Individual at Pentonville

INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING
THE DEATH OF A MAN AT
HMP PENTONVILLE ON 25 JUNE 2004
Report by the Prisons and Probation Ombudsman for England and Wales
March 2005
CONTENTS
Summary
Report by Senior Investigating Officer
2
This is the report of an investigation into the circumstances surrounding the death of a man at
HMP Pentonville in June 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 the senior investigating officer, from
London Area Office. A clinical review was conducted by the Section Head, Substance Misuse
Team from Prison Health. I am very grateful to all members of the team for their meticulous
work.
I have structured this report so that the senior investigating officer’s investigation can be
separately identified.
A colleague from my office liaised with the senior investigating officer throughout this
investigation and visited HMP Pentonville when the investigation commenced. My investigator
also contacted the man’s sister and informed her about the investigation. The man’s sister had
no specific questions about her brother's death. I would like to offer my condolences to the
man’s sister and to his family and friends.
The man’s death was the first self-inflicted death at Pentonville prison since the Ombudsman
was passed responsibility for the investigation of deaths in custody. Sadly, two more prisoners
died in October 2004. The reports into those deaths will include an overview of all three deaths
to see if any lessons can be drawn to try to prevent similar tragedies in the future.
Unfortunately, the man’s story is not an uncommon one amongst those who appear to have
taken their own lives in prison. He was familiar with prison and familiar with staff at Pentonville.
The man had a long history of poly drug and alcohol abuse. It seems he often had hopes of
putting his life back on track but found this task incredibly difficult and returned to drug and
alcohol abuse. It may be worth noting that one of the drugs he used was Crack cocaine, the
withdrawal from which can induce short, sudden periods of deep depression. He was probably
suffering withdrawal symptoms from alcohol and tobacco too. The man died on his first night in
prison custody.
The senior investigating officer from the London Area Office places particular emphasis upon
the staffing on Pentonville's first night centre. However, he judges that the allocation of the man
to a cell where he was the only occupant and the use of the police to inform relatives of his
death were appropriate. I take a somewhat different view of the matter. In particular, I am
disappointed that a prisoner coming off drugs should have been placed in a cell alone, with
neither a radio nor television. It is good practice for prisoners on first night centres to have
access to a television in their cell. It may aid distraction from their anxieties and provide
entertainment during this period when some prisoners are particularly vulnerable. Where it is
not possible for cells to have televisions, a radio should always be provided.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN
JANUARY 2005
3
Summary
This is the report of an investigation into the death of a man at HMP Pentonville in June 2004.
The man had spent one night in police custody before receiving a sentence of three months
and being taken to Pentonville prison. On the Prisoner Escort Record (PER), he was identified
as being at risk of suicide or self-harm. This was given consideration by the reception nurse but
he was not put onto a F2052SH (a mechanism to care and monitor those who are considered at
risk of suicide or self harm). The nurse who screened him said that he expressed no suicidal
thoughts to her and that, because she knew him from previous periods in custody (and he had
never been on a F2052SH), she did not feel that extra monitoring was necessary.
During the reception process, the man was identified as a poly drug abuser and as suffering
from Deep Vein Thrombosis in both legs. The nurse referred him to the Doctor who assessed
him as needing a detoxification programme and provided him with some medication to help him
through the night.
The man was located on the first night centre. It is best practice to locate people detoxing from
drugs in a shared cell with another prisoner, risk assessment allowing. In his case, the cell
sharing risk assessment did not highlight any concerns, and he was allocated to a double cell. It
just so happened that no other newly received prisoner was allocated the same cell that
evening and so he was on his own.
Different staff interacted with the man during the evening of the 24 June, some of whom were
familiar with him. Staff reported that there was no indication that he might be thinking of taking
his own life. An officer on the first night centre was not concerned about him and said that he
had been watching the football with other prisoners. The man had appeared happy and
cheerful and was having a joke with the others. He seemed unconcerned that he had no cell
mate on that first evening and said it would mean he could get “a decent night’s kip now”.
At approximately 5.35am on 25 June, the man was found hanging in his cell. Staff acted quickly
and appropriately in attempts to resuscitate him. Paramedics were at the prison within a very
short time but they were unable to save his life.
The senior investigator's report makes five recommendations. One of the recommendations
concerns the staff complement on the first night centre. The clinical review from the clinical
reviewer concluded that given the man’s drug and alcohol addiction, he should have been
located somewhere that benefited from enhanced staff supervision. It is clear that the first night
centre is not staffed to facilitate this higher level of supervision. The staffing levels at night
should be reviewed if prisoners with complex medical needs are to be located there rather than
in the Healthcare Centre.
4
Senior Investigating Officer's report,
London Area Office
5
Introduction
A.1 On the authority of Mr Stephen Shaw, the Prisons and Probation Ombudsman, an
investigation has been conducted into the tragic death of a prisoner at HMP Pentonville.
A.2 The man was found suspended in his cell by a ligature during the prison's morning count
of 25 June 2004. He failed to respond to resuscitation techniques carried out by staff and
was subsequently pronounced dead by attending ambulance personnel.
A.3 A Lead Investigating Officer tasked to coordinate the investigation on behalf of the
Ombudsman’s office and a Governor from the HM Prison Service London Area
Manager's Office was tasked to carry out the investigation.
A.4 The investigating team would like to thank the Management and Staff of HMP Pentonville
for the co-operation they provided during the course of the investigation. Additional
thanks are extended to the Principal Officer for the assistance he provided to the team
whilst acting as their Establishment Liaison Officer.
A.5 The inquiry team would also wish to extend their thanks to the staff of the Home Office
Typing Centre, Queen Anne’s Gate, London for the service they provided in the
transcribing of all interview tapes.
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INDEX
A. Introduction
Main Report
B. Investigation Process / Methodology
C. HMP Pentonville
D. Sequence of Events – Overview
Reception to HMP Pentonville on 24 June 2004
The Discovery of the Man’s Death and Action Taken
Establishment: Incident / Post Incident Action
C. Findings
Reception to HMP Pentonville on 24 June 2004
Discovery of the Man’s Death and Action Taken
Establishment: Incident / Post Incident Action
Contact with the Man’s Family
D. Level of Compliance with Authorised Procedures
E. Conclusions
Reception to HMP Pentonville - 24 June 2004
The Discovery of the Man’s Death and Action Taken
Establishment: Incident / Post Incident Action
Contact with the Man’s Family
Medical Reviews
Other Issues
F. Recommendations
G. Examples of Good Practice
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. Investigation Process / Methodology
B1 On 29 June 2004, upon receipt of the Terms of Reference I attended HMP Pentonville
and met with the duty governor on the incident day and with a governor who acts as the
establishment family liaison officer. I received a full and in-depth briefing as to the
incident and actions taken by the prison in regards to the after incident management, the
liaison established with the man’s family and of the contacts made with other outside
agencies, (Coroner, Police etc.). I provided the establishment with a list of requirements
and arranged a further meeting when the investigator from the Ombudsman Office could
be present.
B2 On 7 July 2004, accompanied by the Ombudsman Office investigator, I again attended
HMP Pentonville and was able to meet with the principal officer, the team's allocated
establishment liaison officer. The Ombudsman investigator was fully briefed and we
received an update as to the current situation regarding contact with the man’s family.
B3 Whilst at the prison we took the opportunity to meet with representatives from the Prison
Officer's Association and the Independent Monitoring Board. We advised how the
investigation would be conducted and the process of disclosure of the resultant report.
The meeting was concluded with the team extending an open invitation to both offices to
meet with the inquiry team at any time to discuss issues of concern, should they arise.
B4 The Ombudsman investigator and myself took the opportunity during the course of our
visit to plan the investigation strategy, discuss investigation parameters and team
member’s responsibilities. We took possession of a large quantity of documentation from
the principal officer relating to the man’s period in custody within HMP Pentonville and
were able to study these at length.
B5 We visited the scene of the man’s death and were able to gain a briefing as to the area's
function and regime. I was later able to speak with staff and prisoners located within the
wing to gauge if there were any underlying issues relevant to the investigation. There
were none identified.
B6 During the early stages of the inquiry I contacted the Police Officer responsible for
investigating the death on behalf of the Metropolitan Police. We were able to discuss
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areas of mutual concern and agreed on a protocol for co-operation, which we both found
to be extremely useful. The liaison established between Police and the inquiry team
proved to be very effective and I hope beneficial to both offices.
B7 In order to determine the level of medical care received by the man during his period of
custody in the prison, the Ombudsman investigator contacted the Section Head
(Substance Misuse) from the Prison Health Team and requested he conduct a review of
the man’s Inmate Medical Record. His findings have been incorporated into this
report at section F.
B8 I studied all documentation obtained and identified who I would need to interview in order
to gain the facts of this case. I have formally interviewed ten members of prison staff,
with seven further persons having been spoken to and case notes recorded. During the
investigation process I spoke with many other persons within the establishment.
However, I have considered that these persons were unable to contribute information of
evidential value to the investigation.
9
HMP Pentonville
C7 HMP Pentonville was the prototype for a radical design by Major Jebb - after whom the
avenue on which Brixton Prison stands was named. Pentonville was completed 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.
C8 The prison's regime includes education (full time / part time and evening classes),
workshops, training courses and works department. Offending behaviour groups e.g.
enhanced thinking skills are available. The establishment also provides special features
such as a dyslexia project, an NVQ painting shop and community work by the PE
department.
C9 HMP Pentonville has a 24-hour healthcare service supported by a full time senior
medical officer, supporting clinical staff, and nurses. Pentonville provides hospital
officers, healthcare administrative staff and a pharmacy. The establishment has a
Hospital Wing and provides 43 in-patient beds.
C10 Pentonville makes use of NHS services to provide acute emergency general care, mental
health services, dental treatment, radiology and access to the full range of specialist
services available to the wider public.
C11 Prisoners with a drug problem are identified on reception by health care staff, and by
mandatory drug testing. Pentonville is able to provide most treatments needed including
detoxification. Arrangements can be made to provide rehabilitation programmes.
C12 The prison has links with various outside agencies e.g. the probation service sits on the
drug strategy group, there is a group which represents prisoners' families, and the
Rehabilitation of Addicted Prisoners Trust provides drug rehabilitation programmes. The
establishment is represented on the Camden and Islington Drug Action Team.
C13 HMP Pentonville is a local prison, which accepts all suitable prisoners from courts within
its catchment area (North London). It currently has a CNA of 897 and an Op Cap of
1205. On the night of 24 June 2004 the prison housed some 1138 prisoners.
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C14 In the period immediately preceding the incident under report the establishment opened
a ‘First Night Centre’ in E Wing (Attached to end of A Wing). The purpose of the unit was
to house all newly received prisoners into the establishment in order that resources could
be focused and all prisoners’ needs addressed at the point of first reception to the prison.
Prisoners would remain on this unit overnight or until processed and then move on to
other residential wings throughout the establishment, dependent upon individual needs /
categorisation.
C15 The First Night Centre is staffed by a dedicated 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.
C16 On the evening of 24 June 2004, twenty new prisoners were received into the
establishment and subsequently accommodated in the First Night Centre.
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Sequence of Events - Overview
Reception to HMP Pentonville - 24 June 2004
D4 The man was received into HMP Pentonville on 24 June 2004 from the Magistrates Court
convicted and sentenced to three months imprisonment.
D5 After undergoing the reception process he was located onto the First Night Centre where
his induction procedure continued.
D6 The man received a First Reception Health Screening interview conducted by a member
of the establishment’s Healthcare staff and was identified as having a drug dependency
and of suffering from Deep Vein Thrombosis in both legs. He was subsequently referred
to the on duty doctor for further examination.
D7 On completion of his examination by the doctor, the man was interviewed for his Cell
Risk Assessment and given the opportunity to make a telephone call, have a shower and
receive his first night in custody pack.
D8 The man’s cell risk assessment did not raise any issues of concern and so he was
allocated to E4.01, which although a double cell, was not occupied by any other prisoner
at that time. He was the only prisoner allocated to and resident on E4 landing that night.
The discovery of the man suspended and action taken
D9 At approximately 05.35 on 25 June, in accordance with the prisons normal night duty
procedures, the officer responsible for patrolling that area undertook a security count of E
Wing.
D10 Whilst checking the man’s cell he observed him suspended by a ligature made from bed
sheets attached to the cell window. The officer immediately raised the alarm and called
for assistance.
D11 The establishment emergency response procedures were activated and the orderly
officer together with other patrol staff from other wings attended the scene. In
accordance with the emergency response procedures, nursing staff from the prison
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hospital wing attended the scene with emergency medical equipment and proceeded to
carry out resuscitation techniques.
D12 A request was made to the London Ambulance Service to attend the prison and within a
very short time a fast response unit and then ambulance arrived at the establishment.
On their arrival the paramedic personnel were escorted to the scene and took over the
medical treatment being administered to the man.
D13 After continuing CPR for a short period the ambulance crew assessed the man’s
condition and decided that treatment should be discontinued, and he was pronounced
dead. Ambulance staff are recorded as having left the establishment at 06.21, 25 June.
D14 At 07.07 that same day the prison's doctor attended E4-01 and confirmed the earlier
assessment made by ambulance staff that the man had died.
Immediate action taken by the establishment
D15 The management at Pentonville implemented the Prison’s Contingency Orders and
informed all relevant offices / agencies of the incident.
D16 Staff involved in finding and attempting to resuscitate the man received a hot-debrief and
were requested to record statements / Incident Reports of their actions.
D17 The cell was sealed and evidence preservation procedures initiated.
D18 The establishment made contact with the man’s family to advise them of the tragedy and
appointed a senior manager as the family liaison officer.
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E Findings
Events leading to the discovery of the man who died
Reception to HMP Pentonville - 24 June 2004
E1 I interviewed a Prison Service nurse who advised that her main place of duty was in the
Prisoner Reception department of HMP Pentonville. She is a trained general nurse and
had worked in this area for the previous three years.
E2 The reception nurse explained that the process of receiving new prisoners into the prison
had changed recently with the formation of a ‘First Night Centre’ (FNC) within E Wing.
Prisoners were now received into the prison's reception area from the Court Escort
Service and after Court documentation had been checked and prison records raised,
they were taken to the FNC for further processing.
E3 On arrival at this location prisoners were allowed to attend to their ‘domestic’ issues such
as making telephone calls, taking a shower and then allocation to a cell. The reception
nurse further advised that, during this period, every prisoner received a medical
screening from a Healthcare worker and would be seen by the doctor.
E4 I asked her if she had been on duty on the night of the 24 June, when the man had come
into the prison. She confirmed that she had and also that she had conducted the ‘First
Reception Health Screen’ for him.
E5 She continued by saying that she had known him from previous periods of custody at
HMP Pentonville. The man had approached her and requested that he be allowed to
watch the football match being shown on television that evening. She had agreed to this
request and subsequently screened all other prisoners before finally attending to him.
E6 During her health screen of him that evening, the man had identified that he had a drug
dependency and an ongoing problem of Deep Vein Thrombosis (DVT) in both legs. Due
to these complaints the nurse referred him to the doctor.
E7 I asked the nurse if she had seen the Prisoner Escort Record form for him on which it
had been recorded there had been a marker on his record that he had previously been
suicidal. The nurse confirmed that she had seen the form and added that it would have
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been a part of her duty to screen these forms. In addition to this she would have spoken
to the prisoner during screening to ascertain if he was suicidal.
E8 The reception nurse stated that having spoken with the man that evening he expressed
no suicidal thoughts or ideations to her. She had known him from previous periods of
custody and recalled that he had never been the subject of F2052SH monitoring. She
had no concerns and stated that had she had such concerns she would have passed
these on to the doctor for him to address when he saw the man.
E9 I interviewed the prison’s doctor, who is a registered medical practitioner who has worked
at HMP Pentonville since 1998. He explained that he had been the duty doctor on the
evening of 24 June and had examined the man after the reception nurse had screened
him.
E10 The doctor recalled that he had been finishing an entry in another prisoner’s medical
record when the man had entered the examining room. He had asked him to sit down
and on completion of making the entry engaged him in conversation. He went through
his normal questioning of the patient and recalled that he had known the man from his
previous sentence.
E11 The man explained that he had been suffering from DVT and that he had been on
medication for this complaint, which he had last taken some five days previously. The
doctor advised him that the prison pharmacy was currently closed and that this dosage
needed to be confirmed with his medical records at his prescribing hospital the following
day. The man accepted this and the doctor advised that he noted from his response that
he appeared to be aware that this would be the course of action that needed to be taken
before further prescription could be made.
E12 In respect of the man’s declared drug addiction, the doctor referred him for a
detoxification programme and prescribed him medication to sustain him throughout the
night period. The doctor informed the inquiry that tests are currently not available at the
time of a prisoner’s reception to the prison to identify the quantity of any illicit drug that
the prisoner may have stated they had taken.
E13 Current tests available can provide only an indication as to whether there is a presence
of controlled drugs within that person's system at the time of testing. Whenever a
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prisoner declares that they have been taking illicit drugs or that they are currently under
treatment for an addiction, verification can only be obtained by contacting their respective
GP or hospital, during working hours the following day. This process is normally
completed by staff who work in the detoxification unit.
E14 The prison have been unable to locate the man’s treatment card to confirm the
medication prescribed / given to him that evening, however the doctor recorded into his
Medical Record that he had prescribed him Carbamazepine (200mg bd) and Diazepam
(20mg bd). The doctor also explained that he had informed him that he would need to
attend the medical station the following morning to receive a further prescription of this
medication.
E15 I asked the prison doctor what the man’s reaction to receiving this medication was. The
doctor replied, ‘Yea he knew what we do apparently, and he took the medicine and
thanked me and went off’.
E16 In order to confirm that the man received his medication that night I again spoke with the
reception nurse and informed her that I was unable to locate the man’s prescription chart.
She said, ‘He had one, he had one I’m sure because I give him medication myself’.
E17 I asked her to confirm that the medication had been given in the amounts recorded in the
IMR and she replied, ‘It was, ….then he asked me, will I get it again in the morning, so I
said ‘yes, you’ve been here, you know how, you’ve been here before so you know the
process, you get it in the morning and then through-care will see you after medication’.
The nurse further advised that she had signed the man’s prescription chart to confirm
that the medication had been given.
E18 The reception nurse went on to say that, after the man had finished seeing the doctor,
the next stage in the reception process was that an officer would interview him for
completion of his Cell Risk Assessment form. The nurse had input into this form and was
required to complete section 3 to indicate to the officer if there were any issues on health
grounds that would affect the man’s allocation to a cell or type of cell.
E19 On study of the completed document supplied to the inquiry it can be seen that section 3
of the man’s form had not been completed. I asked the nurse why this should be the
16
case. She replied, ‘I don’t know because we do this for every inmate that comes to see
the doctor so I’m surprised that you say this’.
E20 I asked the reception nurse if throughout her interaction with the man that evening, taking
into account his medical problems and her known history of him, if she would have raised
any concerns on this form. She again replied, ‘If he had said anything, if he was
distressed or, we write it, we do document that so that the officer taking him will know
that he needs to be observed’. She advised that in this case there had been no concerns
whatsoever.
E21 I spoke with the prison officer who had completed the interview with the man on 24 June
for his Cell Risk Assessment form. He found him to be polite and to conform to all the
procedures of the risk assessment process. The man displayed no issues of concern
and did not stand out from any other prisoner received into the prison that night. The
officer stated that he had offered the man a telephone call, but that he had declined this
and just requested to be issued with the tobacco from his first night reception pack. The
officer concluded by stating that he had limited contact with him that evening and had not
met him before that night.
E22 I interviewed the officer on duty in the FNC on the evening of 24 June and he explained
that E Wing was his permanent area of work. The officer advised that he had escorted
newly received prisoners from the reception area to E Wing that evening and felt that the
man must have been one of these prisoners, however his first recollection of him was
when he was identified by the nurse as needing to see the doctor. He was one of the
last prisoners to be seen.
E23 He said, ‘he was sitting on A wing with me and a couple of cleaners and we were all just
watching the football and he was happy, he was cheerful, he was having a laugh and a
joke, slagging off the game and what have you, like everyone else was doing’.
E24 The man was one of the last prisoners to go into his cell that evening. The officer had
been waiting for him to finish with the doctor and as he finally came out the man joked,
‘always the same ain't it gov, it is always the bloody junkies the last ones to go in'. The
FNC officer stated that he had received no special instructions from medical staff as to
where the man should be located and so he allocated him to a normal location.
17
E25 The FNC officer said in response to the man’s joke, "I laughed at the comment 'that's the
way it goes mate', and then he asked me 'oh gov any chance of staying out watching the
end of the game?' and I said 'no I would love to but I have got to get you banged up' I
said 'I've got to get the numbers in'".
E26 The officer continued, that the man replied, 'alright, sweet,' and he said 'can I just get a
cup of hot water for a cup of tea' and I said 'yes no problem mate'. So he got some hot
water and I said to him 'you are in E401 mate' and he went 'oh lovely', he seemed to
know where that was, he run straight up outside the cell, I opened the door and he went
'oh am I on my own?' and I went 'yeah is that alright' and he said 'yes no problem I can
get a decent nights kip now' and I went 'alright then mate I will see you later then yeah'
and he said 'yeah alright see you in the morning gov'.
E27 The officer advised that he remained on duty until 21.00 that night. The last time he had
seen the man was when he had completed a count of the wing and he had checked his
cell. The man had been the only prisoner located on the fours landing. He had checked
E4-01 and then worked his way down counting the other landings on route. At the time
of checking him he had been making a cup of tea. The FNC officer stated that
throughout his contact with the man that evening he had not observed any signs of
depression or any indication that he might be contemplating any act of self-harm.
E28 I identified other members of staff working in A & E Wing on the evening of 24 June and
in an attempt to ascertain if these officers interacted with the man during that period, I
spoke with them. All officers stated that they had no knowledge of him and were unable
to offer any information of evidential value to the inquiry.
E29 I interviewed the night patrol officer for A wing who explained that on this particular night,
24 June, he had commenced duty at 20.30. He had arrived on A & E Wing just as the
FNC officer was locating the man into cell E4.01 and he recalls this happening, as he
was one of the last prisoners to be put in to his cell.
E30 After all prisoners had been located and a count completed by the evening duty staff the
night patrol officer stated that he completed his own count to confirm the wing numbers.
The man would have been included within this count.
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E31 The night patrol officer said that the next time he saw the man was during a patrol at
approximately 22.30 / 23.00. He opened the cover of his door observation panel and
looked inside. He observed that he had removed his mattress from the bed and had
placed this on the cell floor. The man heard the officer looking inside and turned his
head to glance at him. The officer then continued with the patrol.
E32 I asked the night patrol officer if he had any further contact with the man during that night
and he stated that he had not. There had been no cell call lights or banging, in fact it had
been a quiet night all over the wing. The officer advised that as part of his patrol duties
he was required to ‘peg’ at certain locations throughout the wing. This means, that the
officer randomly checks cells to see that the prisoner inside is there and ok. Each of
these patrols would have required him to attend E Wing and so he had made regular
visits to the area throughout the night. He had discovered nothing untoward during these
visits.
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The discovery of the man and action taken
E33 The night patrol officer stated that on the morning of 25 June he had commenced his
morning count of A & E Wings. He started on A Wing, counting all the landings and had
then proceeded to E Wing. Starting on the two’s landing he progressed up to E4 landing
where the man’s cell was located.
E34 On opening the cell observation panel cover he looked into the cell and saw that he was
suspended by a ligature secured to the cell window. The officer stated that the man was
facing away from him and that he observed that his feet appeared to be just touching the
cell floor. Initially he was unsure at what he was seeing and so looked again into the cell.
E35 Having realised that his first observation was correct, the officer immediately alerted the
control room and other staff by using his radio, calling a Level 1 emergency. He then
opened his sealed pouch, which contained a cell key and using this entered the cell.
E36 He used his cut down tool to cut the ligature from the window and lowered him onto the
mattress, which was still present on the cell floor. Using this same knife he then cut the
remaining ligature from about the man’s neck. At this juncture the duty senior officer
(SO) and other officers arrived at the scene and took over the incident.
E37 The night patrol officer stated that he felt he was suffering from shock and had to leave
the cell. He played no further part in the incident itself, but remained outside the cell
while the other officers and medical staff were inside.
E38 I interviewed the duty senior officer who had been the manager of the prison that night.
He advised that he had been present on the Centre (All wings branch off from this area)
when he had received a radio message, Level 1, from the communications room
requesting him to attend E4 landing. The SO also stated that he was aware that
healthcare had received the same request. He immediately made his way to the landing
and to cell E4-01 where he observed the night patrol officer to be present and the man
positioned on a mattress on the cell floor.
E39 The SO explained that he observed the night patrol officer attempting to cut the ligature
from about the man’s neck. Other officers had attended the scene and entered the cell.
He requested the communications officer to contact the London Ambulance Service and
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request the attendance of an ambulance. He advised that later he had deployed staff to
allow these personnel into the establishment and provide them escort to the scene.
E40 A wing officer was interviewed and stated that he had been working on C Wing when he
heard the Level 1 call over the radio. He had also immediately ran to the scene saying
that en route he was directly behind the SO and a second wing officer. He confirmed
what had been said by the SO regarding the night patrol officer and his actions and was
able to add that both the second wing officer and he had entered the cell straight away.
On seeing that the night patrol officer was ‘Shaken up’ they instructed him to leave the
cell.
E41 The first and the second wing officers started to prepare to administer CPR to the man.
The first wing officer stated, ‘I checked, I felt his skin and he was cold and clammy, so
then I checked it for a pulse on his neck and on his wrist and couldn’t feel anything and
then I wet my hand and put it by his nose to feel for breathing, put my hand on his chest,
I listened and couldn’t hear anything or feel anything. So I said right he’s not breathing
and he’s not got a pulse, he’s basically he’s dead, we need to try and resuscitate him’.
E42 At this juncture the second wing officer attempted to place his mouth cover (One way
valve) over the man’s face, however the first wing officer stated that the officer was
unable to insert the valve into the man’s mouth, as it would appear that his lower jaw had
locked. They continued to attempt to apply this equipment, without success.
E43 The first wing officer stated that at this point in time the duty nurse had arrived at the
scene with medical equipment. The officer said that the nurse supplied a facemask and
this was placed over the man’s face and was used to deliver air into him. The officer
explained that he then stood back leaving the second wing officer carrying out chest
compressions, while the nurse administered air through the facemask.
E44 This was continued with the first wing officer and a third wing officer who had also now
arrived, eventually taking over from them. These officers continued CPR until the arrival
of ambulance crew some moments later. The first wing officer stated that the third wing
officer was replaced first, but that he continued to administer chest compressions whilst
the ambulance crew connected medical equipment to the man. After they had done this
he was replaced by one of the ambulance personnel and took no further part in the
medical intervention.
21
E45 I was able to interview the third wing officer who verified what had been stated by the first
wing officer. He also added that he had assisted a second prison nurse to take oxygen
to the scene of the incident. A fourth wing nurse who had also attended the scene, was
interviewed and stated that on his arrival both a nurse and officers were in the process of
delivering CPR. He had entered the cell and removed cell furniture to give the staff more
room to operate. He also said that he observed the night patrol officer to be in a
distressed state and so later took him down to A2 landing office.
E46 The duty nurse was interviewed and verified that she had attended the incident. She
said that on receiving the Level 1 call she had been in the hospital wing. She had
collected a small emergency equipment pack and immediately made her way to the
scene. The reason she only took the small emergency bag, was that she found the
larger one too heavy to carry when trying to get to the location at speed. The nurse
stated that the second, larger bag for emergencies was brought to the scene by the
second nurse on duty.
E47 The duty nurse stated that she had arrived at the scene and observed staff to be present
both in and out of the cell. The man was positioned on the cell floor. She checked his
vital signs and found that none were present. She formed the opinion that the man had
already died. However aware that she could not formally make this diagnosis, she
initiated CPR with the assistance of staff present.
E48 The duty nurse continued to explain that the man’s body, ‘was extremely cold and
clammy, his body was actually quite stiff so by my reckoning and reasoning, he had
probably been dead for a while’. She later said, ‘I think what I knew deep down inside is
that I was trying to resuscitate a corpse, I mean I was trying to resuscitate a corpse,
somebody who had already died, I knew but you have to, do your level best’.
E49 She concluded by advising that on the arrival of the ambulance staff she handed control
of the medical treatment of the man to them and that they continued to work on him
before finally stopping. I asked the duty nurse if the ambulance staff had made any
comment to her. She replied, ‘Yes. The paramedic, one of them said he said, obviously
the blood had settled down, the bottom part of the body had, he had probably been dead
for maybe about an hour before they arrived. And he said he was going to put that in his
report’.
22
E50 I interviewed a Prison Service Nurse (PSN), the other nurse on duty that evening. She
confirmed that she had attended the scene of the incident with the second larger medical
response bag. She had arrived at the scene to observe her colleague administering CPR
with the aid of prison discipline staff present. On her arrival she had checked for a pulse,
but had also been unable to locate one.
E51 This nurse stated that the suggestion was made that a defibrillator might be required. As
she attempted to obtain one the ambulance staff arrived and took over. They also were
unable to resuscitate the man and so stopped working. It was at this time that she
decided to return to the main hospital wing to continue to look after the inpatients and to
prepare for prisoners who were due to attend court that day.
E52 Staff present at the scene of the incident advised that the ambulance crew stopped
working on the man at approximately 06.05. Records show that ambulance staff left the
establishment at 06.21. However, what is now clear from evidence obtained is that at
least one of these personnel remained in the establishment to await the arrival of the
prison doctor.
E53 The duty SO stated that shortly after the arrival of prison medical staff at the scene he
had returned to the Centre and had started to telephone and inform relevant personnel of
the incident. One of these persons was the prison doctor, who he requested to attend
the establishment.
E54 The doctor arrived at the prison at 07.05 and, on entering the Centre area, was met by a
remaining London Ambulance Service person who proceeded to brief him on the
situation and of the unsuccessful attempts to resuscitate the man. Having received this
briefing, the doctor immediately went to cell E4-01 where he examined the man’s body
and confirmed that life was in fact extinct.
E55 I have made several attempts to interview the second wing officer with regards to his
involvement in the incident. However, this officer has since the date of the man’s death
been unable to return to work due to the trauma he experienced as a result of these
events.
23
Establishment: Incident / Post Incident Action
E56 The duty SO, having attended the scene of the incident and assessed that appropriate
staff were present, returned to the Centre and followed the establishment Contingency
Orders.
E57 Throughout the incident and post incident period, the officer within the establishment's
Command suite / Communications room maintained a log of all relevant events / actions
taken in the management of the incident. At 0645hrs, a member of staff was positioned
outside of cell E4-01 to preserve the area and to maintain a log of all persons attending
the scene.
E58 The incident was reported to the Metropolitan Police and Coroner's Office without delay.
Next of kin details were obtained and passed to the Police with a request for them to
advise the man’s family of his death.
E59 A hot-debrief of all staff involved in the incident was held at 0853hrs that same day.
Appropriate Care Team staff provided support to all members of staff present.
E60 The prison's Management identified a need to provide prisoners on A & E Wing with
additional support and, to this end, the provision of services from the prisoner Listener
scheme was discussed and made available to all prisoners resident on these wings.
E61 Officers from the Metropolitan Police attended the establishment and E4-01 at 07.47 that
same day. These officers later attended the establishment's Boardroom where they were
able to speak with the staff involved in the incident. Other police officers were to attend
the prison at 11.05 in order to photograph the cell and its contents. Undertakers removed
the man’s body from the establishment at 11.57.
24
Contact with the man’s family
E62 On entry into the prison on the evening of 24 June 2004, the man had recorded his next
of kin as being his sister. However, at this time he did not provide a telephone contact
number for her.
E63 Following the discovery of the man and the conclusion of the unsuccessful attempts to
revive him, the establishment contacted the Metropolitan Police and requested they
contact the man’s sister to advise her of his death. They also asked that the Police pass
a direct contact telephone number to her with a request that she make contact with the
prison’s chaplain, who could address any questions that she might have.
E64 By noon, 25 June no contact had been received from his sister. The establishment
therefore decided to telephone the man’s solicitor and make a further request through
those offices for his sister to contact the prison.
E65 It would appear that the man’s sister telephoned the chaplain at approximately 14.30hrs
on 25 June and it was then that she was told the sad news of the man’s death. The
inquiry was advised that his sister was understandably upset and had a short
conversation with the chaplain.
E66 At approximately 15.00 that same day, the deputy governor of Pentonville, spoke with the
husband of the man’s sister and explained the circumstances of how the man had come
to be in Pentonville and of the assistance and support that the Prison Service could
provide the family, if needed.
E67 The deputy governor provided the man’s sister with the name of a governor who would
act as the prison family liaison officer. It is the understanding of the inquiry that the family
liaison officer later made contact with the family to answer their questions and to facilitate
a visit to the establishment. In addition, he also attended the Coroner's Court with
members of the family to provide support and advice during their meeting with the
Coroner.
E68 The inquiry has been informed that the assistance provided by the establishment and in
particular the help given by the prison family liaison officer during this period was
appreciated by the man’s family.
25
F Medical Review(s)
F1 In order to gain an assessment of the man’s medical treatment during his short period of
custody, the inquiry requested the assistance of the Section Head (Substance Misuse)
Prison Health Team. He was provided with a copy of the man’s Inmate Medical Record
and asked to comment on specific questions and of the appropriateness of the man’s
treatment and location. The inquiry also asked him to identify any issues of concern
which he felt would be relevant to the inquiry. For ease of reference, the report is copied
in its entirety into the following section:
Report on Clinical Substance Misuse Management
F2 On coming into prison on the afternoon/evening of 24 June, the man received a
healthcare screening interview. This process successfully identified his acute and
longer-term health problems (substance withdrawal and deep vein thromboses
respectively). The man was correctly referred for a specialist drug and alcohol
assessment, which would ordinarily have been conducted on the following day (Friday 25
June). A formal detoxification regime would not be prescribed until this detailed clinical
assessment had been completed.
F3 From the medical records I have seen, it appears that the man had substantial alcohol
and drug dependence. He had given a consistent summary of his daily substance
intake, indicating that he was a regular injector of heroin and crack cocaine. He was also
a very heavy drinker, consuming a bottle of whisky plus several cans of high alcohol
content lager per day. The dependence on drugs and alcohol is evidenced by the fact
that he was seen by doctors on three occasions whilst in police custody. On each
examination he was prescribed dihydrocodeine to manage heroin withdrawal symptoms,
and diazepam to contain his withdrawal from alcohol and tranquillisers (also known as
‘benzodiazepines’). One of the doctors noted that the man was ‘Withdrawing + + ’.
F4 Following his arrival into Pentonville prison and his reception healthcare screening
interview, the man was seen by the prison doctor on the evening of 24 June. The
doctor’s notes suggest that he found the community medical management of the man’s
deep vein thromboses had been satisfactory. The doctor also noted that the man had
been in prison on three other occasions. The man’s vital signs (Blood Pressure 132/78,
pulse 83) suggest that he was not in acute drug and alcohol withdrawal at the time of the
prison doctor’s examination. No clinical drug urinalysis was carried out on the first
26
evening. In the absence of any drug urinalysis results, the doctor’s decision to prescribe
20 mgs of diazepam twice daily alongside the anticonvulsant carbamazepine is wholly
understandable.
F5 I will now answer the following questions, which have been formulated to establish the
adequacy of the man’s clinical management.
Findings from the medical review
Should the man have been in a healthcare unit?
F6 In view of the man’s declared recent drug history I believe that he needed to be located
in an area where enhanced supervision was required. This does not mean an in-patient
healthcare centre as his deep vein thromboses were not an acute problem, he had no
history of serious sedative withdrawal problems such as convulsions or delirium tremens,
he had no history of serious mental disorder or of deliberate self harm.
F7 Staff on first night centres have particular awareness of self-harm and suicide, so it was
an appropriate location for him. First night centres generally have a higher staff to
prisoner ratio than general residential locations, but I understand that there was no
enhanced staffing level on the HMP Pentonville first night centre when the man was
located there. I recommend that this circumstance is reviewed if it is to remain the
policy of the prison to accommodate substance-dependent prisoners in the first
night centre.
Was the medication prescribed for him correct and adequate?
F8 The man’s vital signs (see paragraph 3 above) and the reported observations of staff that
he was in ‘Good spirits’ later that night suggest that the medication prescribed (Diazepam
20 mgs twice daily) was adequate.
F9 As mentioned above, there was no first night qualitative urine drug testing in place for the
man. Had there been, it is unlikely that his prescribed care would have varied greatly. I
say this because the man had been given both opiates (dihydrocodeine) and
benzodiazepines (diazepam and temazepam) in police custody, and these drugs would
have yielded positive opiate and benzodiazepine drug tests, irrespective of whatever
drugs he had been using prior to his arrest. Thus the test could not have further
informed the diagnosis of drug dependence.
27
Was the reception screening adequate enough?
F10 In my opinion it was, although it is good practice to follow up reported drug use with a
clinical urine test.
Were there any irregularities in the patient’s medical record (IMR)?
F11 None. The records are consistent and satisfactory.
Was the man’s treatment compliant with Prison Service Order 3550 (Clinical
Services for Substance Misusers)?
F12 It was. PSO 3550 specifies that detoxification regimes should be preceded by urine drug
testing, and both of these events would have been scheduled for the morning of 25 June.
Should any additional medical instructions have been given regarding
the man’s supervision on the night of 24/25 June 2004?
F13 I don’t believe so. Considering the facts that the man had no history of deliberate self-
harm or of serious psychiatric morbidity, that he had been to prison before and that his
offence was very minor, I think that most doctors would have been more concerned
about the emergence of problematic sedative withdrawals on the night of the 24/25 June,
rather than any risk of suicide.
Conclusion
F14 It is my opinion that the clinical management of the man’s substance dependence was
correct.
F15 The police/court staff observation records were particularly good and all who contributed
to these should be commended.
F16 Similarly, all prison staff who came to the man’s assistance on the morning of 25 June
did all they might and their efforts should be acknowledged.
F17 It is impossible to know to what extent drug withdrawal played a part in the man’s death;
certainly he had been drinking in sufficient quantity to create a serious temporary
depression. His injecting use of crack cocaine would also have made him susceptible to
a brief but distinct and sudden lowering of mood. As there is no validated medical
treatment for crack withdrawal, the most viable intervention is simply to observe and
28
support the patient. This I understand was done within the limitations of staffing
resources.
F18 I note that the man declared that he smoked 60 cigarettes per day. It is probable that this
level of consumption was reduced greatly following arrest. Nicotine withdrawal can
increase anxiety; this negative emotion can act in combination with transient but
profound drug and alcohol induced depression to make suicide a greater danger.
F19 As stated on page 1, I recommend that the staffing level at the first night centre should
be reviewed.
Section Head: Substance Misuse, Prison Health 14/09/2004
Establishment's Review of Current and Past Inmate Medical Record’s
F20 In addition to the Section Head of the Substance Misuse Team’s assessment, the
establishment also tasked its own clinical lead nurse to complete a review of the medical
documents held for the man. The resultant report confirms no irregularities were
discovered within the documentation and makes comment that from the documentation
studied all protocols appear to have been followed during the attempted resuscitation of
the man on the morning of 25 June 2004.
29
G. Level of compliance with authorised procedures
G1 HMP Pentonville was found to hold comprehensive Suicide Prevention and Anti-Bullying
Policy documents, which were compliant with current HM Prison Service directives and
requirements.
G2 The systems outlined in the Suicide Prevention policy document for the monitoring of
F2052SH documentation were found to be good and again fully compliant with the
requirements of HM Prison Service directives and requirements.
G3 Contingency Orders were found to be in place within HMP Pentonville which cover
incidents of hanging and of the sudden death of prisoners in custody. These also were
found to be comprehensive and fully compliant with the requirements of HM Prison
Service directives and requirements.
30
H. Conclusions
Reception to HMP Pentonville - 24 June 2004
H1 Although ‘Flagged’ on his Police record as having previously self-harmed, the man had
been adamant to all whose custody he had been in on 23 / 24 June 2004 that this
information had been incorrectly recorded on his records. Certainly from the information
available to the inquiry regarding his previous periods of custody, no information could be
found that would have indicated that he had ever been considered as a suicide risk. It is
also clear that during his return to custody there had not been any concerns raised
regarding his risk of self-harm.
H2 The man was received into HMP Pentonville during the early evening of 24 June 2004
and was processed without incident through the prisons reception area. On completion
he was taken to the ‘First Night Centre’ where he was offered, but declined, a telephone
call and shower. Instead he was more interested in watching television and the ongoing
England / Portugal football match. It is clear to the inquiry that the man was known to
many of the staff in the prison and that he had a good relationship with them. They
allowed him to be ’last in’ to see the doctor so that he could continue to watch the
television.
H3 It is also clear, from the evidence given by both the nurse and doctor who examined him
that evening, that he was familiar with the procedures of the prison and of the treatment
he could expect and was indeed given for his drug addiction. It would appear that he had
accepted this and had not become either demanding or agitated during the subsequent
medical examination. There was no indication that he had been unhappy with his
proposed treatment. This appears to be evident by the way he was still in a jovial mood
when seen by staff, after he had left the examination room after being seen by the prison
doctor.
H4 It was a failure of the nurse not to complete section 3 of the Cell Risk Assessment Form.
However, the inquiry are of the opinion that no information would have been recorded
into this section which would have altered the guidance given to the locating officer
instructing where or in which type of accommodation the man should be located that
evening.
31
H5 The man was located into a double cell of which he was the only occupant. The officer
who located him to this cell stated that he had allocated him to this location because the
only other double occupancy cell available already had a prisoner in. He suggested that
this prisoner had been mentally ill and was acting in a way that would have prevented the
man from gaining a full night sleep. It is considered by the inquiry that this officer carried
out this action with the man’s best interests at heart. Given his presentation that
evening, there was no reason why he should not have been located into a single
occupancy cell.
H6 On locating the man into E4-01 the officer recalled that, although initially making a
comment that he was on his own, the man had raised no objection or issue with this
location. He appeared to have settled well and the officer comments that, when he again
checked on him at the evening lock up count, the man gave no reasons for concern. The
officer commencing night duty that evening, who also checked on and counted him,
echoed this.
H7 The inquiry conclude that the man gave no indication to any person responsible for his
custody and care, whether it be Police, Court or Prison staff, that he might be
contemplating any act of self-harm. The inquiry are also of the opinion that he was
correctly processed into the prison on 24 June and that, given his presentation to all who
had contact with him that evening, was correctly and appropriately located into E4-01 a
single occupancy cell.
H8 The man had been checked and accounted for when the night patrol officer had first
taken control of the First Night Centre (E Wing). Because no concerns had been
expressed in regard to him, he was not the subject of any form of enhanced watch. As
such, there was no responsibility for the officer to conduct a physical check on him again
until the morning count. The only other reason which may have required the officer to
attend the man’s cell during this period would have been if the man had pushed his cell
call light to request assistance from staff.
H9 The inquiry has found no evidence to suggest that the man called for assistance at any
time during the night patrol period. Evidence viewed by the inquiry has confirmed that
the patrol officer visited E Wing regularly throughout this night period.
32
The discovery of the man and action taken
H10 At 05.35 on 25 June, the night patrol officer in accordance with his duties carried out a
roll check of his areas of responsibilities. Starting first on A Wing he then proceeded to E
Wing and to cell 4-01. The inquiry has acknowledged that there is no requirement for the
night officer to carry out this check in any prescribed order. It is a matter of personal
choice, so long as all cells are checked.
H11 On opening the cell door observation panel the officer saw the man suspended by a
ligature. He raised the alarm and then using the cell key from his sealed pouch, entered
the cell and immediately cut the ligature from his neck, laying him down onto the floor.
The inquiry is of the opinion that the night patrol officer acted swiftly on this discovery and
carried out his duties fully and correctly and in compliance with current Prison Service
Orders.
H12 The response to the emergency call was appropriate and fast. On the arrival of other
officers attempts were made to administer CPR to the man. It is accepted by the inquiry
that despite the initial efforts made by these staff, the start of this process was slightly
delayed by the inability to successfully insert a one way valve / mouth-cover to safely
commence mouth to mouth breaths.
H13 Medical staff and resuscitation equipment in the form of the emergency response bag(s)
arrived at the scene extremely quickly. This equipment was deployed appropriately and
again without delay. The inquiry is of the opinion that all staff present, both nurses and
officers, worked extremely hard in their attempts to revive the man that morning.
Although there are some slight differences in the descriptions given by staff of the
events, it is considered by the inquiry that given the trauma experienced by those
present, this is only to be expected and is accepted as such.
H14 It is of concern to the inquiry team that having only two nursing staff on duty that night,
both of whom attended the scene, the forty-three bedded Healthcare Unit would appear
to have been left unsupervised for the period that both nurses were in attendance. It is
noted that one of these nursing staff stated they had to return to staff the unit. Whilst this
issue is highlighted, the inquiry wishes to make it clear that it is of the opinion that the
absence of this second nurse from the scene in no way lessened the standard of medical
intervention being given to the man.
33
H15 The duty SO correctly followed emergency procedures in requesting the attendance of
an ambulance and then ensured that officers were available to allow entry to the
establishment and escort these personnel to the man. The subsequent arrival of these
personnel to the prison was again extremely fast, taking only some five minutes from the
time of the call being made from the Communications room.
H16 On the arrival of London Ambulance staff at the scene, control of the medical intervention
was handed over to them. This is in line with present protocols / procedures and is
considered to be correct. Despite their continued attempts to revive the man they were
unable to do so and at 06.06 made the decision to stop CPR.
H17 It is not clear from the documentation how many London Ambulance Service staff
remained in the establishment, but at least one person did to await the arrival of the
prison's doctor who had earlier been requested to attend the prison. On the prison
doctor’s arrival at the prison, he received a briefing from the member of the London
Ambulance Service and attended the cell where he was able to confirm that the man had
died.
H18 Having assessed the evidence given by the duty nurse and the reported comments made
by the ambulance crew, it is likely that at the time of discovery of the man he had been
dead for some time. It is to the credit of all staff who participated in the administration of
CPR that morning that despite the evident signs that death had already occurred, they
still made valiant attempts to revive the man.
Action taken by the establishment management
H19 The duty SO attended the scene and, having assessed the situation, proceeded to the
Centre of the prison to initiate Establishment Contingency Orders. Whilst this was
correct and in accordance with instructions, he failed to identify an officer to take charge
at the scene (Bronze Commander). A further omission was made when no individual
was appointed to be the scene Log Keeper. Whilst it is accepted that the resources
available to the senior officer were extremely limited, these elements would have been
considered essential if it had become a Police criminal investigation and the cell a scene
of crime. The log being made within the Communications room for the incident would not
have had any evidential value in relation to the scene.
34
H20 On completion of the efforts made by all staff to revive the man, cell E4-01 was sealed
and, at 06.45, a member of staff was posted to commence a log and prevent
unauthorised entry to the scene. The resultant Log provided was extremely helpful to the
inquiry and fulfils all the requirements needed for the preservation of evidence. It is
refreshing that prison management initiated this action, as this is often a requirement that
establishments fail to carry out.
H21 The organisation of a hot-debrief, and provision of staff care and welfare for all staff
involved in finding and trying to help the man, was quickly arranged and implemented.
The provision of both is in line with the requirements of the management of a serious
incident. It is encouraging that all staff reported that they had received good
management support and that this had been ongoing. Appropriate support was also
initiated for prisoners subject to F2052SH monitoring throughout the prison and those
who felt that they had been affected by the incident.
H22 All staff remained on duty beyond their shift timings and co-operated fully with
management and the attending police officers. The inquiry is of the opinion that both the
incident itself, and the management of the actions that followed, were carried out
correctly and in accordance with current instructions.
Contact with the man’s family
H23 The request for Police to make contact with the man’s next of kin in the absence of an
available telephone number is considered to be appropriate and correct. A question
posed and not evidenced in the incident documentation is what, if any, further contact
was made with the Police to identify what actions they had taken in response to this
request. Having stated this, it is commendable that having had no contact from the
man’s family, management at HMP Pentonville took the initiative to make contact through
the man’s solicitors office. It is considered that the establishment made a genuine effort
to make contact with the man’s family at the earliest possible opportunity and to advise
them of his death.
H24 The provision of a named family liaison officer at governor level was appropriate and
helpful. The enquiry has been impressed by the reported actions of this governor and
the extent to which he has gone to provide aid and support to the man’s family.
35
H25 The inquiry are of the opinion that HMP Pentonville and its management carried out its
duties and obligations fully in both contact and provision of support to the man’s next of
kin and family.
Medical Reviews
H26 From the assessment provided by the section head of the substance misuse team and
lead nurse and the observations made by the inquiry itself, it is felt that the man received
appropriate medical treatment during his brief period of custody at HMP Pentonville.
Other Issues
H27 It is has been brought to the attention of the inquiry that, following the man’s death, at
least two members of staff involved took sick leave which they attributed to the stress
and trauma caused them by the events of the incident.
36
I. Recommendations
I.1 The governor should commission a review of the night staffing levels of A & E Wing to
identify if there is a need for additional supervision within the First Night Centre given that
newly received prisoners identified as having a drug dependency are to be located there.
I.2 The governor should commission a review into the systems employed by the Health
Screening Nurse to ensure that in future Section 3 of the Cell Risk Assessment Form is
completed and that Prescription Charts for newly received prisoners to the establishment
are not misplaced or lost.
I.3 The prison doctor supplied protocols for the treatment of prisoners received into the
establishment with a drug dependency to the inquiry. These protocols were dated
August 1998. The inquiry recommends that the governor commission a medical working
group to review and confirm the use of these protocols. Upon completion the group
should ensure that copies are held in all relevant working areas of the prison.
I.4 Instructions for the deployment of emergency staff during the working day are present
within the establishment. It is of concern that the same does not appear to apply during
the night period. The governor should commission an immediate review of the alarm
response instructions for night periods. A formal instruction should be issued which
should allow key personnel to attend the scene of any serious incident, whilst providing
their own areas of responsibility suitable supervision. (Example: In the event of a level 1
emergency call, R Wing OSG will patrol hospital and R Wing for duration of incident. etc).
I.5 The governor should ensure that his night managers are reminded of the importance of
appointing a Bronze Commander to manage the incident scene, when they themselves
need to leave the area and of the need to task the post of Incident Log Keeper to an
individual positioned at the scene.
37
J Examples of Good Practice
J1 It is considered an example of good practice that all night patrol staff on commencing
duty at HMP Pentonville are issued with a utility belt containing a cut down tool to enable
them to remove ligatures and equipment to commence CPR. It is felt that this practice
should be shared with other establishments within the Prison Service Estate with a view
to standardising this procedure throughout the service.
J2 The governor should recognise the actions of all staff involved in the delivery of CPR to
the man on the morning of 25 June 2004. Despite the obvious signs that the man had
already died, these staff initiated CPR during what must have been an extremely
distressing period.
J3 The governor should recognise the actions of governor appointed as family liaison officer
in his contact with the man’s family, in particular visiting the Coroner's court with them.
38