Individual at Pentonville

Investigation into the death in custody of
a man at HMP Pentonville on 10 October 2004
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2005
Contents
SUMMARY
SENIOR INVESTIGATING OFFICER'S REPORT
INVESTIGATION PROCESS/METHODOLOGY
HMP PENTONVILLE
RELEVANT CUSTODIAL INFORMATION
SEQUENCE OF EVENTS – OVERVIEW
LICENCE RECALL AND SENTENCE RECALCULATION
RECEPTION TO PENTONVILLE AND EVENTS LEADING UP TO 10 OCTOBER
THE DISCOVERY OF THE MAN’S DEATH
AFTER THE MAN'S DEATH
NIGHT PROCEDURE GUIDANCE/LOCAL OPERATING PRACTICE
FINDINGS
RECOMMENDATIONS
RECOMMENDATIONS REGARDING STAFF PERFORMANCE
2
This is the report of an investigation into the circumstances surrounding
the death of a man who was found hanged in his cell at HMP Pentonville
on 10 October 2004.
The investigation was conducted under the terms of the transitional
arrangements agreed between my office and the Prison Service, which
came into effect on 1 April 2004. The bulk of the investigative work has
been conducted on my behalf by a Senior Investigation Officer (SIO)
from the Prison Service’s London Area Office. An independent clinical
review was conducted by Islington Primary Care Trust. I am grateful to
all members of the team for their work.
A member of staff from my office liaised with the SIO during this
investigation. I have structured this report so that the SIO’s
investigation can be separately identified.
Two members of my staff visited the man’s sister. I know that they
offered their sympathy and condolences, but I would like to take this
opportunity to add my own sincere condolences to the man’s sister and
friends.
I should record here my thanks to the governing Governor and his staff
for the help the investigators received during the investigation. All staff
co-operated fully and readily with the inquiry.
It appears that the man took his own life, although he had given no
indications that he was considering such a course of action. What was in
his mind can only be guessed at, but it is likely his death followed shortly
after he had learned how long he would have to serve having been
returned to prison for breach of his licence conditions.
There is no doubt that he was in breach of those conditions. However,
his act of sending a very brief letter to his former partner (the mother of
his victim), apparently ending their relationship for good, was scarcely
heinous. It is not comforting that the rigorous enforcement of licence
conditions may have had such a tragic consequence.
STEPHEN SHAW CBE July 2005
PRISONS AND PROBATION OMBUDSMAN
3
SUMMARY
The man had been released from prison in July 2004 having served a
period of nine months in custody. His original sentence had been one of
18 months, with a further four years on extended licence. In October
2004, the man breached one of his licence conditions and that led to him
being re-arrested in the early hours of Wednesday 6 October and taken
into Pentonville later that same day.
There is reason to believe that the man was unaware of what he had
done to trigger his re-arrest, and staff in Pentonville were certainly
unaware of the reasons, until receipt of information that arrived after the
man’s death.
When received at Pentonville, the man was taken through a first
reception health screen by a nurse with a mental health qualification.
The nurse identified no concerns that the man might be at risk of self-
harm or suicide. The man was also seen by a doctor who recorded his
mental condition as stable. The man was initially placed in a single cell in
the prison’s first night centre.
On 7 October, the man declined the offer of an induction interview. He
did not feel he needed this, and it is not unusual for those who had been
in prison before to decline an induction interview.
On Friday 8 October, the man was moved from the first night centre to a
double cell in A-Wing. The man shared that cell with another prisoner for
one night, but the cellmate was moved to another part of the prison on
the morning of 9 October.
When staff in one of Pentonville’s administration units carried out the
man’s sentence recalculation, it resulted in a conditional release date of
19 November 2008. A confirmation slip with this information was sent to
the man through the prison’s internal postal system. It has not proved
possible to trace this confirmation slip, but the indications are that the
man might well have received it on Saturday 9 October. No other
information accompanied the sentence confirmation slip. Information
about the reasons for the man’s recall to prison and about the licence
recall appeal process were included in a ‘representations pack’, issued by
the Prison Service’s Early Release and Recall Section, which arrived in
Pentonville on 11 October, the day after the man died.
When prisoners were unlocked on the morning of Sunday 10 October, the
man was found hanging. Descriptions of his condition when found
suggest that he had been dead for some time.
Although this investigation has not revealed anything to indicate that staff
should have recognised that the man was at possible risk of self-harm, a
4
number of serious omissions have been identified in connection with how
staff carried out their roles and responsibilities on the night of 9 October
and the morning of 10 October. For a substantial period of the night, the
night officer failed to carry out his landing patrols in accordance with
instructions. Nor did the night officer carry out his morning role count in
accordance with instructions. At the time he said he checked the man –
probably some time between 5.45am and 6.30am – the man was almost
certainly dead, yet the night officer saw nothing untoward.
When the night officer was relieved by a day officer at 6.45am, the night
officer said that he had conducted a roll check, that everything was in
order and that it was not necessary for the day officer to conduct her own
roll check. Even though the day officer had not long been trained, and
was aware that she was required to carry out a roll check of her own, she
did not make such a check.
It was not until 9.30am, as prisoners were being unlocked to collect
medication, that staff looked through the man’s cell door hatch and saw
him hanging. The staff panicked. The first officer, on seeing the man,
called a second officer. He looked through the hatch and called a third
officer. The third officer looked through the hatch and, realising that help
was needed, ran to the wing office to make an alarm call. Medical staff
and several senior officers seem to have responded very quickly to the
alarm. In the meantime, the staff who had found the man remained
outside his cell and only unlocked the cell door as assistance arrived.
When the cell was finally entered, there was a further delay in cutting the
ligature from the man’s neck while staff obtained a suitable pair of
scissors – the first pair, described by one member of staff as ‘nail
scissors’, being unsuited to the task.
The likelihood in this case is that the man was already dead at the time of
the night officer’s supposed morning check at between 5.45am and
6.30am. Consequently, the delay in the man being discovered and then
the added delay in the staff response are unlikely to have had an effect
on the outcome. However, in other circumstances, such delays could
have been of paramount importance resulting in a life being needlessly
lost. This is a matter of great concern.
It is also of concern that licence recall prisoners are notified of their
sentence recalculation by being sent a slip of paper via the internal postal
system. Information about the sentence appeals process is not included
with the notification slip. The man’s sentence recalculation gave a
release date of 19 November 2008. This might well have been a surprise
to him, and possibly more difficult to deal with if, as seems likely, he
received the information on Saturday when prison staffing is at a reduced
level.
5
In addition to identifying omissions on the part of individuals, this
investigation has also identified inconsistencies in Pentonville’s night
orders and staff understanding and compliance with those orders. This
report makes recommendations which include a review of the night
orders, the need for staff training, and a change in the manner in which
licence recall prisoners are informed of their sentence recalculation. This
report also recommends that the Prison Service consider undertaking
disciplinary investigations into the actions of two members of staff – the
night patrol officer and the morning relief officer.
6
Senior Investigation Officer’s Report
Investigation Process and Methodology
On 2 November 2004, accompanied by a member of staff from the
Ombudsman’s office, I attended HMP Pentonville and met with members
of the management team. We received a full and in-depth briefing as to
the actions taken by the prison in regard to the incident, post-incident
management, and contacts they had made with the man’s family and
outside agencies such as the Coroner’s Office and police.
I took possession of a large quantity of documentation relating to the
man’s period in prison custody and was able to study these at length. I
later provided the prison’s liaison officer, with a list of additional
documentation which he obtained for me without delay.
I took the opportunity during the visit to plan the investigation strategy,
discuss investigation parameters and agree individual responsibilities. I
visited the scene of the incident and was able to gain a briefing as to A-
Wing’s function and regime. I was later able to speak with staff and
prisoners located on the wing to gauge if there were any underlying
issues relevant to the investigation.
Whilst at the prison, the Ombudsman’s officer and I met with
representatives from both the Prison Officers’ Association (POA) and the
Independent Monitoring Board (IMB) to explain the inquiry process and
how we intended to conduct the investigation. We also explained the
process of disclosure of the resultant Ombudsman’s report and extended
an open invitation to both POA and IMB to meet with us at any time to
discuss issues of concern should they arise.
During the early stages of the inquiry, I contacted the police officer
responsible for investigating the incident on behalf of the Metropolitan
Police and advised him of the Ombudsman’s investigation and the areas
that it would cover. I offered my co-operation and to share any
information which might be of relevance to his inquiry. The liaison
established between police and the inquiry team proved to be very
effective and I hope beneficial to both.
I studied all documentation provided by the establishment and identified
the persons whom I felt would need to interview. During the inquiry, I
have formally interviewed 19 persons and have spoken to a further seven
persons with case notes taken. I have also spoken with a number of
other people within the establishment. However, I considered that they
were unable to contribute information of an evidential value to this
investigation.
7
I would like to thank the management and staff at Pentonville for the co-
operation they provided during the course of the investigation. Additional
thanks are extended to the prison’s liaison officer, a task he fulfilled to an
extremely high standard.
8
HMP Pentonville
Pentonville was built over 150 years ago and has remained in use ever
since as a local prison. Although much refurbishment has taken place,
the original four cellblocks are as they were when the prison opened in
1842.
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. The
establishment also provides special features such as a dyslexia project,
an NVQ painting shop and community work.
Pentonville has a 24-hour healthcare service staffed by a full time senior
medical officer, supporting clinical staff, and nurses. Pentonville has a
hospital wing with 43 in-patient beds.
Pentonville makes use of NHS services to provide acute emergency care,
mental health services, dental treatment, radiology and access to the full
range of specialist services available to the wider public.
Prisoners with a drug problem are identified on reception by healthcare
staff, and by mandatory drug testing. Pentonville is able to provide most
treatments including detoxification. Arrangements can be made to
provide rehabilitation programmes.
The prison has links with outside agencies. For instance, the Probation
Service sits on the drug strategy group, the prison has a group to
represent prisoners' families, and the Rehabilitation of Addicted Prisoners
Trust provides drug rehabilitation programmes. Pentonville is
represented on the Camden and Islington Drug Action Team.
Pentonville accepts all suitable prisoners from courts within its catchment
area of north London. It currently has a certified normal accommodation
of 897 and an operational capacity of 1,205. On the night of 9 October
2004, the prison held some 1,177 prisoners.
In the period immediately preceding the death of the man, the
establishment opened a ‘First Night Centre’ in E-Wing (attached to the
end of A-Wing). The purpose of the unit is to house all newly received
prisoners into the establishment. Prisoners usually remain in this unit
overnight or until processed and then move on to other residential wings,
dependent upon individual needs and categorisation.
The First Night Centre is staffed by officers 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
9
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 their arrival in the prison.
10
Sequence of Events – Overview
Time Line
The following is a list of the significant events during the man’s period in
custody, the discovery of him hanging in his cell, and the events
following that discovery. These events will be covered in greater detail
in the relevant sections of the report.
8 May 2003 Sentenced to 18-months imprisonment
5 July 2004 Released on Extended Licence
1 October Reported breach of Licence
5 October Licence revoked
6 October
2.30am Police arrest and assess the man ‘No Known risk’
1.40pm Received into HMP Pentonville
7.16pm Located to E Wing First Night Centre
8 October
2.58pm Located to A-Wing
The man’s sentence calculated by Inmate
Administration office and sentence advice notice posted
in internal post system
9 October The man’s cellmate relocated because of security status
10 October
6am A-Wing Night Patrol Officer conducted count of wing
with nothing to report
6.45am Night Patrol Officer having been relieved goes off duty
7.30am A-Wing signed as all correct by Officer starting day shift
9.30am Staff unlock cell A5-14 and discover the man suspended
9.35am Alarm raised and medical staff attend scene
9.40am The man is pronounced dead by doctor
9.45hrs Establishment inform Metropolitan Police of incident
9.50am Ambulance and Police attend the prison
10am Staff attempted to obtain next-of-kin telephone but failed
2.14pm Coroner’s Officer arrives at scene
2.18pm The man’s body removed from Pentonville.
The above list is by no means a comprehensive record of all the events
and should not be considered as such. It is provided purely as a guide.
.
11
Licence Recall and Sentence Recalculation
An administrator from Pentonville’s Inmate Administration office
explained that, under the provisions of the Criminal Justice Act 1998, the
courts have powers to extend licence periods in the case of sexual
offences or extremely violent offences. In the man’s case, the custodial
term of his sentence was 18-months, but with a four-year extension of
the licence. As in the case of any person sentenced to 18 months, the
man actually served nine months in custody, but he remained on licence
to an extended licence date of 19 November 2008.
The administrator said that the revocation of licence notice from the Early
Release and Recall Section, in conjunction with the previous sentence
calculation, are used to calculate the new release date. A two-part
computer printout is produced showing the release date. One part is for
the prisoner and is delivered through the prison’s internal post system.
The man’s sentence calculation was completed on 8 October showing the
following information:
Conditional Release Date: 19 November 2008
Home Detention Curfew date: 8 July 2008
Sentence/Licence Expiry Date: 5 April 2009
The earliest date of the man’s release from custody was therefore shown
as 19 November 2008.
An appeal process is built into the recall procedure allowing the prisoner
to put their representations to the Parole Board. The process is explained
in a ‘representations pack’, which also explains the reason for the recall
being activated. Until receipt of the pack, a prisoner would not
necessarily know about the appeals procedure, or even the specific
reason for recall. There can sometimes be delays of two or more weeks
for receipt of these packs, although the man’s pack was received at
Pentonville on 11 October.
The administrator could not confirm when the notification slip would
have been delivered to the man, and it has not proved possible to locate
this form. The administrator suspected that the form might have been
delivered on Saturday 9 October. She had gone into Pentonville on
Sunday 10 October and heard that there had been a death in custody of
a prisoner on an extended licence who had received a notification slip on
Saturday with a release date that he was not expecting.
The procedures and instructions for dealing with Licence Recall prisoners
are governed by Prison Service Order (PSO) 2300 and Prison Service
Instruction (PSI) 6000. These state that within three working days of
notification to the Early Release and Recall Section at Prison Service
Headquarters of a recall prisoner’s return to prison, he/she should
receive a pack explaining reasons for recall and the appeal procedure.
12
Reception to Pentonville and Events Leading up to 10 October
The man was received into Pentonville from police custody at
approximately 1.40pm on Wednesday 6 October. On arrival at
Pentonville, the man was taken through a standard prison reception
process.
The man was interviewed by a reception officer for completion of a Cell
Sharing Risk Assessment. This was to assess the man’s suitability for
sharing accommodation with other prisoners and/or to identify any
individual needs or factors relevant to the type of accommodation
allocated him. At interview, the reception officer described the purpose of
the risk assessment as: ‘To check the inmate’s suitability … to share a
cell, [whether he has] suicidal tendencies, if he’s got any problems, if he’s
on medication’. The reception officer said that, had he noticed any
concerns of this nature, he would have initiated the F2052SH procedure.
However, he did not observe any such signs with the man.
The reception officer’s impression of the man that night was that: ‘He
seemed a bit withdrawn. He seemed a bit confused. When I say
withdrawn … he didn’t portray any suicidal tendencies or he didn’t seem
very disturbed or anything like that, he just seemed a bit confused about
being recalled to prison. I asked him why he had been recalled and he
shrugged his shoulders. I asked when he’d been in prison before did he
have any problems with depression and … he says not. I asked him is he
feeling okay, he says yeh … I made a note for the doctor and there was
nothing out of the ordinary.’
The reception officer confirmed that the man was issued with a reception
pack and given a pin number to allow him to make a telephone call. The
reception officer asked the man whether he wished to be placed on rule
45 due to his original offence, but the man rejected that option (rule 45
provides for the segregation of prisoners who might be vulnerable or who
might pose a threat to prison discipline).
The man underwent a First Reception Health Screen, conducted by a
reception nurse who is a registered general nurse and registered mental
health nurse. At interview, the reception nurse said: ‘The man didn’t
present any sort of debilitating psychiatric problem, he has not presented
any feelings of being agitated, depressed, suicidal, he appears to be calm,
quite settled and all that he wanted was assistance with his irritable
bowel syndrome … I referred him to the doctor so if there was any issue
relating to this man being distressed, disturbed, unstable, low mood, any
form of risk it would have been taken up.’
The reception nurse confirmed that there was no indication of any form of
risk or past self harm incidents recorded on the man’s Prison Escort
Record (PER) or other accompanying documentation. The reception
13
nurse said that he had not observed anything to cause him concern. If
any issues of concern had been identified, a F2052SH (self-harm at risk
form) document would have been opened. There was no need for this in
the man’s case.
The man also saw a reception doctor, during which the reception nurse
remained present. The doctor recorded the man’s mental condition as
stable. The doctor prescribed the man a once only dose of Zopiclone, to
help him sleep. After he had seen the reception doctor, the man was
taken by the reception officer to the First Night Centre.
On 7 October, an induction officer saw the man and gave him an
information pack containing a reception letter, a postage-free letter and a
guide to prison routines and regimes. The induction officer invited the
man to attend a prison induction, comprising a one-to-one interview and
group presentation. The man declined the offer, however, saying that he
was already aware of what would be said. When interviewed for this
investigation, the induction officer said that it was quite common for
prisoners to refuse to attend induction if they had been in prison before.
In accordance with normal procedures, the man remained in the First
Night Centre until the afternoon of 8 October when he was relocated to A-
Wing to help make space for new prisoners to be received into the prison
that day. The man was allocated to cell A5-14 on A-Wing. This was a
double occupancy cell situated on the top landing. Between 6.30pm and
7.30pm that evening, a second prisoner was located into the cell with the
man.
The man’s cellmate confirmed that he shared the cell with the man for
just one night, the night of 8/9 October. They had spoken about their
sentences. The man said that he was a licence recall prisoner, but did
not talk about his sentence or his offences. The man mentioned his
probation officer and that he had contacted him in the recent past. The
cellmate lent the man some tobacco. The cellmate believed that he
eventually went to sleep about midnight. On the morning of Saturday 9
October, the cellmate was taken to the segregation unit, as he was facing
possible re-classification to a category A prisoner. That was the last time
that the cellmate saw the man. The cellmate said that he was shocked to
learn subsequently that the man had taken his life.
No information was recorded in the man’s records in respect of any
interaction between him and staff, or with other prisoners, during the
day, evening and night of Saturday 9 October. The A-Wing roll was
signed at 6pm. As the man was not employed as a cleaner, it is probable
that he would have been locked in his cell at some time prior to the 6pm
roll being taken. He would not have been allowed out of his cell for the
remainder of that night.
14
An undated letter from the man to his sister, postmarked 11 October,
asked her to send him some money and, perhaps more importantly,
comments that he was still unaware of why he had been recalled to
prison. This letter must have been sent between 6 and 9 October for it to
have a postmark of 11 October.
The night officer on night duty in A and E Wings for 9/10 October had
worked in Pentonville for over 12 years. During this time he had
completed many night duty shifts. It was not the practice for the Night
Orderly Officer to brief the night patrol staff at the beginning of a period
of duty, but the night officer did not consider that he needed a briefing
due to his level of experience. In the case of new officers, one of the
more senior officers would go round with them to show them how to carry
out their role.
On 9 October, the night officer arrived at the prison at about 7.40pm.
This was around one hour earlier than the normal start time for a night
shift, but he had agreed to do this to allow the day duty officer to leave
early.
The night officer counted the prisoners in A and E Wings, and this took
approximately 45 minutes. This was the final count required of the Night
Patrol Officers; the next count would not be until 5.45am the following
morning. It was only during formal counts that staff were required to
look into the cells during the night, apart from in the case of increased
observations for prisoners on self-harm monitoring. The man was not
subject to this increased level of observation and the night officer had no
interaction with him that night.
The night officer said at interview that practice at the prison was just to
‘sight’ prisoners during the evening roll count. The night officer was
asked about Pentonville’s orders for night patrol officers, suggesting that
the officer be required to get a response from prisoners. The night officer
said that he had never seen those orders.
After completing the count, the night officer said that his duties were to
then answer all the emergency light bells and to ‘peg out’. (‘Peg out’
refers to a computerised monitoring system requiring staff to press
buttons located on patrol routes within the wings. The system records
time and location of buttons pressed and therefore confirms that patrols
are being carried out).
The night officer was asked at interview about discrepancies in the night
report sheets which show that between 1.55am and 4.58am on the night
of the 9/10 October, no pegging had been completed on either A or E
Wings. Furthermore, there was no explanation in the night report sheet
to account for these omissions. The night officer said: ‘There was quite a
few incidents that night and I was on my own on A and E Wing and
15
usually I’ll have someone else in up there with me but that night we
didn’t have the staff. So I just had so much to do, we were moving
[people] from B and G Wing over to E Wing which was my wing because
there was flooding and Listeners backwards and forwards as well and an
hour of that would have been my lunch hour as well and my tea break.’
On the night of 9/10 October, only one of the cells next to the man’s was
occupied (A5-15). Neither of the prisoners occupying that cell heard
anything untoward during the night.
At 5.45am on 10 October, the night officer started his morning count.
This required him to make a visual observation of every prisoner.
Although it had been dark at the time of the check, the night officer said
that he did not need to use a torch. The sun was rising and there was
enough light to see. He said that he did not recall the man’s cell in
particular, and nothing occurred to cause him to remember it. The night
officer stated that he had not seen the man hanging at the window. Nor
had he seen any ligature.
The night officer said his count had taken 35 to 45 minutes to complete
and he then signed his night report sheet, timing the form at 6am. He
said that all staff normally recorded 6am on the sheets even though the
count was not necessarily carried out at precisely that time.
When the day officer came on duty that morning, the night officer advised
her that she did not need to count the prisoners because he had already
done so. The night officer was present when the day officer signed to
confirm the wing numbers and to take over the area. The night officer
left the prison at 6.45am.
16
The Discovery of the man’s Death
At interview, the day officer said that she had previously been an Officer
Support Grade within the prison’s canteen, and had been employed as a
Prison Officer since June 2004. She had completed her officer training
course and was serving her probationary period. In training she had
been told that it was a requirement, on taking over a wing from another
officer that the on-coming officer should count the prisoners and then
sign to confirm that all were present. She understood that the purpose of
that count was to check that all prisoners were present and that all were
well.
The day officer arrived at the prison at about 6.45am on the morning of
10 October. She had not counted the prisoners on taking over from the
night officer because she trusted him, as an experienced officer, when he
said that he had completed a count and it was not necessary for her to
make her own count. Since starting work on A-Wing, the day officer had
found that the practice was for day staff to trust the statement made by
the night officer that all was fine and not to carry out their own check.
At about 9.30am, the day officer, working with colleagues, began to
unlock cells for prisoners to collect medication. When the day officer
opened the observation flap on the man’s door she saw him by the
window and realised he was hanging. She could see the ligature. She
called to a second day officer who was close by. The second day officer
looked through the observation flap and then called to the third day
officer to help and to raise the alarm. The day officer played no further
part in dealing with the incident, instead began to lock prisoners back into
their cells.
The second day officer said that the day officer was at the cell ahead of
him when she called his name. The second day officer opened the
observation flap of the man’s cell door and saw him hanging from a
ligature at the window. The second day officer was certain that the man
was dead. The second day officer called to the third day officer.
Although the second day officer was carrying a radio, the third day officer
went to the wing office to call for assistance from there.
The second day officer acknowledged that he panicked. He did not enter
the man’s cell, but waited for several minutes until other staff arrived.
When support arrived, the second day officer unlocked the man’s cell
door and then rushed to the wing office to collect scissors and a chair to
help free the man from the ligature. The second day officer said that
staff do not carry anti-ligature knives or scissors as part of their standard
equipment.
The third day officer confirmed what the other day officers had stated.
He was called by the second day officer and saw that a prisoner was
17
hanging with a bed sheet around his neck that appeared to be tied to the
window. The prisoner seemed to be lifeless. The third day officer ran to
the wing office to telephone the emergency prison number, as this would
get the quickest response. Help arrived within a few minutes.
After making the call, the third day officer concentrated on ensuring that
prisoners were locked back into their cells and the landing kept clear for
the medical staff. The third day officer said that his first thought was to
obtain medical assistance, rather than to enter the man’s cell with a view
to giving medical assistance himself.
The fourth day officer was the first member of staff to arrive on the scene
in response to the alarm call. The fourth day officer looked through the
cell door observation flap and saw the man hanging by a ligature that was
clearly visible. The second day officer unlocked the cell door. As the
fourth day officer entered the cell, senior staff arrived, took charge of the
scene, and instructed the fourth day officer to help clear the landing.
Two senior officers were together when they heard the alarm call from A5
landing. They responded immediately and entered the man’s cell. While
the first senior officer took over the wing telling prisoners to get behind
their doors, the second the second senior officer cut the ligature from the
man, assisted by the principal officer. The principal officer said that he
could see the ligature attached to the window as he entered the cell.
There was some initial difficulty in cutting the ligature because the first
scissors brought were ‘tiny nail scissors’. Someone then brought the
correct scissors and the ligature was cut through.
A staff nurse arrived at that moment and assisted in lying the man onto
the floor. The staff nurse said that this had been quite difficult, as rigor
mortis had set in. As soon as the man had been laid down, the duty
doctor arrived. The duty doctor examined the man and recorded that his
face was cyanosed (blue in colour), that his neck and body were stiff and
cold, that he had no pulse or heart sounds, and that he was not
breathing. The duty doctor pronounced the man to be dead. This record
was timed at 9.40am.
18
After the man’s death
The governor in charge of the prison that day opened the Command Suite
and followed the establishment’s Contingency Orders for dealing with
deaths in custody.
The man’s cell was sealed and evidence preservation procedures were
initiated. An activity log was opened without delay.
All relevant outside agencies and departments: the police, Coroner,
Prison Service National Operations Unit, Samaritans and IMB, were
contacted.
At 2pm, the governor in charge held a hot debrief for all staff involved in
the incident. He later held a second debrief in the prison chapel to advise
all establishment staff of the incident and of what action had been taken.
Staff involved were requested to write statements and incident reports
about their actions.
On call support staff were called in to Pentonville to provide ongoing
assistance to both staff and prisoners who might have been affected by
the events.
Initial attempts to contact the man’s family were unsuccessful. Contact
was eventually made, later on 10 October by the governor in charge.
However, he discovered that the family had already been visited by the
police and told of the man’s death.
Staff from Pentonville maintained close contact with the man’s sister
thereafter and she, accompanied by her family, visited the prison on 12
October. The man’s sister met the prison’s governing Governor and was
shown the cell in which her brother had died. She was accompanied to
the cell by a Church of England chaplain who said a prayer for the man.
At the request of the family, the chaplain conducted the man’s funeral
service on 20 October. The governor in charge also attended the service.
Further contact with the family was made to answer questions about the
circumstances surrounding the man’s death and to assist with funeral
expenditure.
19
Night Procedure Guidance/Local Operating Practice guidance and
actual practice at weekends.
I spoke with a senior officer and a principal officer about actual operating
practices compared to Pentonville’s procedural guidance.
I was told that practice for many years has been for staff to disregard the
instruction in the night patrol officer’s job description that they should
obtain a response from prisoners when carrying out the morning count.
The principal officer said that waking 1200 prisoners at 5am or 6am was
not practical and would cause disruption.
Day staff officially start work at 8am, but are allowed to take over from
the night staff as early as they want – day staff will often arrive early to
relieve the night staff, who reciprocate by arriving early the following
evening to relieve the day staff. Although the night guidance orders state
that a roll call should be carried out by day staff at 7.30am, this is not
feasible because, technically, no day staff are on duty at that time. In
practice, the roll call is carried out over a period as day staff arrive.
Again, practice for many years has been for the night staff to leave the
prison once relieved by the day staff – night staff are not held back while
the day staff carry out their count. This practice accorded with a
Governor’s Order issued on 1 May 2003, although the local operating
practice instruction issued in February 2004 made it clear that night staff
should not leave the prison until day staff had completed their count.
I found the normal practice at weekends was for one night patrol officer
to cover both A and E Wings, although Pentonville’s local operating
practice instructions state that one officer should be deployed on A-Wing
and a second officer deployed onto E-Wing.
20
Findings
Discharge from HMP Littlehey
On discharge from Littlehey in July 2004, the man was given a copy of
the licence showing the conditions that had been imposed. While in
custody, and at the time of discharge, he would have had the opportunity
to seek clarification of these conditions and the extended licence
procedure.
The letter that the man wrote to his ex-partner amounted to some three
lines of a non-threatening nature. It could even be viewed as a final
farewell letter, when it ends in ‘Goodbye’.
It does not appear that the man was approached by his Supervising
Officer and asked for an explanation for his actions. However, regardless
of its contents, sending the letter constituted a breach in the man’s
licence conditions and as such was grounds to revoke his licence. Once
the man’s licence had been revoked, the degree of the breach would be
open to scrutiny at any subsequent appeal hearing.
The nature of the breach was not recorded on the order to revoke the
licence. This led to confusion, possibly for the man, but certainly for the
police responsible for carrying out the arrest and also for Pentonville upon
receiving the man.
Wednesday 6 October
The man was received into Pentonville on Wednesday 6 October. He
received a health-screening interview during which no issues of concern
were identified with regard to his mental health by any of the personnel
who saw him.
The man had a Cell Sharing Risk Assessment and was confirmed as
presenting no reason why he should not be located with other prisoners.
Due to the nature of his original offence, the man was given the
opportunity to request removal from normal location, but he declined this
offer.
I am of the opinion that the prison reception process was conducted
properly.
Thursday 7 October
I am satisfied that the man was offered a full prisoner induction package
and interview, but chose not to become involved. Had he engaged in the
process, this would have provided him a further opportunity to raise any
concerns he might have had regarding his return to custody, the licence
revocation procedure, and appeals process.
21
Friday 8 October
In accordance with Pentonville’s induction procedures, the man was
relocated to A-Wing on the afternoon of Friday 8 October to facilitate
space for new receptions to the prison.
The man was located to a double occupancy cell on A5 landing and was
joined by a second prisoner that evening. There is no evidence that there
were any problems between the two individuals. Indeed, it seems the
two spoke at length during the period that followed, during which time
the man told his cellmate that he was unaware of why he had been
returned to prison. (It might of course be that he did not wish to mention
the nature of his original offence.)
Staff in Pentonville’s Inmate Administration office calculated the man’s
release and sentence expiry dates based on information received from
Littlehey. A notification form showing these dates was despatched to the
man through the prison’s internal post system.
The man’s reception pack had still not arrived at this point, so staff at
Pentonville were probably unaware why he had been recalled to custody.
No information explaining the licence recall process is given on a
prisoner’s return to custody, nor when the prisoner is issued his new
sentence calculation dates. This information is supplied in the
‘representations pack’, but there can often be a substantial delay in
receipt of this pack.
Saturday 9 October
The man’s cellmate was relocated during the Saturday morning as a
result of his potential heightened security status. The man remained in
the cell on his own. The man presented with no self-harm or mental
health concerns, and the fact that he remained in the cell on his own for
the rest of that day was normal practice.
Although I have been unable to verify that the man received his sentence
calculation notification, I am confident that he would have received this
sometime during either the morning or afternoon of Saturday 9 October.
The method of delivery of this information could be viewed as being
somewhat insensitive or impersonal. However, given the high volume of
prisoner movements on and off of the wing and the officer/prisoner ratio,
it is understandable why the current procedure is followed.
I have found no evidence that the man raised any concerns with staff
regarding his sentence calculation.
22
Night Procedure Guidance Notes and Operating Practices
I have great concerns that establishment orders are in place, which:
• appear not to be read or complied with by managers and staff alike.
• set out a regulated and documented handover system, but which
again are not followed by managers and staff who, at best, follow a
fragmented version of the system.
• do not take account of shift attendance times at weekends – night
duty staff finish at 7.45am, day staff commence their shifts at 8am.
• are unrealistic of what is required of an officer – does the Governor
really want staff to wake prisoners at 6.15am on Saturday and
Sunday? Staff are clearly unsure as to what is required.
I am further concerned that there appears to be no formal briefing by
night managers when staff commence their shift and that no record is
kept to confirm that staff have read and understood their orders.
I am also concerned that it would appear that, instead of providing staff
with these written orders, the routines are simply passed from one officer
to another. The likelihood that bad habits or omissions in duty will also be
passed on at these times is apparent.
Night of 9/10 October
Pentonville’s night orders state that there should be one patrol officer for
A-Wing and one patrol officer for E-Wing. In practice, this has never
been the case and only one officer is normally supplied to patrol both
wings. I am advised that, when the First Night Centre was created on E-
Wing, this new function was not re-profiled to identify if any extra staffing
was needed for night duty.
The night officer, the patrol officer on duty in A-Wing on the night of 9/10
October, said that he had been busy that night and that was why there
was a gap in pegging of some three hours between 1.55am and 4.58am.
The night officer’s statement is not reflected in his night patrol report that
only records four, timed, Night Orderly Officer visits and a non-timed
entry about two prisoners being moved between wings due to flooding in
a cell. The night officer recorded that this latter incident caused him to
miss the ‘peg’ at 1.30am, but he made no record to explain why pegging
from 1.55am to 4.58am had been missed – night patrol officers
instructions require them to record all events and to record the reason for
missing pegging.
23
There remains no explanation as to why the officer failed to peg and this
must raise doubts as to whether patrolling was actually taking place.
The Morning Count
The night officer stated that he commenced his morning count at 5.45am.
He also said that this count took him between 30 to 45 minutes to
complete. The night officer said that he would have observed every
prisoner and that he was able to see in the cells using the available
natural light. The sun would have risen at 7.15am that morning. Many
of the staff who attended the incident at 9.30am advised that, as they
looked through the cell door, they were able to see the ligature from
which the man was suspended. When found, the man was cold and rigor
mortis had already set in. The condition that the man presented when
found would tend to indicate that he had been dead at the time of the
night officer’s check.
I am therefore surprised that the night officer did not discover the man
during his morning check of A-Wing. Whilst I am not suggesting that this
would have prevented the man’s death, I have doubts as to the
effectiveness of this count or indeed whether this check was ever carried
out. This is compounded by the fact that the night officer signed and
timed his Report of Night Patrol at 6am, when it must have been
completed later than that, as he acknowledged. His statement
suggesting others routinely timed their reports at 6am was not supported
when these other reports were studied. Many contained different timings.
Handover from Night to Day Staff
There are clear directions contained within the establishment’s night
orders as to how staff should hand/take over duty in the mornings.
Unfortunately, these orders do not seem either to have been read or
complied with on this occasion.
Day staff seem to drift into the establishment as they deem fit and this
has the undesirable effect that night staff tend to go off duty at different
times. In terms of management of the handover, this must prove
extremely difficult and, in the event of an incident occurring or being
discovered, almost impossible to manage effectively.
The day officer was not due to start her shift until 8am on 10 October,
but had come in early to relieve the night officer. She had not been
tasked to relieve the night officer that morning, in fact no officer had
been allocated that duty. Although the day officer had received training,
she was probably not confident of what was required of her that morning
as she had never previously taken over duty from a night officer.
24
The fact that the night officer had stated that he had just completed a
count of the wing should have made no difference to her. She had been
made fully aware during her training of what was required of her when
taking over a prison wing. She knew that signing the wing number
record signified that a count had been completed and that she had
accounted for all prisoners in her area. Her statement that no officer in
her experience carried out a count in the morning is not a valid excuse for
failing to do so.
I am of the opinion that, even if these counts had been completed in
accordance with requirements, the man’s life would not have been saved.
However, he would and should have been found earlier than he was.
The Incident
A-Wing followed its normal regime for Sunday morning and staff started
unlocking prisoners for them to collect medication. The day officer looked
through the observation panel of the man’s cell door and saw him
hanging. Instead of immediately raising the alarm, she called to her
colleague, the second day officer. He looked into the cell and called to
the third day officer. The third day officer attended, looked into the cell,
and raised the alarm by calling the emergency number from the
telephone in the landing office.
None of the day officers entered the cell until the arrival of a responding
Senior Officer. Upon his arrival, the second day officer unlocked the cell
door whereupon the fourth day officer, closely followed by the Senior
Officers, entered the cell. What is of serious concern is that no one up to
this point entered the cell to examine the man to ascertain whether he
was still alive.
PSO2710 advises all staff that, on discovery of a person hanging, they
should enter the cell, cut the prisoner from the ligature, check for signs of
life and, if the prisoner is not breathing and has no pulse, attempt
resuscitation unless rigor mortis has clearly set in.
I accept that the man was already dead. Had this not have been the
case, staff’s failure to respond as per PSO2710 might have caused a
decisive delay in the chances of saving him.
When the cell was entered, a further delay occurred in cutting the man
free of the ligature while staff obtained a suitable cutting implement. The
man’s body was, however, supported while this was happening.
Once the alarm was raised, all appropriate staff, including emergency
medical staff, responded extremely quickly and on arrival followed correct
procedures in dealing with a prisoner found hanging from a ligature. The
duty doctor arrived promptly and confirmed that CPR was unnecessary.
25
Management of the Scene
The incident scene was effectively managed and the requirements of both
Prison Service Orders and preservation of evidence were fully followed.
Immediate Action Taken by Establishment
The governor in charge for the day and the duty governor attended the
scene and, having completed an assessment, correctly withdrew to open
the establishment’s Command Suite and initiate the prison’s Contingency
Plan for Deaths in Custody. A Command Suite log was maintained
throughout the incident.
Management and staff effectively followed these plans. A staff hot debrief
was held, Staff Care and Welfare facilities were provided, reviews were
carried out on prisoners subject to F2052SH monitoring and liaison was
effected with all relevant outside agencies.
Contact was made with the man’s family, and this contact was maintained
including an offer for the family to visit the prison and assistance offered
with funeral expenses.
Level of Compliance with Authorised Procedures
Pentonville has an effective suicide prevention policy and team. The
F2052SH system is well managed and effectively administered. The
Suicide Prevention Policy and Anti-Bullying documentation and systems
fully comply with the requirements of national policy. I have no concerns
in respect of these policies. However it is apparent that these policy
documents are not fully understood by all staff.
Pentonville’s contingency orders covering deaths in custody were found to
be effective and correctly applied by the establishment.
I found that the emergency medical response procedure in place within
the prison was of a particularly high standard. All staff I spoke to were
fully aware of the system and how to initiate it. I found it to be fast and
effective and am confident that, when deployed correctly, it would be able
to effectively deal with most medical situations.
Maintenance Issues
I carried out a check of the man’s cell call bell and found that it was
faulty. When the call button was pushed, the light outside the cell
illuminated, as did all lights on the main alarm panel on A1 landing.
However the audible alarm failed to sound. Although there is no
suggestion that this had any bearing in this case, it is of concern that,
had the man wished to speak with someone, he might have had difficulty
in attempting to alert staff.
26
Local Recommendations
The Governor should consider introducing anti-ligature knives as a
standard piece of equipment to be carried by all staff who might be first
on scene when a hanging is discovered.
The Governor should commission a review of the establishment’s Night
Orders to address the issues raised by this report in respect of
compliance, training, briefing, roll checks, reporting procedures, handover
systems and the discrepancy within staff shift timings at weekends.
The establishment should produce an information sheet, to be given to
prisoners subject to licence recall at the point of their reception, to
explain the system and the appeals procedure. In addition, the
establishment’s induction process should be reviewed to include this
information for prisoners to whom it applies.
The Governor should commission a review of the system used in advising
prisoners of their sentence calculation with a view to implementing a
system which not only provides privacy, but also offers support to the
individual should they require it.
The Governor should commission a review of the A-Wing cell bell system
and of the checks used to ensure the system is working. The current
system of reliance on cell fabric checks is not sufficient as in this case it
failed to identify the problem.
The Governor should commission a training needs review of his staff in
respect of:
• First aid training.
• First at the scene of a serious incident.
• Night duty – staff responsibilities.
• Suicide prevention – policy awareness.
• Anti-bullying – policy awareness.
27
Recommendations Regarding Staff Performance
The Governor should consider commissioning a disciplinary investigation
into the actions and conduct of the night officer to address:
• Why there was a three hour gap in pegging on the night of 9/10
October without explanation on his Night Report sheet;
• Why he recorded that he completed a wing count at 6am when his
count, by his own admission, was not completed at that time;
• Why he advised the day officer that she did not need to conduct a
wing count that morning.
The Governor should consider commissioning a disciplinary investigation
into the actions and conduct of the day officer to address:
• Why she did not conduct a wing count on the morning of 10
October, which she was aware she was required to do;
• Why she made a false declaration in signing the centre numbers
sheet to confirm that she had completed the count and that all
prisoners had been accounted for.
Prison Service Comments on Recommendations Regarding Staff
Performance
In its response to the Ombudsman’s draft report dated 27 June 2005, the
Prison Service stated that disciplinary investigations against the two
above named members of staff had been initiated in January 2005.
Those investigations, along with subsequent follow-up action, have now
been completed.
28