Individual at Pentonville

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INVESTIGATION INTO THE CIRCUMSTANCES
SURROUNDING THE DEATH OF A MAN AT HMP
PENTONVILLE IN JUNE 2005
Report by the Prisons and Probation Ombudsman for England and
Wales
January 2006
This is the report of an investigation into the death of a man who died on 12
June 2005 in HMP Pentonville. The man was found hanging in his cell. He
was 24 years of age. The toxicology report reveals that he had alcohol in his
bloodstream.
I would like to offer my sincere condolences to his family on their loss.
The investigation was conducted on my behalf by one of my colleagues, and a
family liaison officer from my office, visited the man’s family. Along with the
investigator she also met with the man’s partner. In both meetings, the aim
was to discuss the investigation and to elicit any questions they would like
answered.
I thank the Governor of Pentonville and his staff for their assistance during the
investigation. I am particularly grateful to the governor who acted as the local
liaison officer. Thanks are also due to the doctor from Islington Primary Care
Trust who conducted a clinical review of the man’s healthcare needs and how
they were met.
The man was in prison just 36 hours before he died and few staff or prisoners
had any contact with him. Every effort was made to save him. However,
there are improvements that can be made at Pentonville in respect of
reception and the first night centre.
Another prisoner sadly died apparently at their own hand in Pentonville on
another wing two days after the death of the man who is the subject of this
report. The report into that death will consider if there are any lessons that
can be drawn together from both investigations.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2006
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Contents
Summary
Investigation process
Background
12 June
Contingency plans
Contact with the man’s family
Background details of HMP Pentonville
Findings and Conclusions
Summary of recommendations
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Summary
The man was just 24 years old when he died at Pentonville prison on 12 June
2005. He had been in custody only 36 hours.
When he arrived at Pentonville, his Prisoner Escort Record (PER) had a box
relating to his risk of suicide and self-harm ticked. This was because he had
previously taken an overdose of medication.
He underwent a healthcare reception screening. The nurse who completed
this found it difficult to persuade him to talk openly. The nurse was concerned
by his low mood and so asked the doctor to see him. The doctor assessed
him but did not ask about any mental health issues. However, he did consider
the nurse’s concerns and requested that he be placed in a shared cell.
On the first night centre, he shared a cell with prisoner A. He reported that the
man did not say much. The only thing he really talked about was being
concerned he was not going to see his daughter, and thinking he might
receive a long sentence. He spent most of his time laid on his bunk.
Toxicology reports show that at some point, probably on Saturday 11 June,
the man consumed a large amount of alcohol. This was very out of character
for him. On learning this fact my investigation team returned to Pentonville.
They reinterviewed the man’s cellmate and examined security information.
Prisoner A could shed no light on the situation. He did not see the man
consume any alcohol or anything unusual and reported that he was not aware
how to obtain it in the prison.
The amount of alcohol that the man consumed is likely to have altered his
mood, possibly making him feel very low.
The man was found hanging by his cellmate when he awoke on 12 June just
before 6am. He raised the alarm by pressing the cell bell. Help arrived
quickly and attempts were made to save his life. Paramedics arrived and
pronounced death. It is thought the man had been dead for some time.
Due to the short period of time he was in custody, it was difficult to find
anyone who knew him, or had a good understanding of any problems he
faced. It also appears he was reluctant to talk with staff.
I conclude that the first night centre affords an unwelcoming environment and
there is much that can be done to improve it. Communication between
reception and the first night centre also needs to be enhanced.
My report makes four recommendations.
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Investigation process
I appointed one of my colleagues to conduct the investigation on my behalf,
and she was supported by two other members of the investigation team.
The team visited HMP Pentonville, where they met the Governor. They
visited the cell where the man was found. They also met with members of the
local branch committee of the Prison Officers' Association (POA) and the
Independent Monitoring Board (IMB).
Notices were issued to both prisoners and staff, inviting anyone whom might
have information relating to the man to make themselves known to the inquiry.
Along with the investigator, one of my family liaison officers visited the man’s
family to ascertain their particular concerns and questions about the
investigation.
The investigation team interviewed prison staff and prisoners both formally
and informally.
The team examined the man’s prison record, medical records and a series of
prison documents. They also assessed the care that he received against
Prison Service orders and policies.
A clinical review of his health care whilst in prison custody was undertaken by
a doctor from Islington Primary Care Trust.
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Background
The man was born in 1980, and was 24 years old when he died. Prior to
going into Pentonville, he was employed as a security guard. He lived with his
partner and young daughter. This relationship was a turbulent one, and
coming to an end. He had made arrangements to live elsewhere whilst
maintaining contact with his daughter.
On Friday 10 June, he was remanded into custody for alleged offences
against his partner.
He arrived at Pentonville at approximately 3.30pm. On his Prisoner Escort
Record (PER), the “risk of suicide” box had been ticked. This is because he
disclosed to the police that he had previously attempted suicide. The man
saw an officer who explained what was going to happen, and recorded his
possessions. He was then strip searched, given some prison issue clothes
and placed in a holding room to wait to be seen by the nurse.
The reception nurse completed a health screen with him. During interview,
the nurse explained that he had seemed particularly low in mood. He would
not answer some questions and was generally reluctant to talk. When the
nurse asked if he had ever self harmed, he initially did not answer, then
replied that he had previously taken an overdose. When the nurse tried to
find out more, he was again reluctant to answer. The nurse found his low
mood and reluctance to answer questions a little concerning, and
appropriately thought it best that he see the doctor.
The reception nurse accompanied him to see the prison doctor, and said in
interview that the man was different with the doctor and did not appear as low.
The doctor asked no further questions relating to self-harm or suicide. The
doctor marked on his Cell Sharing Risk Assessment that he should share a
cell. When asked in interview, the doctor said that everyone was to share a
cell on their first night unless they were considered a risk to others. This was
a lesson learned from a previous death in custody. Otherwise, the man was a
healthy young man who was fit, did not use drugs, and did not regularly drink
alcohol.
The man was taken to the first night centre and allocated his cell on A3
landing. He was given a reception pack. Wing staff were not aware that he
had previously attempted suicide, or that his PER form was marked as a risk.
Prisoner A was allocated to the same cell as the man who died. He arrived at
the cell a couple of hours after the man. He reported that the man was quiet
but seemed okay.
Prisoner A reported that the man did not say much, he mainly lay on his bunk.
The only thing he really spoke of was his concern about not seeing his
daughter.
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That night, the prison officer was working in the security department. Part of
his role is to complete a Security Collator’s Initial Assessment on new
prisoners. In order to complete this form, he must consider documentation
from courts, police and the PER form. He completed the assessment
regarding the man, and, noting that the suicide marker had been ticked on the
PER form, contacted the night orderly officer who reported that this was not a
requirement, but that the prison officer is a particularly experienced and
thorough in his work. The man was one of two prisoners who had a marker
on their PER. The orderly officer then checked the names were not on the list
of those on F2052SH’s (a form used to monitor and support those at risk of
suicide or self-harm). He then checked their details on the Inmate Information
System, and saw that the man had been in Pentonville previously for a brief
period.
The night orderly officer went to A3 landing and opened the flap on the man’s
cell. The man looked up and the officer asked him if he was okay. The man
responded that he was fine. He checked once more later in the early hours of
the following morning. The man was asleep.
The following day (Saturday), the man stayed mainly in his cell. He
underwent an induction assessment with the induction officer, who is the team
leader of the induction group. The officer did not specifically remember him
as he conducted a lot of interviews that day and the man did not present any
immediate problems. Referring to the assessment, he reported that the man
had said he did not have any mental health issues or medical issues that
needed addressing. He did not cause any concern.
The man also made a telephone call on the Saturday afternoon and spoke
with his brother. He asked for telephone numbers of other family members,
and told his brother his court date was 24 June. He also told his brother that
his former partner’s father was in Pentonville as well, but that he did not know
what wing he was on. The man’s brother was concerned about this. The man
said that if he was found guilty his solicitor had said that he could be
sentenced to years rather than months. His brother told him to go to the gym
and read books, and that the 24th was not far away. He also reassured him
that he would take care of things outside of prison and look into visiting rights
for his daughter.
It is unclear whether the man took lunch, but he did collect his meal from the
servery on A2 landing on Saturday evening. Another prisoner on the wing
recalled seeing him at the servery area. The man had asked the prisoner
where to collect food. He said that the man did not appear to mix with other
prisoners and that he did not have any further contact with him.
That evening, the prisoners were locked behind their doors from
approximately 7pm. The man was in his cell with his cellmate. There was no
radio or television. There were some newspapers, but his cellmate reported
that the man, in the main, just lay on his bunk looking at the ceiling. The last
conversation they had was the man enquiring about a small piece of sheet
that was attached to the window bars outside the window. Prisoner A said it
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was probably prisoners trying to keep their milk cool by tying it outside.
(Prisoners are given breakfast packs each evening, including some milk.)
The man wrote a letter to his family. It was a rather confused letter. On the
one hand, he asks that his family make sure he has a suit ready for his court
appearance. But at other times in the letter he expresses a sense of
hopelessness.
Prisoner A said he fell asleep around 10pm. He said he is a heavy sleeper
and slept through till the morning.
At some point, almost certainly on the Saturday, the man consumed a large
amount of alcohol. His cellmate says he did not see him drink anything, and
was not aware how he could have obtained the alcohol.
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12 June
The man’s cellmate woke shortly before 6am. He rolled over and saw the
man hanging from the window bars with a bed sheet around his neck. He
immediately rang the cell bell. A wing officer was patrolling and was near the
cell when the bell was pressed so attended the cell almost immediately.
Prisoner A recalls the officer shouting “get an ambulance quick”. The officer
put a “code one” out over the radio. (A code one signifies urgent assistance
required because of a medical emergency.)
At night, the prison is in patrol state. This means that only the night orderly
officer has access to all keys. Other staff have a cell key in a sealed pouch
which is only to be used in emergencies under certain guidance. The gates
from the centre of the prison onto the two’s landing are left open to allow staff
free movement over all floors of an individual wing. At the time of the radio
call, the night orderly officer and a second wing officer were located on the
centre, and ran to cell A3 17 where the man was located. They reported that
they were there within seconds.
The night orderly officer opened the cell. The two wing officers lifted the man
whilst the orderly officer removed the ligature. The orderly officer
remembered that the ligature was made from a whole bedsheet and the
ligature knife could not cut through it, so he had to lift the bedsheet over the
man’s head. They placed him on the floor. The night orderly officer
remembered that the man felt very stiff. By this time, the duty nurse had
arrived. He had been based in the treatment room on the centre, and picked
up some emergency equipment; the resuscitation bag, the ECG machine and
oxygen.
The officers moved prisoner A into the cell next door while they dealt with the
emergency.
The duty nurse recalled checking for an airway and any signs of life. He
observed that rigor mortis had set in and that the man was cyanosed (a blue
tinge to the skin) and cold. There was no heartbeat, there was no pulse, and
there was no respiratory effort. The nurse still attempted cardio pulmonary
resuscitation (CPR), beginning with a large thump on the sternum. He
continued CPR until the paramedics were in attendance.
Once the ambulance arrived, the paramedics used the ECG machine which
recorded that there was no heart output. The duty nurse reported that he
recalled the ambulance crew felt that the man might have been dead for
approximately six hours due to the level of rigor mortis. The paramedics
pronounced him dead, and the cell was sealed. The police arrived at 6.45am.
The prison doctor was called and arrived at approximately 9am and certified
the man’s death.
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Contingency plans
The duty governor arrived and took charge of the situation. He ensured all
documents relating to the man were collected. The man had recorded his
grandparents as the people to contact in an emergency. The duty governor
telephoned the man’s family.
All contingency plans were appropriately followed. The duty governor
conducted a hot debrief with staff involved. All staff reported feeling
supported and said they knew how to access help.
The governor phoned a member of staff who was particularly affected, later in
the day, to again check how he was feeling. He also followed up on staff the
next day.
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Contact with the man’s family
The duty governor broke the news by phoning the man’s grandparents at their
home at 6.40am in the morning. He said he decided to phone, as he knew
the importance of the family being contacted as soon as possible. He also did
not feel in a position to leave the prison, especially given that it was a Sunday
and there were fewer staff on duty than usual.
The man’s grandfather telephoned his mother. She phoned a directory
enquiries number to obtain the number for Pentonville and then had to go via
the switchboard to contact the governor. By the time she spoke to the duty
governor, it was 8.45 am. She was concerned as she was told that they were
still waiting for a doctor and the police to arrive, and she thought this was a
long time as her son had been found at 6am.
The mother wanted to see her son’s body that day and was very upset by the
initial response from the Coroner’s office that it could not be done on a
Sunday. She finally managed to see her son at 6pm on the Sunday evening.
The duty governor visited the family the following day along with the prison
chaplain, and delivered the man’s possessions.
His mother visited the prison, was met by the in charge governor, and was
able to meet and speak with her son’s cellmate.
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Background details of HMP Pentonville
Pentonville was built over 160 years ago. It is a local prison which accepts all
suitable prisoners from courts within its catchment area (North East London).
It has a certified normal accommodation of 897 prisoners, but an operational
capacity (maximum crowded capacity) of 1,189. Although much
refurbishment has taken place, the original four residential units are much as
they were when the prison opened in 1842.
The First Night Centre is housed on A wing, landing 3, and is staffed by a
group of officers who are responsible for the delivery of the prison's induction
programme. They also ensure that prisoners receive ‘First night welcome
packs’, are allowed to make a telephone call, have a shower and are allocated
appropriate accommodation. Medical staff also take part in the First Night
Centre process, with all prisoners receiving a Reception Healthcare Screen
and provided access to the Duty Medical Officer.
On Friday 10 June, over 200 prisoners passed through reception (this
includes those going either to or from court, those released and those newly
received). The man was one of 30 new prisoners that day.
The man was the fourth prisoner to die apparently by their own hand in
Pentonville since June 2004. All died in their first few days in custody. Sadly,
another prisoner died three days after the man who is the subject of this
report.
Pentonville has worked hard to improve practices since these deaths and a
review of their procedures was undertaken by the National Offender
Management Service’s Safer Custody Group. Most of the recommendations
from this review have been implemented, and there has been a great
emphasis on safer custody led by the head of residence. I recognise this
much needed improvement. However, there is still a long way to go.
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Findings and Conclusions
Reception
The investigation team found Pentonville’s reception area to be clean, but
basic. On the day that the man came into Pentonville, there were 200
movements of prisoners in and out of the prison. The demands on staff
working in reception with this number of prisoners passing through need no
elucidation.
A senior officer completed the first part of the man’s cell sharing risk
assessment. This assessment is used to assess the risk a prisoner may pose
to others. He assessed him as medium risk. In interview, he reported that
this was because part of the man’s alleged offence involved false
imprisonment. Later in the interview, he mentioned that potential self-harm
issues formed part of this decision as well.
• Healthcare assessment
The reception nurse acted appropriately by referring the man to the doctor
when he had concerns. However, the doctor failed to ask further questions
relating to the man’s mood, feelings or previous overdose. The clinical
reviewer comments that the prison doctor had received no specific training in
mental health assessment, either before coming to work in the prison service
or during his seven years of working there. He was not aware of the
existence of Pentonville’s local suicide and self-harm prevention policy.
As the prison doctor has been employed in a locum capacity throughout his
service at Pentonville, he has not been entitled to any paid time for study
leave or continued professional development. Although he has had annual
appraisals, there does not appear to be a mechanism for linking development
needs with any actions. There do not appear to be arrangements in place for
regular team meetings within the prison service, nor systematic clinical
support for medical officers.
It is the responsibility of the Prison Service to ensure that doctors working in
prison have the training and skills necessary for their role, whether they are in
substantive or locum posts. It does not appear that sufficient attention has
been paid to the doctor’s training needs in respect of mental health, and risk
of self-harm assessment. I therefore endorse the following recommendation
from the clinical review;
I recommend that Pentonville ensures that training and clinical support
is given for prison doctors as required. This responsibility extends to
doctors employed on a locum basis, as well as in substantive posts.
• Decision making regarding opening a F2052SH
The standard documentation for the First Reception Health Screen suggests
that, if a prisoner has a relevant history of self-harm, consideration should be
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given to opening a F20252SH. This could have been done at any time by any
member of staff who had concerns. If this had happened in the man’s case,
he would have had more frequent observation and monitoring during the
period that the F20252SH was open. However, assessment of risk of self-
harm is difficult and often subjective.
As the clinical review shows, the recent National Institute for Clinical
Excellence (NICE) guidelines on self-harm consider in some detail the risk
factors for repetition of self-harm. Applying these risk factors to the man, of
the ten factors suggesting increased risk of non fatal self-harm he had three
(possibly four), and of the ten factors suggesting increased risk of fatal self-
harm, he again had three (possibly four). In practice, risk assessment is
informed initially by consideration of known risk factors, and is necessarily in
part a subjective exercise. These judgements can never be foolproof. I note
the clinical reviewer’s assessment that there are insufficient grounds to
suggest that those interviewing and assessing the man who died should have
opened an F20252SH.
• Referral for mental health assessment
The standard documentation for the First Reception Health Screen directs that
if a prisoner answers ‘yes’ to the question about previous self-harm outside
prison, he should be referred for mental health assessment. The reception
nurse noted the previous attempt but did not refer him for a mental health
assessment, although he did refer him to see the doctor that same evening.
The prison doctor did not discuss the man’s previous self-harm attempt with
him, and did not consider he needed referral for mental health assessment
(although, by his own admission, he did not explore the man’s mental state
with him).
In this case, referral to the mental health team for a mental health assessment
probably would not have affected the outcome, as such an assessment would
not have taken place for several days. However, the directions in the First
Reception Health Screen about who to refer for a mental health assessment
were not followed. In her clinical review, the doctor in charge found that it was
accepted practice that there is room for discretion in individual cases. This
situation needs clarification.
• Communication issues
There was a lack of communication between departments regarding the man
who died. He had a suicide marker ticked on his PER form. The reception
nurse felt he was particularly low in mood. He had also been charged with an
offence against his partner – a factor known to increase risk. Although none
of this means that a F2052SH should have been opened, it is important the
information is shared with wing staff.
The local induction policy states that;
4.1.1 Reception Staff will photocopy all available information and pass
it to Induction Staff for use with initial interviews.
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I would go further than this and expect that any concerns are also recorded
such as low mood, unresponsiveness etc. Some ten per cent of self-inflicted
deaths occur within the first 24 hours in custody, and 21 per cent within the
first week. It is important for staff to be aware of all forms of risk and not
merely have regard for those prisoners with active suicidal intent.
It does appear that the man had little personal or meaningful interaction with
anybody, particularly staff.
The report of the most recent inspection of Pentonville by HM Chief Inspector
of Prisons commented that there was no formal expectation for induction staff
to check information contained in the admissions initial information pack. If
staff had been aware of the issues, if risk factors had been recorded in his file
at each stage of the reception process, and if it had then been taken to the
first night centre, they would have been more likely to have attempted to
engage with the man. If someone presents risk factors, the information
should also be written in the handover book on the first night centre so staff
coming on duty are made aware of particular issues relating to specific
prisoners.
On the man’s first night, the prison officer, who was based in security,
contacted the night orderly officer to provide information about prisoners
whose PERs had ticks. This led to the night orderly officer checking on the
man twice during the night. Whilst, I commend these two members of staff,
this information should have been acknowledged by wing staff at the point of
the man’s transfer to the first night centre from reception.
I recommend that any factors relating to a prisoner’s risk should be
noted in his wing file at reception. These issues should also be
recorded in the handover book on the first night centre.
First night and induction
The first night centre gives me some cause for concern.
There are many positive aspects to first night arrangements. A member of
chaplaincy visits daily, as do Listeners (prisoners trained by the Samaritans).
The Listeners are clearly visible as they wear orange t-shirts.
Furthermore, it is pleasing to see that consideration has clearly been given to
improvements following recommendations in previous death in custody
investigations. The staffing levels at night are being increased. It is also
usual to have prisoners share a cell on their first few nights in custody unless
they are considered a risk to other prisoners. The induction programme has
been improved and is under continual assessment.
However, the first night centre is a cold and unwelcoming environment. (I am
conscious that its previous location on E wing was also criticised for being
unfit, and that - given the age and layout of Pentonville – nowhere else
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immediately presents itself.) My investigation team found the cells to be
bleak, and there is no in cell electricity meaning prisoners do not have access
to televisions or radios. Provision has been made for in cell electricity to be
installed, but this is likely to take a year to complete. I particularly regret that
there is no provision for radios, given that prisoners are usually locked in their
cells from 7pm with no other distraction.
The Chief Inspector of Prisons had similar concerns about the first night
centre. The inspectorate found that only 53 per cent of prisoners reported
feeling safe on their first night in prison compared to 70 per cent in other local
prisons.
Ideally, a new first night centre to be built. However, I appreciate this is
unlikely to occur for several years. However, immediate action at low cost can
be taken to improve first night arrangements. For example, duvets can be
used rather than blankets. An effective cell-cleaning programme can be
introduced to ensure that cells are clean when new prisoners enter them. A
light coloured paint can be used on the wing and in the cells, and some
pictures can be put on the walls of the landing.
I recommend the urgent consideration of action to improve the physical
condition of the first night centre and in cell facilities, including
completing the in cell electricity programme as speedily as possible.
Alcohol
Following the man’s death, a post mortem was conducted and toxicology tests
undertaken. The test results took some time to be processed. They indicated
that the man had consumed a large amount of alcohol. This was very out of
character for him. The amount is likely to have caused an effect on his mood.
Another prisoner died two days after him, apparently at his own hand. He too
had consumed alcohol. The investigation team reinterviewed prisoners and
examined security incident reports. Prisoner A said that he did not know how
to get alcohol in Pentonville, or how the man had, and that he had not seen
him consuming any.
There was no indication from the security reports that there is a problem with
the production of alcohol in Pentonville or that any had been found on the first
night centre in the previous 12 months.
Furthermore, there was no evidence of any container in the man’s cell which
may have contained alcohol.
The effect of alcohol had the potential to alter his mood, perhaps making him
feel particularly low.
It is manifestly of concern that alcohol was available to him, particularly as he
had only been in prison for a very short time and was based on the first night
centre. Prison-brewed hooch represents a real threat to health and it is
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important that the Governor investigates the extent of production of alcohol in
Pentonville.
I recommend that the Governor investigates the extent of alcohol
production in Pentonville and establishes a plan to deal with the
findings and to provide continued monitoring.
Potential contact with the father of the man’s alleged victim
The father of the man’s alleged victim was also located on A wing, on the floor
below the man’s floor. The man’s family were understandably concerned of
the potential contact between the two, and what may have been said.
The victim’s father insists he did not know the man was in Pentonville,
although he knew that he had been charged with an offence against his
daughter. The first he knew of him being in Pentonville was when he saw the
notice regarding his death. He then identified himself to wing staff and police
as knowing him. The victim’s father cellmate confirms that he never spoke of
the man who died being in Pentonville until he saw the notices.
The man did not go on association or for outside exercise in his short time at
Pentonville. When meals were served, they go to each landing in turn. It is
possible but not especially likely that the two men could have seen one
another at this point.
During the man’s phone call to his brother he mentioned that his partner’s
father was in Pentonville, but he did not know which wing he was on. This
phone call was made on Saturday afternoon.
Staff were not aware of the relationship between the man and the father of his
alleged victim. Furthermore, the man was asked on his induction if he had
any particular concerns, and he replied “no”.
Crisis Management
When prisoner A woke to find the man hanging he raised the alarm by
pressing the cell bell. This was responded to quickly by the wing officer, who
in turn radioed for urgent assistance. Staff were present in seconds, including
the duty nurse. This is because Pentonville has two nurses on duty at night:
one on the healthcare centre and one situated in the main part of the prison to
enable a quick response to wings.
The duty nurse acted admirably in attempts to resuscitate the man despite the
presence of rigor mortis.
Furthermore, all night staff carry fish knives (to cut ligatures) as standard
issue. I consider this to be good practice.
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Breaking the news to the man’s family
The duty governor broke the news by phoning the man’s grandparents at their
home at 6.40am in the morning. I understand the governor’s reasoning
(making sure the sad news was passed on quickly, and not feeling able to
leave the prison on a Sunday morning when fewer staff were on duty).
However, I remain of the view that it is best practice wherever possible for a
governor to visit in person to break the news.
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Summary of Recommendations
I recommend that Pentonville ensures that training and clinical support is
given for prison doctors. This responsibility extends to doctors employed on a
locum basis, as well as in substantive posts.
I recommend that any factors relating to a prisoner’s risk should be noted in
his wing file at reception. These issues should also be recorded in the
handover book on the first night centre.
I recommend the urgent consideration of action to improve the physical
condition of the first night centre and in cell facilities, including completing the
in cell electricity programme as speedily as possible.
I recommend that the Governor investigates the extent of alcohol production
in Pentonville and establishes a plan to deal with the findings and to provide
continued monitoring.
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