(POA) and the Independent Monitoring Board (IMB) who both offered their
full co-operation with the investigation. Contact was made with the
Metropolitan Police who carried out their own inquiries.
11. Documents relating to the man’s time in custody were examined. My
investigators contacted the coroner’s officer, to brief her on the nature and
scope of my investigation and request a copy of the post mortem report.
They also obtained a copy of the report of the London Probation Area which
notified the man’s breach of his licence, and requested a review by the
Parole Board.
12. Camden Primary Care Trust commissioned a Reviewer to prepare a clinical
review of the man’s care whilst in prison custody.
13. One of my Family Liaison Officers, has spoken and written to members of
the man’s family who are aware of nature and scope of my investigation.
My Family Liaison Officer has offered to visit members of the family with my
investigators. At the time of writing, this offer has not been accepted. To
date, the man’s family have not voiced any concerns for my investigators to
consider but they are keen to be kept informed of my findings.
5
The Man
14. The man was born on 15 September 1973 and was aged 31 years when he
died.
15. He was released on licence from Maidstone prison on 17 May 2004, and
was to be supervised by the London Probation Area until 17 May 2008. On
release, he was found accommodation in one of the probation area’s
Approved Premises (hostels). His response to supervision on licence was
described as good. He reported regularly and punctually, and complied with
the conditions of the licence and the supervision plan. He was undertaking
courses aimed to address his offending behaviour, and his feedback was
positive. Due to the man’s compliance with the licence conditions, he was
able to leave the Approved Premises when he secured his own semi-
supported housing.
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HMP Pentonville
16. Pentonville was built over 160 years ago. It is a local prison which
accepts all suitable prisoners from courts within its catchment area in
north London. It has a certified normal accommodation of 897
prisoners, but an operational capacity (maximum crowded capacity)
of 1,189. Although a good deal of refurbishment has taken place, the
original four cellblocks are much as they were when the prison
opened in 1842.
17. The prison’s regime includes education with full time/part time and
evening classes, workshops and training courses. Offending
behaviour courses such as Enhanced Thinking Skills are available.
18. Prisoners with a drug problem are identified by healthcare staff in
reception and through mandatory drug testing. Pentonville is able to
provide most treatments including detoxification. Arrangements can
be made to provide rehabilitation programmes.
19. The prison has links with outside agencies. For instance, the
Probation Service sits on the drug strategy group, and the prison has
a group to represent prisoners' families. The Rehabilitation of
Addicted Prisoners Trust (RAPT) provides drug rehabilitation
programmes. Pentonville is represented on the Camden and
Islington Drug Action Team.
20. R wing is the Vulnerable Prisoners wing. However, C wing is used
as an overspill for R wing. Vulnerable Prisoners who on C wing are
unlocked separately from the rest of the prison population and taken
to R wing to participate in their activities.
21. On the night of 15 June, the prison held some 1,169 prisoners, of
whom 105 were located in C-Wing. Cell C2:14, where the man died,
is a double occupancy cell with a metal framed bunk bed. It has in
cell sanitation, two small tables and a chair, but does not have in cell
electricity.
22. The man was the fifth prisoner to die apparently by their own hand at
Pentonville since June 2004. All died within a short period after
arriving in custody.
23. Pentonville has worked hard to improve practices since these deaths.
The National Offender Management Service’s Safer Custody Group
has undertaken a review of their procedures and made a number of
recommendations. Most of the recommendations have been
implemented and there has been a large emphasis on safer custody
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led by the Head of Residence. I recognise this much needed
improvement. It is also important to note there is still a very long way
to go, and resources need to be applied to support the development
of a better environment, policies and practices.
8
Events prior to the man’s death
24. The man was sentenced to 14 years imprisonment in September
1997. His sentence was reduced on appeal to 12 years, and he was
released on licence from HMP Maidstone on 17 May 2004. His
licence was due to expire on 17 May 2008.
25. The man was arrested on Wednesday 25 May 2005, and
subsequently charged with two serious offences. He appeared at
Highbury Corner Magistrates’ Court in May where bail was refused
on the following grounds:
A that he would fail to surrender;
B would commit offences on bail;
C the nature and gravity of the offences charged;
D his previous criminal record; and
E the likely sentence if found guilty at trial.
26. In addition, the circumstances of his arrest were communicated to the
London Probation Area who revoked the man’s licence, and issued
an order for his emergency recall to prison. After his appearance at
court, he was taken to Pentonville.
27. At Pentonville, the man went through the reception procedure. A
Healthcare Officer interviewed him as part of his healthcare screen,
and completed a healthcare screening form. The man indicated that
he had been in Pentonville in 1996, and said that he had not
previously attempted to harm himself or felt like harming himself.
The healthcare officer recorded on the man’s Cell Sharing Risk
Assessment (CSRA) form that he was suitable for multi-cell location,
and that she had no concerns about him.
28. A reception officer, completed sections one and two of the CSRA,
and recorded that the man was of no immediate risk but that his
situation would need to be reviewed regularly.
29. Because of the seriousness of the offences with which he was
charged, and because he was recalled from licence, he was
identified as a Vulnerable Prisoner. R wing, the Vulnerable Prisoners
wing was full, and so he was located on C wing in cell C2:14. C wing
is used as an overspill for the Vulnerable Prisoners wing. He shared
the cell with other prisoners until the evening of 14 June when he
was alone for the first time, his cellmate having been moved to
another establishment.
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30. The cellmate said in interview that he had known the man for three
years, first meeting him in Maidstone prison. On 27 May, he returned
to Pentonville from court and was asked by prison staff to share a cell
with a new reception prisoner. He immediately recognised the
prisoner as the man and was pleased to see him. The two men
shared Cell C2:14 for a number of days. The cellmate said that the
man was initially reluctant to speak about his imprisonment, but
eventually spoke about the circumstances of his arrest. The cellmate
thought that by talking about it the man had lightened his worries. He
went on to say that the man had just finished a 12 year sentence,
serving the maximum period in custody without parole. He said the
man felt that, all of a sudden a year later, he faced at least a three
year recall to prison as well a sentence for the new charges. He said
that the man also knew that changes in the law meant that his
previous sentences could be mentioned in court. The cellmate said
that the man sensed he was up “against it”.
31. The cellmate described the man’s interaction with other prisoners
and staff as being kept to a minimum. He described him as a quiet
man, “the type of person you wouldn’t notice”. He said that you
would not have noticed him because, whenever he was on
association, he would sit in the same spot and be quiet.
32. My investigator asked the cellmate if the prison could have seen any
indication that the man might have been contemplating harming
himself. He said, that he did not think so. The night before he died,
the man asked the cell mate and his new cellmate for any old
newspapers. They gave him their newspapers and the man went off
to his cell. The cellmate said that he was not worried about the man
going to harm himself. He did not detect anything from his
mannerisms or anything else, and he did not anticipate that the man
would cause himself injury.
33. Another prisoner at Pentonville, said that he arrived there on 10 June
and was allocated to cell C2:07 which was opposite to the man’s cell.
The two men had previously met whilst at Maidstone. The man told
him that he had been recalled from his licence and that he had not
done anything wrong. He told this prisoner that he was not his usual
self. The day before his death, the man asked the prisoner if he was
sharing his cell which the prisoner thought might have been because
he wanted to share himself. Subsequently on the morning of 15
June, the prisoner said that he saw a lot of activity in the man’s cell,
and was told later that he had died.
34. A life sentence prisoner who also arrived at Pentonville on 10 June.
He was placed in the cell opposite to the man. The life sentenced
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prisoner said that he had been a Listener for the Samaritans for the
last four years. Listeners are prisoners who are selected, trained and
supported by the Samaritans to provide a listening ear for any
prisoner who feels vulnerable and at risk. As well as having face to
face contact, prisoners can also use the direct telephone to the
Samaritans. As far as the man was concerned, the life sentenced
prisoner said that he was quiet and kept himself to himself, but he did
not think he was at risk of suicide.
35. A prisoner on C wing located in cell C2:15, who said that he knew the
man. They had spoken and he found him to be friendly and polite,
but also distant from other people and quiet. The C wing prisoner
thought the man was shy. The C wing prisoner was shocked to learn
of the man’s death and said that he had not thought he would harm
himself. When he was interviewed for this investigation, The C wing
prisoner said that he felt that the support he received after the man’s
death was non-existent. He said that he asked to use the
Samaritans telephone but was told that it was broken, and he did not
see a Listener until four days later.
36. An officer met the man as he was carrying out his duties. He
described having a number of conversations with him, and found him
to be a pleasant man, who seemed happy and liked to watch
television. He said that the man seemed fine with himself. He last
saw the man at about 6:00pm on Tuesday 14 June. The man was
alone in his cell and the officer asked him how he was doing the man
replied “I’m alright, cheers, Gov”, and gave a wave.
37. At night, the prison is in patrol state which means that only the Night
Orderly Officer (Officer in Charge) has access to all the keys. Other
staff carry a cell key in a sealed pouch, to be used in emergencies.
38. A night duty officer started duty on C wing at 8:30pm on 14 June. He
was given an electronic pegging wand and a pegging card. The
wand allows an officer to record his location at specific points on the
wing which are pre-determined by the card. The system is designed
to ensure that an officer physically checks the landings every half
hour, as well as responding to cell bells or any other events. At the
end of the shift, the officer returns the wand to the Night Orderly
Officer who downloads and checks the information.
39. The night duty officer physically checked and counted all the
prisoners in their cells. Throughout the night he walked the C wing
landing, electronically pegging his movements. His pegging routine
was carried out correctly. The man did not ring his cell bell during the
night. The night duty officer began a further physical check of all
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prisoners in their cells on C wing shortly after 5:30am. At 5:45am, he
looked inside cell C2:14 and saw the man. He could see clearly that
there was a ligature around his neck, made from a bed sheet and tied
to, what he believed to be, the outer cage of his window.
40. In accordance with procedures, the night duty officer radioed in his
position and radioed call sign “level 1” to indicate that a prisoner had
been found hanging. He broke the seal on his key pouch and
opened the cell door, ran into the cell and lifted the man up. He
shouted to him to see if he could get his attention. The night duty
officer removed the anti ligature knife from his belt and cut the
ligature off of the man’s neck. He laid him on the ground and tried to
get a response. He checked his condition, and then again radioed in
his location. He commenced cardio pulmonary resuscitation (CPR)
with skin to skin contact through the man’s mouth and nose. The
night duty officer was joined and assisted by a nurse and another
officer. The nurse used a defibrillator on the man.
41. An ambulance was summoned to the prison at 5:46am, and arrived
at 5:55am. The paramedics took over the administration of CPR at
5:56am, but at 6:05am it was stopped. The cell was sealed for
forensic examination, and at 8:30am a doctor pronounced that the
man had died.
42. A governor arrived at Pentonville at 6:00am, and immediately took
overall command. He ensured all documentation relating to the man
was collected and securely stored. All contingency plans were
followed and the governor conducted a hot debrief with all the staff
involved.
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Events after the man’s death
43. The Metropolitan Police commenced an investigation, and carried out
a forensic examination of cell C2:14. The undertakers removed the
man from the prison at 11:50am.
44. The Governing Governor visited the man’s next of kin that morning
and subsequently delivered the sad news of his death. He appointed
a prison family liaison officer who was able to meet the family’s initial
needs.
45. Members of the man’s family visited the prison on 17 June. A Senior
Officer met the family on C wing and showed them the cell where the
man died. The cell was still sealed, and so the family could only look
in through the observation panel. The Senior Officer said that they
commented that the cell was untidy, and he explained that items
would have been moved as staff attempted to resuscitate the man.
He also said that they commented that the cell bars were low, and
wondered how he could have hung himself. The Senior Officer said
that he explained how the wing operated and informed them that it
was not solely for Vulnerable Prisoners.
46. A doctor carried out a post mortem at Camden Mortuary on 17 June.
I am still awaiting the results of the post mortem, which will, if
necessary result in a supplementary report. The man’s medical
toxicology report was received at the PPO office on 3 October. It
shows that at the time of his death the man had 2.3g/l of Ethanol in
his blood. The legal limit for driving is 0.8g/l. Concentrations above
3 g/l are associated with serious toxicity. The deputy governor was
informed of this finding on 3 October. My investigator returned to
Pentonville on Thursday 14 October and re-interviewed the man’s
first cellmate. He was aware that the man knew how to make alcohol.
However, he said he had no knowledge of the man making it or
consuming it at Pentonville. He re-stated that the man was someone
who kept himself to himself.
47. My family liaison team, has spoken and written to the man’s family
but no additional matters have been raised by them.
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Clinical Review
48. The clinical review was conducted by a doctor who considered the
following information:
A Inmate Medical Record, including first reception
health screen
B Cell Sharing Risk Assessment
C log relating to action taken when the man’s death was
discovered
D transcript of interview with the healthcare officer who
completed the first reception health screen
E transcripts of interviews with prison staff who were
involved with the man in various capacities
F transcripts of interviews with prisoners.
49. The doctor found that the first reception health screen did not identify
any health problems or risk factors for self harm such as alcohol or
substance misuse, mental health problems or previous episodes of
self harm. This was reflected in the healthcare officer’s contribution to
section three of the cell sharing risk assessment where she assessed
the man as low risk of harm to others, with no concerns about self
harm.
50. The man had no further contact with healthcare services in the
prison.
51. From accounts of prisoners and prison staff, the doctor established
that the man appeared to be quiet, kept himself to himself, and was
reluctant to talk about his feelings during his stay. The man’s cell
mate who had known him previously, felt he was initially shocked to
be back in prison but seemed to open up to him and become more
relaxed and calm as time went on. A fellow prisoner who had known
him previously noticed that he seemed a bit upset and quiet,
compared to how he had been when they were together in Maidstone
in 2004. This was particularly so on the day before the man was
found hanging. However, he did not appear to have spoken or
behaved in a way that aroused any suspicion of the possibility of self
harm during the three weeks he was in custody.
52. The man’s first reception health screen was conducted in
accordance with usual procedures and the health record was
completed clearly and fully. There were anomalies in that the prison
officer who completed section two of the form assessed his risk as
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medium, but the healthcare officer completing section three assessed
his risk as ‘low’. 1
53. The man’s subsequent demeanour and behaviour did not suggest
any mental health problems requiring intervention from the
healthcare team or prison staff.
54. The clinical reviewer considered that it might be significant that the
man took his own life on the first night that he was alone in his cell.
However, there had been nothing to indicate that he might be in more
need of the companionship of a cell mate then any other prisoner.
55. The reviewer went on to conclude that the actions taken after the
discovery of the man appeared to be timely and appropriate.
Unfortunately he was discovered too late for resuscitation to be
successful. The review states that prison procedures were correctly
followed throughout the man’s time at Pentonville, and his death
could not have been foreseen or prevented under the present
conditions.
56. The clinical review contains the following recommendations:
i Consideration should be given to the way in which cell sharing risk
assessment is documented. The form does not clearly distinguish
between the risk of a prisoner harming others in the cell, the risk to
the prisoner from a cell mate and the risk of a prisoner harming
himself.2
ii Strategies to reduce risk of fatal self harm in prison should include
assessment of the effect of single cell occupancy and lack of
television in cells on the mental well being of prisoners.3
1 I am aware of much recent work within the Prison Service on the subject of cell sharing risk
assessment. I simply draw to the Service’s attention these views from an independent clinician.
2 I share the clinical reviewer’s concern about the absence of in-cell television. I make my own
recommendation in relation to this matter.
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Conclusion
57. The man was arrested whilst on licence and was charged with
serious offences. The Probation Service revoked his licence. He
expected to be imprisoned until 2008 following the revocation of his
licence. A further substantial term of imprisonment would have
followed conviction for the new offences.
58. The man was remanded in custody in May and taken to Pentonville.
During the reception process and his time in the prison, he did not
present as a person likely to harm himself. He shared a cell with
other men until 14 June, and was then alone for the first time since
his arrival.
59. Facilities in the man’s cell were limited. There was no electricity,
which meant that there was no television. He would spend at least
12 hours alone overnight. This is self-evidently a long time to be
without human contact or other distraction.
60. During the evening of 14 June, the man gave no outward indication
that he might harm himself, and he was last seen alive at
approximately 8:30pm during the C wing roll check. He was found
hanging in his cell at 5:45am the following day.
61. All procedures were followed correctly. However, some of the
prisoners interviewed in the course of this investigation felt they
received little or no support from prison staff.
62. The post mortem toxicology results showed that the man had
consumed a substantial amount of alcohol. The toxicology report on
another prisoner who died at Pentonville two days earlier showed a
similar result. The investigation team re-interviewed prisoners and
examined security incident reports.
63. There was no indication from the security reports that a special
problem concerning the production of alcohol has been identified at
Pentonville.
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Recommendations
Operational
1. The Governor should review the prison’s arrangements for providing
support for prisoners after a death in custody.
2. The Governor and Area Manager should review the programme for
installing in-cell electricity and in-cell television at Pentonville with a view
to accelerating the programme as resources allow.
3. I recommend that the Governor investigates the extent of alcohol
production at Pentonville and establishes a plan to deal with the findings
and to provide continued monitoring.
Good Practice
1 The two officers and the nurse should be commended for their
attempts to resuscitate the man.
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