Individual at Rye Hill

Circumstances surrounding the death of a man
at HMP Rye Hill in March 2005
Report by the Prisons and Probation Ombudsman for England and Wales
July 2007
I have now opened investigations into approaching 300 self-inflicted deaths in
prisons, hostels and immigration detention. The circumstances surrounding
the man’s death are among the most disturbing I have come across. This is
an account of individual and systemic failures of disturbing proportions.
The man died at his own hand in the segregation unit at HMP Rye Hill in
March 2005. However, this investigation was on hold for many months before
the police would allow me to proceed. They conducted a lengthy and detailed
investigation of their own into the man’s death, and this resulted in three
members of staff being charged with manslaughter by gross neglect. One of
those accused, together with a fourth member of staff, was also charged with
attempting to pervert the course of justice. In the event, the judge directed
that there was no case to answer on grounds of lack of causality in respect of
the first charge and lack of intent in the second.
Given the thoroughness of the police investigation and the amount of time that
has now passed, my own investigation has relied heavily on the vast amount
of evidence which the police have shared with me. I record here my very
grateful thanks for their willingness to facilitate my investigation and to furnish
my staff with information and documentation.
One consequence of the delay in conducting my investigation is that some of
the family’s many questions about how the man came to take his own life
remained unanswered for far too long. I hope that this report now gives them
the answers they seek. However, I am all too conscious that neither they, nor
any other reader, will derive any comfort from what I have discovered.
In some of my investigations into self-inflicted deaths, I have found a failure by
the authorities to adhere to proper systems and safeguards. In others, I have
found that procedures were adhered to but there was a lack of compassion or
imagination in the way an at-risk prisoner was managed. In the case of the
man who is the subject of this report, I have uncovered both an appalling
breakdown in procedures and a lack of sensitivity and kindness (or worse) in
the treatment of a vulnerable and broken man. I have taken the very unusual
step of recommending that this report should be sent both to the Minister and
to the Chief Executive of the National Offender Management Service for their
consideration.
I should conclude here by saying I very much regret the delay in completing
this investigation, and hope that the man’s family will accept my sincere, if
belated, sympathies for their loss.
STEPHEN SHAW CBE
PRISONS AND PROBATION OMBUDSMAN July 2007
1
CONTENTS
Summary
PART I – BACKGROUND
Investigation
HMP Rye Hill
PART II - EVENTS AT RYE HILL
9 December 2004 – 23 March 2005
24 March 2005
PART III - CLINICAL REVIEW
PART IV – THE MAN’S MOTHER’S CONCERNS
Contact with the prison
PART V - EXAMINATION OF THE ISSUES
Location in the segregation unit
72 hour review of segregation
Segregation unit
Falsification of suicide watch record
Self Harm and Suicide Prevention Policy and Procedures
Ligature point
Response after the man was found behind his door
Healthcare
Corruption allegations
Racism
Contact with the family
PART VI
Conclusion
Recommendations
2
SUMMARY
The man was serving a sentence of four years for two offences of possessing
class A drugs with intent to supply. He had spent time on remand at
Birmingham, Nottingham and Blakenhurst prisons, before transferring to HMP
Rye Hill on 9 December 2004. Whilst at Rye Hill he was suspected of
involvement with the drug culture at the prison, but otherwise the first few
months of his time there were unremarkable. On 8 March 2005, however, an
officer alleged that the man was pressuring him into bringing in drugs. At the
same time (or perhaps in response) the man alleged that a member of staff
was bringing items into the prison for prisoners. He was placed in
segregation whilst the matter was investigated. He had no problems with
segregation and was returned to normal location (albeit a different unit) on 14
March.
On 18 March, the man had an altercation with a member of staff about a fan
which she said he had taken from the wing office. He overturned a pool table
in temper and was subsequently removed once again to the segregation unit
to await adjudication. Whilst there, his demeanour changed completely. He
had a violent outburst the following day when he tried to force his way out of
his cell past the Director and assaulted an officer in the process. He
subsequently became tearful and said he wanted to be baptised as he was
ready to die. The man was placed on a F2052SH (suicide and self harm
management form). The following day he wrote a note on the back of a menu
sheet addressed to his mother saying that he wished, “the Almighty would
take him away with his mighty hands as he sat in his cell”. The note
amounted to a suicide note. The man had episodes of uncontrolled crying
and was clearly confused. During exercise on 20 March, he took off all his
clothes and continued to walk around in the cold outside reciting the Lord’s
Prayer and saying he was ready to die. On the Monday (21 March), he
agreed to go for a shower but stopped on the stairs and refused to go
backwards or forwards. Eventually, he was removed by staff using Control
and Restraint techniques. He had no memory of the incident the following
day and continued to be very confused.
On the afternoon of 22 March, the man had a visit during which his
appearance and manner caused his family great concern. They also saw
marks on his hand, neck and throat where, he told them, he had deliberately
hurt himself.
On 23 March, the man’s segregation was reviewed. During the review, he sat
with his hands on his temples and appeared not to be taking anything in. He
was unkempt and his personal hygiene was not good. He did not understand
why he was segregated and said he wanted to go back to his unit. He was
apparently upset when he was told he would remain in segregation. He was
told he would see the psychiatrist the next day and that his uncle would also
visit.
On 24 March, the man was offered a shower and a change of clothes. He
started to come out of his cell, but then picked up his stereo and some papers
3
saying that he wanted to take them with him. He was told he could not and
went to sit on his bed. He then refused to come out. At 11.00 am, he asked
to have his shower, but this could not happen because adjudications were
being carried out.
At 11:55 pm, a manager from one of the residential units went to see the man
as she had promised a couple of days previously. He was slumped against
the cell door and not responding when spoken to. As he was on a four-man
unlock, they waited for another member of staff to attend before opening the
door. When they did so, they found that the man had hanged himself with a
shoelace attached to a small hole in the metal plate on the back of the door.
Staff tried to resuscitate him and an ambulance attended, but he was
pronounced dead at 12:38 pm.
The man’s mother has raised a number of serious concerns. Amongst these
were that, following her visit on 22 March, she had phoned the prison and told
them about the marks on her son’s hand, neck and throat. She said no action
was taken as a result and that her son had remained in the segregation unit
rather than being transferred to the healthcare centre. The man’s mother has
suggested that staff neglected her son because of the allegation he had made
about one of their colleagues and because they were racist.1
I have considered these matters - and others - as part of my investigation. I
found no evidence to suggest that staff had deliberately neglected the man,
and could reach no finding on whether staff had failed to act on information
from his mother about marks on his body. However, I did find that staff failed
to carry out and document proper checks on him and to communicate
effectively and forcefully enough with healthcare staff. I also found evidence
that documents had been tampered with to cover up the failure to carry out
proper checks. I discovered that routine security checks of cells in the
segregation unit had not been carried out for some time (or not been
recorded), and that two residential managers had been appalled at the
condition of the cells just two days before the man’s death. (They cleaned
them out personally.)
Although I uncovered no evidence that staff had neglected the man because
of the allegations he had made or for racist reasons, I formed the strong
suspicion that staff did not engage effectively with the man because they were
scared of him following his outburst on 19 March.2 Despite assurances by the
1 The Group Managing Director, Care and Justice Services, GSL wrote to me on 18 June
2007, commenting on a draft of this report. He said, “We feel we are justified in questioning
why in the brief summary you include this allegation by the man’s mother which is based on
hearsay when you found no substantiation for it.” The fact that an allegation has not been
substantiated should never mean the allegation and the finding should not be reported –
especially when it concerns racism.
2 GSL went on to say, “it was recorded that on 19 March the man had carried out a serious
assault on members of staff injuring one seriously and force was used to return him to his cell.
On 21 March he had again been subjected to C&R techniques during the incident when he
refused to go to the shower or return to his cell despite staff attempts to reason with him. He
was on a four-man unlock because of the risk he presented to staff.” I would suggest that this
tends to substantiate my comment rather than otherwise.
4
Home Office Controller that the segregation unit was the best in the prison
and a beacon of good practice, I was concerned by the picture that emerged
of a segregation unit struggling to discharge its basic daily functions, let alone
offer any real care for the prisoners accommodated within it.
I made some 28 recommendations in my draft report. I am pleased to report
that, having read the draft, GSL accepted all of them. They told me that they
had either been implemented or an action plan was being prepared “for their
swift implementation”.
I have amended or expanded some of these recommendations and added
eight new ones following representations from solicitors acting for the man’s
mother and a conversation between a former residential manager at Rye Hill
and the Assistant Ombudsman, who conducted this investigation on my
behalf.
5
PART I - BACKGROUND
Investigation
This investigation was opened on my behalf by an Assistant Ombudsman,
assisted by a Family Liaison Officer. They met the man’s mother and her
legal representatives and liaised closely with the police while the criminal
investigation was ongoing. My Family Liaison Officer has been in touch with
the man’s mother periodically since.
Another Assistant Ombudsman took over the investigation after the original
investigator went on maternity leave.
The Assistant Ombudsman reviewed the vast number of documents helpfully
supplied by the police. These included contemporaneous records from the
prison, as well as statements and transcripts resulting from detailed interviews
with staff, prisoners and others.3 The Assistant Ombudsman visited the
prison, obtained additional documents and information and interviewed the
Home Office Controller.4
A clinical review was conducted for the police investigation. (The reviewer is
also regularly engaged by my office for the same purpose.) I am grateful to
her for allowing me to incorporate her findings in this report.
The report was shared at draft stage with the police, the man’s family, the
Prison Service, Global Solutions Ltd (GSL) and the Regional Offender
Manager. Some amendments have been made as a result.
Following representations by a former residential manager at Rye Hill, in
relation to the draft report, the Assistant Ombudsman interviewed her
informally. Her comments are also reflected in this final report, as are those
of two officers who provided feedback by phone.
HMP Rye Hill
Rye Hill opened in January 2001 and has been run since that time by GSL. It
is a category B prison and holds up to 660 prisoners accommodated in eight
living units. All cells, including those in the segregation unit, are built to Prison
Service safer cell specifications.
The prison is contracted to act in accordance with all Prison Service Orders
(PSOs).5
3 In their letter, GSL suggested that it was important to bear in mind that the evidence was
gathered in the pursuit of a criminal investigation. They also said that the statements of those
officers who were charged should be placed in the context “that they were made either to the
police when under investigation or in their defence or mitigation against serious criminal
charges and internal disciplinary measures. As such they cannot be considered unbiased.”
4 Controllers are engaged by the Home Office to monitor and enforce contract compliance by
Contractors in privately run prisons. They operate from within the establishment itself.
5 PSOs provide guidance and instructions to all Prison Service establishments on operational
and policy matters. They typically have some advisory and some mandatory elements.
6
The segregation unit, which is separated from the main prison, holds a
maximum of 16 prisoners on two levels. It does not have in-cell television or
CCTV coverage. The healthcare centre has eight beds and a ward that can
be used as a crisis suite for suicidal prisoners.
In April 2005, three weeks after the man’s death, an unannounced inspection
of the prison was undertaken by Her Majesty’s Inspectorate of Prisons. (The
previous full inspection was in 2003.) The unannounced inspection looked at
key concerns raised by the earlier one. The HM Chief Inspector of Prisons
commented positively on efforts made by staff to provide a good environment
for prisoners from a basis of mutual respect and reported that race relations
were reasonably good and that prisoners with mental health problems were
managed on normal location wherever possible. However, she also
commented:
“The prison undertook to put in place more effective management and
support systems. However, this full unannounced follow up inspection
found that those key concerns had not been dealt with. Indeed, the
prison had deteriorated to the extent that we considered that it was at
that time an unsafe and unstable environment, both for prisoners and
staff.”
And:
“We had very serious concerns about the safety at Rye Hill. Staff
lacked experience and confidence in managing an experienced
prisoner population; this was exacerbated by the absence of visible
management support, very low staffing levels and high staff turnover.
As a consequence, it was by no means clear that staff were in control
of prisoners on some wings … Induction and the management of safer
custody had improved, but the implementation of anti-bullying and
suicide prevention at wing level was inadequate. There was no
Listeners scheme. The regime for vulnerable prisoners had improved,
but agreed staff training had not been provided. The prison was
performing poorly against this healthy prison test.”
HM Chief Inspector was very concerned about issues relating to staffing and
recommended that the Office for Contracted Prisons should review the
position at Rye Hill, taking into account recruitment, retention, deployment and
management. She said the review should include a risk assessment of safe
staffing levels and mechanisms to ensure a visible and experienced
management presence on all residential units. The Chief Inspector noted that
30 per cent of Prison Custody Officers (PCOs) had less than 6 months
experience in the job and there was a 40 per cent turnover of staff in 2004 –
2005.
In relation to suicide and self-harm prevention, HM Chief Inspector noted that
reviews were carried out on time and that there was a consistent and broad
membership of the suicide prevention group. At least one counsellor was
7
available every day. In addition, the Safer Custody Manager had recently
produced a safer custody bulletin which provided staff with information about
trends and initiatives. However, the Chief Inspector also commented that the
frequency and standard of entry on SASH [Suicide and Self Harm] forms was
often poor and that staff had little time to engage with the prisoners.6 She
also noted that there was no prisoner-Listener scheme in operation because
of a breakdown in relations with the Samaritans.7
Of the segregation unit, HM Chief Inspector noted that her earlier
recommendation for the installation of CCTV coverage had not yet been
implemented. She also commented that staff did not have sufficient
confidence to challenge prisoners, hence there was a “poor level of
cleanliness and untidy state of many of the cells”. In addition, entries in wing
history files provided “little evidence of engagement with the individual
concerned”. On the positive side, someone from education attended the
segregation unit daily to enable prisoners to partake in education.
Finally, and with reference to the healthcare centre, HM Chief Inspector noted
that the beds were rarely used and there were no strategies in place for
dealing with the mentally ill. As a result, they spent long periods in their cells.
6 F2052SH is a documented process until recently used throughout the Prison Service for
caring for and monitoring those identified as being at risk of suicide or self-harm. At Rye Hill,
this is known as ‘SASH’.
7 Listeners are prisoners trained by the Samaritans to listen to other prisoners who are
contemplating self-harm or suicide.
8
PART II - EVENTS AT RYE HILL
9 December 2004 – 23 March 2005
The man transferred from Blakenhurst to Rye Hill on 9 December 2004,
following sentencing in November. He was assessed on reception. His
behaviour and attitude gave no cause for concern and he was not considered
to be a suicide risk. He acknowledged having used cocaine in the past. He
completed a form on which he recorded that he did not suffer from any
physical disabilities and had no mental health problems.
He was placed on Hastings Unit, but moved to Edwards Unit on 23
December. On 21 December, the man received an initial assessment from
the CARATs (Counselling Assessment Referral Advice Throughcare) team.
He apparently claimed he had been ‘clean’ for the whole of his sentence but
had not done a lot of work regarding CARATs. He was listed as urgent for the
drugs awareness course. The man was recorded as saying that he had no
concerns regarding drugs and wanted to focus on his parole and re-
categorisation (having recently been upgraded to B) so that he could gain
qualifications in higher education. Three objectives were set:-
• To maintain contact with the CARATs team;
• Raise awareness of drugs [shown as completed in February 2005]; and
• Remain drug free.
His wing history sheets note on 9 January 2005 that the man was very vocal
on racial issues, claiming that the unit was racist as there were no black men
on the servery. The entry said he could be quite verbally abusive and
aggressive at times. It warned staff to be aware that his mood swings were
unpredictable.
On 11 January, a Prison Custody Officer (PCO) submitted a Security
Information Report (SIR) saying that the man told him, “I have spoken to my
people and you will be getting a call soon.” The PCO reported that the man
and another prisoner dished out veiled threats to staff at every opportunity.
Five subsequent wing history entries recorded “No concerns”, and on 5
February a Remission of Additional Days form was completed. It said the
man had settled on the wing, associated with only a few others, complied with
the prison regime and caused no major concerns. It said he was polite when
speaking to staff. A governor noted that he was making good progress at Rye
Hill and granted the application, remitting to the man five added days
previously imposed as a disciplinary punishment.
On 21 February, the man applied to become a Listener. (He was turned down
on 16 March for security reasons.)
On 5 March, however, the wing history sheet reported that he was “rapidly
becoming a major control problem. He is rude, demanding and very
9
disrespectful to staff. He seems to believe that if he shouts the loudest then
he is right.”
Intelligence suggested the man might have been involved in criminality within
the prison. On 8 March, he allegedly tried to corrupt a PCO by passing him a
note asking him to obtain cannabis, heroin and a mobile phone. The man
was removed to the segregation unit while the matter was investigated.8
It seems that a decision was initially made to transfer the man to Norwich
prison on 8 March, as there is a note in his Inmate Medical Record (IMR) that
he was fit for travel and transfer and an escort form had been prepared. In
the event, he did not go. No reasons are recorded.
The man’s segregation was reviewed on 11 March. It was noted that his
general attitude and behaviour had been of a very good standard. He was to
remain segregated until 16 March, “Pending investigation into allegations you
attempted to compromise a member of staff.”
Staff reported that he had no problems while he was in segregation and that
they had established a good rapport with him. He was returned to normal
location, but to a different unit (Davies unit), on 16 March.
On 17 March, a CARATs team worker reported in the man’s CARATs file that
he was:
“… very angry about incidents which have occurred on Edwards Unit …
He is in no state to talk about drug issues. He states that he has no
dealings with the drug culture within the prison. Another inmate who
works with the team joined us to try and calm the man down and we
both got him to focus on some positive issues such as parole and
getting home to his partner/family."
The Davies handover book noted that the man appeared agitated on the
morning of 18 March.
On 19 March, the handover book reported, “the man has left the unit!!” It said
First Response had been called after he up-ended a pool table. It said he
was very irate, shouting and swearing, and that he was going to be ‘lifted’
(that is, moved under Control and Restraint), but decided eventually to walk.
8 An SIR submitted on 20 May 2005 (sic) recorded a conversation between an officer and a
prisoner. It said the prisoner told him that an officer had been bringing in drugs for a group of
prisoners and that the man had asked the officer to bring in drugs for him also. When the
officer refused, the man said he would report him. The officer then went to security and said
the man was pressuring him to bring in drugs. (GSL commented that the fact that one officer
was prepared to report on an allegation against a colleague ran contrary to conspiracy
theories relating to staff corruption.) Another SIR relating to the same conversation reported
that the prisoner said that, after the man came back from segregation, an officer deliberately
wound him up by taking his fan.
10
The segregation unit log book showed that the man was received in the unit
on 18 March, “on 53.4 pending adjudication from Davies Unit”.9
A prisoner told the police that he heard the man crying at about 6:00 am on 19
March. It went on for about an hour. After a member of staff spoke to him, he
was quiet until around 9:00 am.
A PCO recorded that, “The man’s behaviour is varied, ranging from hostility
towards staff right through to sobbing and crying. I believe that he took
something on the wing and at present is coming down from it.”
An entry in the chaplaincy log book (possibly dated 19 March, although it is
unclear) said:
“Spent a long time with the man. He is very stressful and has a lot
family related problems on the outside. We prayed together. I
encouraged him to be strong. He would like the support of the
chaplains on a daily basis until he gets through this period. The staff
gave him a bible while I was there."
The Duty Director’s log and Control and Restraint report forms show that on
19 March at about 2:00 pm, the Director was doing his segregation rounds.
The man initially declined to speak to him, but an officer subsequently called
the Director back saying that the man had changed his mind. However, when
the cell door was opened, the man threw his bible at the officers and the
Director before then trying to barge his way out of the cell. In the process, he
apparently struck one officer repeatedly in the face. Staff reported that the
man showed incredible strength and it took a number of officers to bring him
under control sufficiently to force him back into the cell. They put him face
down on the floor and then exited the cell in the prescribed manner.
However, he managed to get up and jam his foot in the door. They then had
to restrain him once again before finally managing to secure the cell door.
The PCO recorded in the segregation unit log that three officers had been
injured during the incident.
The Duty Director noted in the Duty Director log that the man had fought with
“unnatural strength” and it took very many staff on an ‘all staff’ call eventually
to deal with him. He added, “He is clearly mentally unbalanced and paranoid.
I don’t think he really knew what he was doing.”
A Report of Injury to Inmate form dated 19 March recorded that, following an
incident at 3:10 pm when the man had tried to get out of his cell, First
Response had been called and force was used to put him back into his cell.
The form noted that he was complaining of a sore arm and face, but
commented, “Unable to assess because the inmate is still very volatile.” (A
prisoner who witnessed the incident said he saw an officer strike the man in
the face. Others said they saw no such thing.) The Medical Officer noted that
9 53.4 is the Prison Rule allowing a prisoner charged with a disciplinary offence to be
segregated pending the governor's first inquiry.
11
the man was complaining of a sore right arm and swollen face and neck –
“Very aggressive behaviour at present, not happy to open him up at present.
Will check him when calmed down.”
An officer opened a F2052SH form at 4:30 pm. She said she was concerned
because the man had stated that he wanted to be baptised as he was ready
to die. She advised that staff should offer support and counselling if required.
She noted on the Daily Supervision and Support Record that:
“The man is in a highly agitated state. He is constantly saying he
wants to see a chaplain as he wants to be baptised, as he is ready to
die. He is also standing by his door reading passages from the bible
incoherently.”
The Duty Security Manager noted on the form at 6.00 pm that the man
wanted to die and was reading the bible. He advised that the man should be
offered “full support as per Rye Hill policies” and that he should have
counsellor support. Perhaps surprisingly, given that the man had said he was
ready to die, he did not refer the case immediately to healthcare. Instead, he
ticked the box to advise that he should be managed on normal location.
The healthcare assessment section was completed at 6:15 pm. Under “Give
your assessment”, the Nurse has written, “Sitting in cell reading bible, states
that he is ‘sound’.” She advised that the man should remain in a single cell in
segregation and be subject to six times hourly watches. She made no other
interim instructions.
An entry in the chaplaincy log recorded that the man and another prisoner had
been very abusive towards staff that evening. It said they were asking to see
a chaplain in order to be baptised that day. The chaplain noted that he had
gone to the segregation unit as the incident with the man was coming to an
end. The chaplain said he did not see either prisoner and that, although the
healthcare counsellor was present, she had not seen them either.
A Crisis Intervention Record sheet dated 19 March and timed at 6.00 pm
recorded that the Counselling Service had been called that morning by the
chaplaincy. It recorded, “Chaplaincy v. concerned about this man. Seems
unstable – assault to officers in seg, then crying – reading bible – has found
God this morning. By the afternoon (after the assault) he wished to be
baptised before killing himself tonight. Spoke to him thro’ door. Said he was
‘safe’.” Action/Outcome was recorded as, “Officers and nurses believe he is
coming down off drugs.10 GP feels symptoms point to cannabis psychosis.
Possibly needs psychiatric assessment?” The time spent with the man was
about five minutes.
A form entitled “F2052SH Opened/Counsellor Support Visit” and dated 19
March recorded under Inmate’s Response/Mood/Feelings, “Assaults to staff,
talking about suicide, very erratic and unstable.” Counsellor Comments were
10 As I report later, the post mortem toxicology report found no illicit drugs in the man’s body.
12
“Unsuitable to be seen by counsellor. Referred to the RMN [Registered
Mental Nurse]).” The form was unsigned. The counsellor told the police that
the reason why she judged the man unsuitable for counselling was that he
refused to engage with her.
At 9:00 pm that evening, the man was issued with three notices of report:
• one for using threatening, abusive or insulting words or behaviour on
Davies unit the previous day, when he was alleged to have said to a
female officer, “What you fucking looking at?” (this apparently followed
the incident when he overturned the pool table (for which he was not
charged));
• one for having in his possession two mobile phone SIM cards (he had
apparently handed these over on being searched on arrival in
segregation the previous day); and
• one for assaulting an officer during the incident when he tried to barge
his way out of his cell.
(The former residential manager said there was a further outstanding
adjudication for possession of cannabis. Whilst I understand that a substance
believed to be cannabis was found on the man when he went to the
segregation unit, I have not found any corresponding adjudication paperwork.)
An entry in the segregation unit log book on 20 March recorded that, “Whilst
out on exercise the man stripped naked and walked in continuous circles
reciting the Lord’s Prayer. After two and a half hours he voluntarily came in
having no recollection of how or why he was naked.” In interviews with the
police, staff said it was a cold day and they tried to encourage him to get
dressed and to come back in but he just ignored him. They therefore left him
to it, observing him through the window. No segregation manager was on
duty that day so staff informed the Duty Security Manager (DSM) (who
happened on that occasion to be the Safer Custody Manager). She
discussed the incident with the Duty Director. They agreed to leave the man
in the exercise yard, but to have a counsellor on stand-by for when he came
in. This decision was not documented anywhere. (I have to say that,
notwithstanding that staff were anxious about how he might react if
challenged, I am baffled why more rigorous steps were not taken to bring him
inside much earlier.11) Although the Safer Custody Manager was present
when he came back in, she decided not to refer him to healthcare because he
said he did not want to see or talk to anyone. (Surprisingly, given her primary
role in the prison, she did not record any of this in his F2052SH.)
11 GSL commented that there was no reason for staff to be anxious as they could call for
back-up and restrain the man if necessary. This had happened on a previous occasion.
They said the Safer Custody Officer and Duty Director agreed not to use C&R but instead “to
keep the man under observation to see if he would return voluntarily (which he did) and to
have a counsellor on stand-by. This was an operational decision that, like any other, may be
questioned with hindsight. However, under the circumstances it is difficult to conclude the
decision to be a wrong one.” My point was a different one. I criticise not the decision not to
use C&R, but the fact that a vulnerable, naked man was outside for two and a half hours
without being offered a blanket and with no engagement by the chaplain or senior staff.
13
The Unit Occurrence Log for 20 March recorded that, “On exercise has
stripped naked is ignoring staff. He is reciting passages from the bible. His
state of mind seems somewhat out of sync.” There is no corresponding entry
in the man’s Inmate Medical Record to show that this incident was reported to
healthcare staff.
The Safer Custody Manager recorded that she spoke to the man after he got
dressed and that he seemed very confused and did not know why he had
taken off his clothes. She said she had offered him a counsellor but he said
he did not want to talk to anyone.
A Chaplain noted in the chaplaincy log that when he saw him, the man
referred to several bible passages, “but on the whole seemed quite subdued
and calm”. He told the police that he nevertheless voiced his concerns to an
officer, suggesting that his behaviour might have been due to a breakdown
rather than to drug use. He advised her to contact healthcare which she did.
A member of healthcare staff arrived while the Chaplain was still on the unit.
The Duty Director recorded later that the man had a pain in his stomach and
that he (the Duty Director) had agreed to contact healthcare. (There is no
corresponding record of this in the man’s IMR.)
During the evening of 20 March, the man wrote a letter to his mother on the
back of his menu choice sheet and pushed it under his cell door. In it, he said
he wished the Almighty would take him away:
“… with his mighty hands as I sit in my cell for judgement to be passed
on me. All I ask for me to be remembered in your heart and tell gran to
keep on trying as my heart grows weak but stronger every day as you
pray.”
To “[My brother] and Son” he wrote, “I miss you so much and forever for your
touch when you are older promise me you will follow the bible in great detail
and pray for everlasting peace.”
A doctor completed his section of the F2052SH at 7:20 pm on 20 March (that
is, more than the prescribed “to be completed by Doctor as soon as possible
following all referrals to the Health Care Centre (and in any event within 24
hours)”). He noted, “Wanted 2 paracetamol – otherwise he claims he is O.K.”
A further entry dated 21 March said, “Appears to be in a mental confusional
state. Refer to RMN to psych. See tomorrow. Stay in segregation.”
At 7:15 am on 21 March, the night officer reported on the Daily Supervision
and Support Record that, “The man seems to be very upset and disturbed –
keep reading bible and asking WHY? Think he needs to speak to Chaplaincy
– not a good night at all.” On the Unit Special Watch Record he made a
number of entries between 3:00 and 5:15am stating that the man was crying.
At the end of his shift he wrote, “Very upset and disturbed. Keep a close eye
on.”
14
On 21 March at about 9:30 am, the man was let out of his cell for a shower.
He stopped half way down the stairs when he saw one of the exercise yards
being hosed down by an orderly. He asked if he could be hosed down too.
He was told he could not. The man then refused to move either on to the
shower or back to his cell. Staff tried to talk him round, but eventually it was
decided to return him to his cell using Control and Restraint procedures. A
Use of Force form noted that handcuffs were applied “due to the violent
nature of the inmate”. He was charged later that evening with assaulting an
officer by spitting on him.
A note in the man’s Inmate Medical Record reported that he had not
sustained any injuries during the return to his cell, but that he “appeared very
distressed he was rambling about ‘the demons talking to him’ and that he
wanted to die as he had nothing to live for. Appeared agitated and unable to
sit or stand still and very difficult to engage in conversation.” The nurse who
made the entry noted that she had discussed the man with the Healthcare
Manager (also a Registered Mental Nurse) and that a Doctor had been asked
to see him.
The following entry reported on a conversation between the Healthcare
Manager and a Forensic Consultant Psychiatrist. The Healthcare Manager
recorded that she informed the Forensic Consultant Psychiatrist of the man’s
details since Friday, and that he said the man was suffering from a psychosis.
He did not know the reason but advised he required medication. He
prescribed olanzapine and diazepam. The Healthcare Manager noted that
the man was to be reviewed the following Thursday by another Doctor (a
psychiatrist).
(In the event, a doctor instructed that the medication proposed by the
Forensic Consultant Psychiatrist should not be administered. The clinical
reviewer considers this decision in her report)
The Duty Director visited the man at 11:45 am on 21 March. He noted in the
Daily Supervision and Support Record that he appeared low – “very different
to when I spoke to him 2 weeks ago”. In the segregation unit log, he wrote,
“Acting very strange – stating ‘I went about it the wrong way’. Asked if he had
pressure put on him to which he replied ‘No’.”
The Chaplain visited subsequently and wrote in the segregation log, “Quiet
and uncommunicative. NTR [nothing to report].”
At 10.00 pm that evening, the Daily Supervision and Support Record reads,
“Seems low and upset. Not happy.”
The man was seen by a Registered Mental Nurse at 10:15 am on 22 March.
Speaking to him from the cell doorway, he found the man to be calm and
rational and showing no psychotic symptoms. The man apparently told him
he felt well and had no problems. The RMN told the police that the man’s
15
condition did not give him any reason whatsoever to suggest he should be
removed from the segregation unit to the healthcare centre.
On 22 March, the man was due to appear before the Home Office Controller
for adjudication. (The Controller told the Assistant Ombudsman that the
hearings had been opened the previous day but adjourned for medical
assessments without any plea being heard.) The Controller noted that he had
opened and adjourned the hearing because the man was on a visit. He
advised that the man should be fitted for adjudication by the medical officer.
For some reason, the medical officer who saw him at 10:15 am had not
apparently been asked to consider fitness for adjudication, even though it was
known that he was to appear before the Controller. (I understand in any case
that it is the Controller’s normal practice to adjourn adjudications where the
prisoner is on an open F2052SH.)
On 22 March, the only entry in the Daily Supervision and Support Record said
that the man was lying on his bed talking (to the prisoner next door - they
communicated through the pipes) at night manager’s visit. The segregation
unit log shows that both the Duty Director and the Chaplain visited. The
former recorded, “No reported problems” and the latter “Sitting quietly. NTR.”
The chaplain told the police that on this occasion, although he was teary, he
was more lucid and clear. His speech was clearer, he maintained better eye
contact and he appeared more positive. The Chaplain thought the man was
significantly improved as compared with the previous Sunday.
The man went for a visit during the afternoon. His F2052SH did not go with
him and staff on visits were unaware that he was considered to be a suicide
risk.
The man’s mother told my colleagues that the family noticed some marks on
her son’s skin for the first time during the visit. There was a large mark to the
right side of his neck. When asked, the man said he had tried to hurt himself
as he had been told his family were dead. He had also hurt himself with a
pen, hurt the palm of his right hand with his radio, and had marks on his wrist
– possibly from handcuffs. He told them he had not been sleeping in the
segregation unit, and believed the food he was being given was poisoned or
that something was given to the prisoners in their food to control them. As a
result, he was not eating (except the sausages) and was constipated. His
mother said that, when the visit ended, her son became very agitated saying,
“Please, please, I can’t go back to the seg.”
The man’s return was substantially delayed due to difficulties on the unit and,
when he did come back, he was placed in a different cell because his own
had no power. Managers who arranged the cell moves said the cells were in
a disgusting state. In particular, they said of the man’s cell that there were
plates in his cell and old bits of food. One said it smelled appallingly bad.
They cleaned the cells themselves before they were re-occupied. Both
managers told the Assistant Ombudsman that the man seemed fine when he
returned, notwithstanding that he had had to wait so long in visits.
16
During 22 March, a member of staff reported to the Safer Custody Manager
that there were gaps in the F2052SH supervision sheets for the segregation
unit. She spoke to the Segregation Unit Manager about this the next morning.
He said at first that staff were all fully occupied with a hostage taking situation.
When it was pointed out to him that the incident referred to lasted for a much
shorter period than that for which there were no entries in the forms, he said
that staff had been very busy.
At 10:30 am on 23 March, the man rang his call bell and asked to use a
phone. I have not been able to establish what response he was given. The
last call he made using the PINphone system was at 6:45 pm on 21 March
when he tried to phone his brother..
On 23 March, the man’s continued segregation was reviewed. The then Duty
Director recorded in the segregation unit log that the man:
“… seems confused and requesting to return to normal location.
Advised he is to remain segregated pending further assessment by
HCC [healthcare centre]. Nurse present on review to arrange visit by
counsellor today. [There is no evidence that this happened.] Told I
had spoken with his mother today and he is to receive visits Thursday
and Friday. Requested he take a shower and allow us to launder his
clothes. The response was vague.”
The then Duty Director told the police that, before making his decision, he
asked the nursing assistant if there was any medical reason why the man
should not remain in the segregation unit and that she had said there was not.
He said he explained to the man that, even though he was authorising
continued segregation for a further seven days, he was not necessarily going
to stay there for the entire period, but that he wanted him to be assessed by
healthcare.
An Independent Monitoring Board (IMB) member,12 told the police:
“When the man did enter the adjudication room he was being escorted
by two PCO's. He appeared a lot scruffier than most prisoners that
have entered review hearings in the past at which I have been present.
He looked dejected to an extent that I have not seen this before in a
prisoner. He entered shuffling rather than walking; he was stooping,
looking at the floor rather than at persons present in the room. He
made no engagement with any person as he entered the room ...
I didn't think he was at all with us; I didn't think that he had the ability to
think. In my view a psychologist was required for him ...
Once the man had left the room the then Duty Director spoke to the
representative from healthcare saying that she needs to ensure that the
12 IMB members are appointed by the Home Secretary to monitor conditions in each
establishment. They also have a formal role in monitoring the continued segregation of
prisoners (beyond the first three days).
17
man gets an examination that afternoon. The healthcare
representative replied that she will make sure he is examined.”13
The nursing assistant gave a different account. She said:
“I do not recall any specific questions being put to me with regard to his
suitability to remain within the unit however I would have had no issues
to the contrary.
From my brief contact with the man I did not consider him being moved
to healthcare as his condition did not warrant this ...
He did not display anything to me in the manner that he spoke or his
behaviour that would necessitate me bringing it to the attention of either
the Healthcare Manager or indeed the doctor. Furthermore
segregation staff addressed no concerns with regard to his behaviour
or mental state to me.”
The Segregation Unit Manager told the police that he did not consider it was
appropriate for the man to remain in the segregation unit in light of his mental
state. He said that there was a discussion during the review about whether
he would be better located in healthcare. He said healthcare were reluctant
because of the man’s violent behaviour. (The reluctance to treat potentially
difficult or violent prisoners in the Healthcare Centre is confirmed by what both
a member of healthcare staff and the Healthcare Manager said in their police
statements.)
The Segregation Unit Manager completed an F2052SH case review entry
following the review of the man’s continued segregation. It listed the then
Duty Director, the Segregation Unit Manager and the member of healthcare
as being present. It was recorded that it was believed that the man had taken
illicit drugs and that he had confirmed he smoked something prior to ‘losing it’
the previous Friday. The support plan was for him to be offered full support
(segregation staff to be responsible) and to speak to a counsellor (healthcare
responsible). It was noted that his mother was to visit the following day.
The then Duty Director was shown the form by the police. He said he had not
seen the man’s SASH form before and had not taken part in any review. (He
was aware, however, that the man was on SASH.) He noted that what was
written reflected what was said at the Rule 45 review and that, although it was
right that the findings of the review should be recorded on the SASH form, the
case review was not the appropriate place to do so.14
13 The IMB member who attended the Rule 45 review told the police that the Segregation Unit
Manager did not leave the room during five reviews. However, he filled in the observation
sheet for the man for this period.
14 Rule 45 is the Prison Rule that allows Governors to remove prisoners from association with
other prisoners (that is, to segregate them) in order to maintain good order or discipline within
the establishment.
18
A PCO recorded in the Unit Special Watch Record for 23 March that at 3:45
pm the man called her to his cell. He was very upset and seeing writing on
the walls which he said was talking to him. She advised him to lie down and
try to calm down. He called her back at 4:00 pm. He was sobbing and saying
that he wanted to see his mummy. The PCO noted that she had informed
segregation unit staff again and that the psychiatrist was coming to see him
the next day. She advised the man once again to lie down and calm down.
The PCO told the police that she phoned healthcare to arrange for a
counsellor to see the man. She was told that none was available.
On 23 March a second chaplain recorded in the segregation unit log book that
the man was in tears requesting to be baptised. He told the chaplain he was
feeling scared and was sorry and that he had made a complete mess of his
life. She noted that she was sending him some literature. She recorded in
the Daily Supervision and Support Record that she had spoken and prayed
with him and that he was “very tearful”.
A large number of both prisoners and staff spoke during interview with the
police about the man sobbing uncontrollably in his cell on many occasions
during his time in segregation. They said he was not just crying but bawling.
He could be heard throughout the unit. Several prisoners said that staff
attended the cell when this happened and spoke to him until he calmed down.
On 24 March, the Safer Custody Manager sent a warning letter to a member
of staff who had typewritten entries in the segregation unit F2052SHs. She
also tried once again to speak to the Unit Manager about shortcomings in
completing the forms.
24 March 2005
Three PCOs and the Unit Manager were detailed to run the segregation unit
on 24 March. One of the PCOs regularly worked in the segregation unit.
Another had only worked there for a couple of hours about two years
previously and the third had been a PCO for only a few weeks in total and
never worked in segregation before that week.
From 9:00 am, the Segregation Unit Manager and the experienced PCO were
both involved with the adjudications. This left just two officers to carry out the
routine tasks of the unit. Both officers said they were given no briefing on
starting work and muddled through what needed to be done. One was aware
that the man was on special watch; the other was not (even though this was
his third day on the unit). (Extraordinarily, although the Unit Manager knew
the man was on SASH, he was unaware that another prisoner on his unit also
was.)
In addition to the ‘bespoke’ segregation unit staff, a number of other staff were
present for a time because of the planned movement of a difficult prisoner.
Others came and went in connection with the adjudications being carried out
that morning. (The Home Officer Controller was also present for part of the
morning, as he was conducting adjudications.) At about 10:30 am, however,
19
it transpired that the planned movement would not be taking place after all,
and the staff deployed for the task gradually left the unit and were all gone by
11:00 am. One of the officers designated to work in the segregation unit that
day was given permission to attend a meeting elsewhere in the prison, and he
too disappeared at about 11:00 am. The Segregation Unit Manager was
occupied full time first with the Home Office Controller’s adjudications (which
lasted from about 9:30 am to 10:10 am) and then with preparing for and
assisting with the independent adjudicator’s arrival and the subsequent
adjudications (independent adjudicators are district judges who conduct the
most serious adjudications). Between about 11:05 am and 11:25 am, the
experienced segregation unit officer was away from the unit whilst he fetched
an orderly, leaving just the manager and one officer from the original team of
four. Both were wholly consumed with the adjudications – as was the second
officer once he returned to the unit. (It was suggested that this position was
not unusual and that it was usually dealt with by asking for another member of
staff to come to cover the SASH watches or by asking staff who attended for
adjudications to hang around to help out. Neither apparently happened on
this occasion.)
The man was the first to be served his breakfast on 24 March. This was at
about 8:15 am. No-one could recall if he actually ate it. Staff who were
present described him variously as upset and much more in control of himself
than he had been. One described him as ‘humbled’. He apparently said
repeatedly that he did not understand what was wrong with him. Dirty,
‘stinking’ plates from the previous couple of days were at this time removed
from his cell. (Apparently no-one had removed them previously because the
man was considered unpredictable and possibly violent.15)
The man summoned staff via his cell bell on six occasions between 9:00 am
and 10:17 am. He complained of having a headache and hearing voices. He
was also concerned and confused about an envelope that had been handed
to him earlier that morning. (It is not known what this was.) The electronic
print out shows that he did not use his cell bell after that time.
The man apparently asked two or three times for a shower and this was
reported to the Unit Manager. At some time between 10:00 am and 11:00 am
(frustratingly, but understandably, staff were unable to give specific times of
events), the Segregation Unit Manager offered the man a shower and a
change of clothing. The man picked up his stereo and some papers and said
he wanted to take them with him to the shower. The Segregation Unit
15 This chimes with HM Chief Inspector’s finding that staff avoided challenging difficult
prisoners, resulting in their cells being unclean. GSL have commented that the situation was
more complex than this. They said the man was not merely difficult but violent. He was
agitated and disturbed and staff were unable to engage with and persuade him. GSL
continued, “staff removed plates from the man’s cell when they considered they were able to
do so safely without risk of confrontation and possible violence and that staff also cleaned his
cell. Importantly, had the decision been taken to intervene with the use of force for the
purposes of cleaning cells and removing dirty plates, I am sure we would now be facing
justified criticism for doing so.” They said the same considerations applied to ensuring the
man showered and changed his clothes.
20
Manager explained that this was not appropriate and the man refused to
come out. The Segregation Unit Manager said he would try him again later.
The Unit Special Watch Record shows that the man was checked frequently
during the morning. The entries are as follows:
7:39 Appears asleep
7:40 Woken up, breakfast
8:00 Appears disturbed
8:09 Talking with PCO (the experienced officer)
8:21 Still disturbed
8:30 In cell
8:39 In cell
8:48 In cell still disturbed
9:00 In cell
9:09 In cell under duvet
9:21 Under duvet
9:30 Under duvet appears to be crying
9:39 Under duvet showed face
9:48 Under duvet
10:04 Under duvet
10:09 Under duvet
10:13 Request shower
10:30 Need shower
10:38 In cell
10:49 In cell
11:00 In cell
11:09 In cell
11:17 In cell
11:30 In cell
11:43 In cell
During one check, timed at 9:30 am, it was noted that the man was crying and
rocking on his bed. He had pulled the duvet right up and just his head was
showing.
The PCO that had only been in Seg for a couple of hours made all the entries
up until 11:00 am. At that time, he was put on other duties. No-one was
specifically detailed to carry out the checks and the police established that the
entries on the record after 11:00 am were made only after staff became
concerned about the man, after 12:00 pm.
Despite the recorded checks and one officer stating that he spoke to the man
about four times during the morning and looked on him eight to ten times,
several prisoners told the police that no checks were carried out on him in the
period leading to 12:00 pm. (Some suggested that the period was over two
hours, but the evidence of the electronic cell bell record refutes this.) Another
prisoner who was on an open F2052SH told the police that neither the man
nor he was checked regularly. He said whether checks were carried out
depended which staff were on. Some would simply endorse the form without
21
carrying out the checks. He added that many of the checks that were done on
him did not involve any conversation between him and the officer who was
doing it. The prisoner said that staff at Rye Hill were “very relaxed” about the
F2052SH checks as compared with staff in other prisons.
A Unit Manager, was in the segregation unit because she was required as a
witness in an adjudication. Once she had discharged this duty, she went to
the man’s cell at about 11:55 am because she had previously promised to go
to see him. When she looked through the hatch of his cell door, she could
see the back of his head partially covering the hatch. His feet were pointing
towards the back of the cell. She told the police that she formed the opinion
that he was slouched against the cell door and was ‘playing up’. She said the
orderly told her that the man had not been checked for two hours. The Unit
Manager told the police she then ran to the office and told the experienced
PCO that she could not get any response from the man and that he was
slumped against the door. She said she then returned to the cell with the
experienced PCO following behind. As they went, he told her the observation
book was not up to date. The experienced PCO then returned to the office
and phoned the communications office and asked for the then Duty Security
Manager to attend. As he left the office, a PCO arrived with a prisoner. The
experienced PCO locked the prisoner away (he was the only one with
segregation unit keys at that time) and returned to the man’s cell. The then
Duty Security Manager arrived and the experienced PCO explained the
position. They both ran up the stairs calling for the Manager to join them.
The experienced PCO explained to the police that the man was on a four-man
unlock due to his unpredictable behaviour. He said he and the Unit Manager
had discussed at the door whether they should open it, but they were not sure
how the man would be. He said they feared that he would come rushing out
and attack them. The then Duty Security Manager unlocked the door and a
PCO was sent to the office for a ligature knife.
The PCO who had been in the Seg unit for a couple of hours told the Deputy
Ombudsman, after seeing a draft of this report, that he was “third on scene”.
He said he was on his way back to the segregation unit and passed the
Segregation Unit Manager escorting the judge in the opposite direction. He
said he offered to escort the judge, but the Segregation Manager declined,
saying he was needed in the segregation unit. The PCO who had been in the
Seg unit for a couple of hours said he was not aware of anything going on, as
he had turned down his radio whilst he was assisting with adjudications. He
said that, when he arrived, the Unit Manager and the experienced PCO were
at the cell. The Duty Security Manager arrived subsequently.
The then Duty Security Manager recorded in an Incident Report that at about
12:10 pm, he was called to the segregation unit by the experienced PCO who
told him that the man was sitting behind his cell door. (the Deputy
Ombudsman established that the then Duty Security Manager was no more
than a couple of minutes away from the segregation unit at the time.) The
then Duty Security Manager said he went to the cell and lifted the viewing
panel cover. He could see the man who appeared to be pushing the back of
the cell door. He realised the man was too high up to be doing this and
22
pushed the door open. On looking behind the door, he found that the man
had tied a shoe-lace to a hole in the viewing panel edge and placed the other
end round his neck. He said he lifted the man up and, with the assistance of
the Unit Manager, removed the ligature. A PCO administered CPR [cardio
pulmonary resuscitation] while the Unit Manager gave mouth to mouth. The
then Security Manager said he then called a Code 1 [the code indicating the
nature of the emergency] and asked for the air ambulance. Healthcare
nurses arrived and took over treatment.
The Senior Nurse said in an Incident Report that at about 12:10 pm a call
went over the radio for Hotel 2 [the code for healthcare response] to attend
the segregation unit. She said she phoned to ascertain what was happening
and was told only that the man appeared to be in a collapsed state. She and
three colleagues started to make their way there. At about 12:15 pm, they
received a radio message to take resuscitation equipment with them. She
therefore returned to healthcare to collect the defibrillator and suction. At
about 12:17 pm, a Code 1 call was put out. She said when she arrived at the
man’s cell she found him lying on his back, and that CPR had been started by
a PCO and the Unit Manager. She said she requested a blue light ambulance
at 12:19 pm (in fact the Duty Director had already done this). The air
ambulance arrived at about 12:29 pm. A doctor took over management of the
situation and the man was intubated and intravenous access gained. Full
CPR continued throughout, but the man was pronounced dead at
approximately 12:39 pm.
The man left a note. In it, he said he had led a troubled life ruled or led by
money and material things “that are of a sinful nature”. He said he had left it
to the last of his days to seek God. He asked for forgiveness and said he was
a sinner and a heartless person who only cared about himself and what
pleased him. He asked why he was like this.
23
PART III - CLINICAL REVIEW
(What follows is taken from the clinical review conducted for the police.)
Until he went to the segregation unit, the man was virtually unknown to the
doctors and nurses at Rye Hill. On reception on 9 December 2004, he stated
he was fit and well apart from a hernia. The assessing nurse recorded
specifically ‘No mental health problems’.
Apart from an entry about his hernia, the next healthcare intervention was
when the Senior Nurse attended the man’s move from Edwards Unit to the
segregation unit on 8 March without the application of restraint. The Senior
Nurse completed the segregation safety algorithm advising that segregation
would not be detrimental to the man’s mental health. Thereafter a nurse saw
him daily in the segregation unit, as required by Prison Service Order (PSO)
1700, with the visits being recorded in the medical record. (However, the
clinical reviewer noted that the integrity of the medical record entries was
undermined by entries on 15 and 17 March suggesting the man was still in the
segregation unit when in fact he had been relocated to Davies Unit.)
On 18 March, the Senior Nurse again attended a move of the man to the
segregation unit after he overturned a pool table. The clinical reviewer noted
that, in the event, the man once again walked without application of restraint
and the Senior Nurse completed the algorithm as before.16
There was a nurse in attendance on 19 March when the man had to be
forcibly restrained after throwing a bible at the Director and resisting being put
back in his cell. Two PCOs were injured during the struggle. The Nurse was
unable to examine the man for injuries immediately after the incident because
he was too aggressive. The healthcare assessment Nurse visited the unit
later to see him and spoke to him at his door. He reported that he was
‘sound’.
However, the man’s behaviour had concerned the officers in the segregation
unit. He was distressed, speaking of wanting baptism and wanting to die.
They duly opened a F2052SH. The healthcare assessment Nurse carried out
the required nursing assessment at 6:15 pm. She recorded that the man was
“sitting in his cell, reading bible, states he’s sound”. She found no reason he
should not stay in the segregation unit in a single cell and endorsed the
proposal for six times per hour observations.
When interviewed and shown the medical record, the healthcare assessment
Nurse recalled seeing the man in the segregation unit on 19 March and that
he was “being very noisy”. The relevant entry is not timed but was made
before the incident in which Control and Restraint was used. She also
recalled seeing him later that day, “because he had earlier refused to return to
his cell and Control and Restraint techniques had to be used”. The healthcare
assessment Nurse had visited because the nurse attending the use of force
16 The Deputy Ombudsman was unable to locate a copy of the algorithm.
24
incident had not been able to carry out the required health check due to the
man’s aggression. The entries in the medical record regarding these
encounters are not timed. It appears that all the healthcare assessment
Nurse’s exchanges with the man were conducted at or through the door
without physical examination.
The medical assessment of the man was completed by a doctor at 7:20 pm
on Sunday 20 March. The clinical reviewer noted that the medical
assessment should have been completed within 24 hours of the referral to
healthcare, which, she suggested, could be timed from the healthcare
assessment Nurse’s entry in the F2052SH at 6:15 pm the previous day.
There is no evidence that the doctor examined the man. His entry reads,
“wanted 2 paracetamol – otherwise he claims he’s OK”.
Notwithstanding the entry in the F2052SH, the clinical reviewer has noted that
there was no record of a healthcare visit to the man in the medical record on
20 March. This is a breach of PSO 1700 (Prison Service rules covering
segregation).
The clinical reviewer commented that there was no evidence that the nurses
or the doctor knew about an episode earlier in the day when the man stripped
naked in the exercise yard and paced round reciting prayers. The
experienced PCO managed the incident and recorded it in the man’s history
sheet and the unit log. However, the clinical reviewer suggested that he did
not appear to have recognised its significance, and did not consult healthcare
about this deterioration as required by national policy on suicide prevention
(PSO 2700). The clinical reviewer also noted that, although the man received
support from the Safer Custody Manager (also Duty Security Manager on the
day), and her offer of a counsellor was refused, there is no evidence that she
suggested involving a doctor or nurse.
On 21 March, the Senior Nurse made a comprehensive entry in the medical
record describing Use of Force to relocate the man after he refused to go
back in his cell. She described him as very distressed, rambling about
demons talking to him and wanting to die. She reported her concern to
Healthcare Manager and asked the regular prison doctor to see the man. The
Healthcare Manager discussed the Senior Nurse’s report with the Consultant
Forensic Psychiatrist, by telephone. He recommended olanzapine (an
antipsychotic drug) and diazepam (an anxiolytic drug) and agreed a plan for
his colleague to assess the man on 24 March. This was duly noted in the
medical record.
The regular prison doctor, endorsed the doctor’s entry in the F2052SH on
Monday 21 March writing, “appears to be in acute confusional state. Refer
RMN → psych. See tomorrow. Stay in segregation.”
The same day, he wrote in the medical record:
“Assessed briefly in seg. Appears confused and can’t explain how he
feels. Made appropriate eye contact. Speech rate/content normal but
25
just ‘can’t explain how he feels’. For psychiatrist this week. I will
review later today or tomorrow. Strongly suspicious of drug induced
psychosis.”
(The clinical reviewer noted that there was no record that the regular prison
doctor saw the man again. At interview with the police, he claimed that he
had done so but was unclear if it was on 22 or 23 March.)
The regular prison doctor wrote a prescription along the lines suggested by
the Forensic Consultant Psychiatrist (the clinical reviewer has noted that the
prescriptions are signed but undated.) He told the police that he wrote it in
case it should be needed at a later date if the man’s condition deteriorated.
(the clinical reviewer commented that the nurses who were interviewed had
limited knowledge that these prescriptions were available.) The olanzapine
was prescribed to be given once a day in the evening. The diazepam was
prescribed eight hourly prn (if required) although administration times of am,
noon and pm were circled on the chart. Neither medication had been
dispensed. The clinical reviewer commented that the Healthcare Manager
described the suggested medication as forming part of the man’s
‘management plan’, but that there was no evidence of such a ‘management
plan’ in the medical record or the F2052SH.
On 22 March, the man was seen by psychiatric nurse, probably in response to
a request from the regular prison doctor or possibly from the counsellor . He
found no signs of psychosis. He offered to see the man again if requested.
(It was widely thought by both discipline and healthcare staff that the man was
‘coming down’ from some sort of illicit drug. The clinical reviewer has
commented that the suggestion that he was suffering from a psychosis
induced by illicit drugs was never tested by any drug test.)
The clinical reviewer noted that a healthcare assistant, and not a registered
nurse, represented healthcare at the man’s Rule 45 review board. The
clinical reviewer reported that the healthcare assistant had not familiarised
herself with the man’s medical record or any other history before attending the
review. She had, in her words:
“… picked up through general conversation with staff members that he
had displayed violence towards prison staff. Furthermore, I was made
aware, however I am not sure from whom, that [the regular prison
doctor] and [the RMN] had seen him owing to his bizarre behaviour. I
was also of the belief that a psychiatrist had seen him.”
The healthcare assistant saw no reason for the man to be moved from the
segregation unit to healthcare. The healthcare manager corroborated this
and emphasised that the healthcare centre was not considered as a suitable
location for the man. The clinical reviewer recorded that at no time did the
healthcare manager visit the man to assess him for her own information.
The IMB member wrote up the Rule 45 review as follows:
26
“23-03-05 SRB. The man not at all well. His condition appears to be
induced by taking of drugs. Was signed up for 7 days but an
assessment by healthcare was considered very necessary. This will
take place today. Signed up for 7 days.”
The healthcare assistant recorded in the medical record:
“23.3.05 Inmate seen in seg for Rule 45 Review board. Inmate
appeared confused and not fully aware of his surroundings. Didn’t
appear to remember events of past few days and his actions. To
remain in seg 7 days and be seen by healthcare.”
The Duty Director wrote in the history sheet:
“Seems confused and requesting to return to normal location. Advised
he is to remain segregated pending further assessment by HCC.
Nurse present on review to arrange counsellor. Told him I had spoken
to his mother and he will be having visits.”
The clinical reviewer noted that these accounts were significantly
contradictory with both the IMB member’s and the Duty Director recording
actions to be taken by healthcare of which the healthcare assistant had made
no record.
On the morning of 24 March, the healthcare assessment Nurse did the
segregation round and recorded that the man had been “seen in seg, talking
to officer, waiting to see psychiatrist this pm”. She did not appear to have
actually spoken to him or considered his clinical state.
The clinical reviewer reported that the remaining healthcare entries referred to
the attempt to resuscitate the man following the discovery of him hanging in
his cell at around 12:10 pm.
27
PART IV – THE MAN’S MOTHER’S CONCERNS17
My colleagues met the man’s mother with her legal representatives on 27
April 2005.
She said that, at around the end of February, an officer had approached her
son offering to get him a mobile phone. He had discussed this with his
girlfriend who told him not to as his parole was coming up soon. The officer
kept on at her son, however, until he eventually agreed to get a mobile and
some ‘weed’ from him. Someone else wanted heroin so this was also
‘ordered’. The officer asked the man to write down his request. When he did
so, however, this was then taken straight to the Director. The officer
apparently told the Director that the man had been threatening him to make
him bring in the items.
The family believed that the man saw the Director on Thursday 17 March as
“something had gone wrong”. The man’s mother had received a call from her
son during which he was very distressed and crying. He told her that “they
had had him in the office again about the same thing”. This was the third time
he had been taken into the office. This time the police were involved and he
had given them the names of five officers who, he said, were bringing in drugs
and mobile phones, as he did not want the full blame. He was told they had
been suspended. The man was concerned about the safety of his family and
the “Coventry lot” had been mentioned to him. The man’s mother thought her
son sounded as if he had been smoking weed in this phone call and he told
her he had been passed a smoke, not rolled it himself. The man’s mother
wanted to know what had happened to the officers her son had named.
She said that her son was fine on Friday 18 March. His girlfriend had spoken
to him and he sounded much better. He was still talking about safety
concerns, however, and about threats being made against his family.
On the Saturday, a prisoner called the family to tell them that something had
happened and that fourteen officers had taken the man to the segregation
unit.
The man’s mother said she called the prison several times to express serious
concerns, and spoke to different people including the Duty Director and the
former residential manager. She had even spoken to the Director’s secretary
on the Monday morning. She said it had been extremely difficult to get to
speak to the same person each time. She was only told that her son was
being watched. She said the former residential manager had also told her on
17 In his letter of 18 June, the Group Managing Director noted that the man’s mother’s
evidence included “speculation, hearsay and inconsistencies together with allegations that
cannot be substantiated and are at odds with other evidence and witness statements. In the
interests of accuracy and balance, I believe this evidence should not be included without
some notes of qualification.” However, the purpose of this section of my report is to give full
voice to her many concerns. I have therefore simply reflected without comment or other
footnote what she told my investigators. The principal matters she raises are either explicitly
or implicitly considered in the section entitled “Examination of the issues”. GSL’s comments
on her evidence are therefore incorporated in that section.
28
the phone that staff thought the man had been given something [that is, some
sort of drug], and that if he had a positive urine test they would not hold it
against him.
The man’s mother visited him on Tuesday 22 March. She said that, when he
was brought into the visiting room, she did not recognise him as he was so
different from his usual self. He used to dress especially for visits, but had not
done so on this occasion and was drawing attention from other visitors as he
appeared odd. She said he was clearly distressed. When they eventually got
him to sit down, he had said “they told me you were dead”. She said that her
son had started to cry on several occasions so they had had to refrain from
talking about certain things.
The man’s mother said conversation had been difficult, as her son thought the
prison officers were watching him. This was because he had been positioned
to face them whereas in other visits he had had his back to them. He seemed
desperate to talk to his family but found it difficult as he felt he was being
watched. Nevertheless, he was able to hold a conversation and was not
confused at all. The family remembered talking about his brother’s birthday.
The man had written two cards for him but been told he could not post them
and they were never sent.
The man’s mother also said it was clear that her son did not know why he had
been put in the segregation unit. He had been there on previous occasions in
Rye Hill and again had said he was unclear why. She had called his solicitor
about this as she was concerned. The man had also written to his solicitor
about being taken to the segregation unit, and said he was being victimised
as the prison was racist. The man’s mother said her son had given examples
of this racism in the letter. She was not sure if he made a formal complaint
about it, but was sure other prisoners had and had received no reply. She
was also aware that her son had complained to the Commission for Racial
Equality, but had received a reply saying there was nothing they could do.
During the visit, the man’s mother had noticed injuries on her son’s hands and
neck. Given that he was on a self-harm/suicide watch (F2052SH), she was
especially concerned that staff had apparently not noticed these, even though
the former residential manager had made a comment that without his
moisturiser his skin was breaking out again (that is, she had been close
enough to notice). The man’s mother said she had specifically mentioned the
marks to the former residential manager when they spoke on the phone.
The man’s mother said that, when the visit ended, her son became very
agitated saying, “Please, please, I can’t go back to the seg.” She had told her
son to write things down. He told her his pen did not work and he had tried
without success to get a new one. He showed them his dirty teeth and said
he had not been able to brush them or wash since Friday when he was taken
to the segregation unit at 7:30 pm. (No toothbrush was found in his cell, and
no moisturiser. The man’s mother was concerned that he was allowed his
shoelaces in his cell but not a toothbrush.)
29
This visit was the last time anyone in the family spoke to the man. After the
visit, they were so concerned they asked to speak to the Director
straightaway. No-one came to speak to them, and they were told that there
had been a problem on the segregation unit so all the managers were there to
deal with that. The man’s mother was given a number for the then Duty
Director. She said she tried three times to call him when she got back to the
car, but was eventually told by reception that he would not be available until
the next day. She was then given details of another person to whom to
convey her concerns, but they too had not been available.
The man’s family were certain that he had not tried to harm himself before.
He had seen other prisoners carried out [dead] in the past and his girlfriend
had asked him if he had ever thought of doing this. He had become angry at
this suggestion and was adamant that he would not. The family had trouble
understanding that he took his life, as he only had six months left to serve and
everything to live for. He was going to go to university and had worked as a
fitness instructor. They described him as someone who loved life. He had
been in prisons in the past and been segregated, but never got into the state
he was in Rye Hill. He had never been on an F2052SH before and the family
were concerned that he was on this occasion. They believed the difference
this time was that he knew something about the officers.
The man’s mother was angry that several prison officers knew her son, and
knew what he was normally like, and should therefore have noticed the
changes in him and realised something was wrong. She also said that a
police officer had told the family that he had a statement from another
prisoner to say he had heard her son crying. The man’s mother believed that
if another prisoner heard her son crying, then so must staff have done. She
wanted to know why nothing was done to help him. She understood that the
chaplain had voiced concerns about her son’s state of mind. She questioned
why, in that case, he was still in the segregation unit rather than moved to
healthcare. She was also aware of an incident when her son was on exercise
in the yard with another prisoner when he had taken all of his clothes off to
draw attention to himself. She thought this might have been a cry for help.
There was also a series of other incidents in the segregation unit that were
managed as (mainly disciplinary) incidents at the time, and no follow up care
was ever given.
The man’s mother believed her son had been put into a dirty cell, as dirty
dishes were found after his death which exceeded what he would have
accrued in the timeframe. She said this cell had a badly repaired door
offering a ligature point, and was concerned that someone on an open self-
harm/suicide form was placed there with such an obvious risk.
The man’s mother was concerned that she had received some unopened mail
back, which suggested her son was not getting his post, and that he was
30
being denied essential contact with his family and loved ones at a time when
he was obviously having problems coping.18
She also had concerns about the suicide note. She said that, although it was
her son’s writing, it might have been written under duress as it said “he was”
as if this was being dictated, then “he” had been crossed out and replaced
with “I”. It also did not mention his aunt’s and uncle’s names even though
they were due to visit him that day.
Finally, she referred to the age and experience of the officers at Rye Hill and
asked what the minimum age for a prison officer there was. She said
prisoners said staff did not know what they were doing.
Contact with the prison
The man’s mother was angry that the prison had contacted her sister-in-law
about her son’s death, rather than her. She said the prison would have had
her details as the man’s next of kin and because she had called so many
times to relay her concerns. When the man’s mother then called them back,
she had to go through the switchboard as no direct number or contact name
to call had been given to her sister-in-law. She was told staff had tried to call
her, but she did not believe this as she had her mobile phone on her and her
other son was at home near the land line number.
The man’s mother said that when she spoke to the Director, he would not let
her come to the prison until the police had been. The family had had very
limited contact with the prison since the death and no letter of condolence was
sent. 19
Unfortunately, the man’s mother had been unable to see her son’s body until
the weekend due to the police investigation, and due to being told (wrongly,
by a police officer) there were no viewing facilities at the Infirmary.
She said the police facilitated a visit to the prison, but this was made more
upsetting by their being searched and having their phones taken away. She
also heard a prisoner on the wing shouting “murderers” to the prison staff.
The man’s mother said she was prevented from talking to another prisoner on
the segregation unit who appeared to want to talk to her. During this visit, she
18 Given the passage of time, I have not investigated why the man’s mail was returned
unopened. My guess is that the correspondence office forwarded it to the man’s residential
wing (rather than the segregation unit), thus causing a delay in it reaching him. I agree with
the man’s mother that her son would almost certainly have benefited from the contact with his
family.
19 On 14 December 2006, my office received a letter from solicitors acting for the man’s
mother. They said that, despite the Director’s agreement (on 14 August 2006) to pay £3,000
towards the funeral expenses, this had not as yet been paid and the man’s mother had
received a letter from the funeral directors about the outstanding amount. They asked for the
assistance of my Family Liaison Officer in ensuring the prison fulfilled its ‘obligation’. My
Family Liaison Officer duly contacted the prison and discovered the delay was due to their not
having received an invoice. She advised the man’s mother accordingly.
31
saw trainers outside a cell in the segregation unit and wondered why her
son’s were left with him.
32
PART V - EXAMINATION OF THE ISSUES
Location in the segregation unit
The man was taken to the segregation unit on 18 March to await adjudication.
When his adjudications were remanded the following Monday, a decision was
taken to retain him in the segregation unit on grounds of good order or
discipline. This was because of the incident when he tried to force his way
out of his cell and assaulted an officer.20
Safety algorithm
Since I became responsible for the investigation of fatal incidents on 1 April
2004, I have been very concerned at the number of deaths occurring in
segregation units. Segregation is stressful and demanding. It is recognised
that it can have a deleterious effect on emotional and mental health, and PSO
2700 emphasises that statistically the risk of suicide is elevated when
prisoners are in the segregation unit. For this reason, it is important that a risk
assessment is carried out before a prisoner is placed in segregation and that
this is reviewed in light of significant events. However, I can find little
evidence on the man’s care plan or elsewhere that the dangers of holding him
in the segregation unit were actively considered. A safety algorithm was
completed when he was segregated on 8 March, but I have been unable to
find a corresponding form for the second period of segregation (although one
of the police statements refers to one having been completed). There is
therefore no evidence that the safety of segregating the man for the period 18
– 24 March was ever formally assessed. This is a matter of significant
concern.
Even if the need to complete the algorithm was overlooked on 18 March (or
one was completed and has gone astray), there were several incidents during
the man’s time in the segregation unit that should have resulted in a new
assessment of his fitness to be there. The first of these was the opening of
the F2052SH form. (National guidelines and local policy both refer to
prisoners on F2052SH not being routinely located in the segregation unit.)
The second was the finding of the suicide note, and the third the episode
where he stripped off in the exercise yard. Of course, I cannot say that staff
would have concluded that the man should not have been segregated or that
he should be segregated somewhere other than the segregation unit (in
principle, a prisoner may be segregated anywhere in a prison), but manifestly
the question should have been specifically and explicitly considered.21
20 I have found no paperwork recording any of this. The Controller assured the Deputy
Ombudsman that the necessary paperwork would have been completed, but its unavailability
is a matter for concern nonetheless. Referring to the man’s mother’s suggestion that her son
did not know why he was in segregation, GSL commented that he was “fully informed of the
reasons for his removal to segregation.” In light of the lack of any relevant paperwork, I
simply do not know which account is correct.
21 GSL commented that “it is apparent from other evidence that the man’s retention in
segregation was considered and reconsidered with healthcare staff and so he was not
‘routinely’ confined. Whether healthcare staff took the correct decision may be open to
question but it is apparent that the matter was specifically considered. It was also discussed
33
Support available
The Home Office Controller told the Deputy Ombudsman that he, the Deputy
Controller, and the Duty Director, discussed the man on the morning of 21
March. He said they concluded that he should be segregated in light of his
behaviour. The Controller said he was aware of the events of the weekend
and that the man was on an F2052SH. (He said he was not aware of the
suicide note found the previous evening, but that it would have made no
difference if he had been.) The Controller said authorising segregation did not
necessarily mean the man had to remain in the segregation unit, but that both
he and his Deputy had understood that this would in fact be the case. He said
he was comfortable with this because the man would be closely supervised
there. The Controller explained that the segregation unit had an excellent
record of caring for volatile, unpredictable individuals and that segregation unit
staff at Rye Hill had done some of the best work he had seen. In addition, the
segregation unit was smaller and the staff/prisoners ratio was better than
elsewhere – on normal location, there were one or two staff per 80 prisoners,
whereas the segregation unit had a manager and two PCOs to a maximum of
16 prisoners. The Controller said the segregation unit was also quieter and
there was more conversation between prisoners. Finally, it was staffed by
good, caring officers. In particular, the Segregation Unit Manager approached
his role from a perspective of care.
I take note of what the Controller has said, but have serious reservations
about the decision. PSO 2700 says:
“Prisoners who are at risk of suicide or self-harm must not be routinely
held in the Segregation Unit under Rule 45 GOOD (good order and
discipline). Such prisoners must only be placed in a Segregation Unit
in exceptional circumstances, or where all other options have been
tried, but considered inappropriate and only where it is possible to
provide the degree of continual care identified as necessary in the
prisoner’s care plan. A case review must be held as soon as possible
to take account of events leading up to the decision to segregate. If the
decision is taken to locate prisoners at risk of self-harm within the
Segregation Unit this must be for as short a period of time as possible,
and the temporary nature of this must be reflected in the care plan.”
GSL argued that the man was not “routinely” held in the segregation unit.
They said,
“There were exceptional circumstances in that he was placed in
segregation not because he was a suicide risk but because of his
violent outburst and his subsequent assault on officers the following
day and history of violence. As previously stated, on admission to
segregation he was found to be in possession of a substance thought
with the Home Office Controller.” With the exception of the last point, I do not know to what
evidence GSL refer. I found no other evidence that the matter was critically considered.
34
to have been cannabis and mobile phone SIM cards. Notwithstanding
his violent behaviour, this in itself might also have been reason for him
to have been removed to segregation. The medical staff considered
that it was possible to provide appropriate care with the segregation
unit.”
There are a two points I should make. The first is that I believe this comment
is based on a misunderstanding of the PSO. The PSO does not say that
prisoners should not be placed in segregation because they are at risk of
suicide (although manifestly this is true). What it says is that those at risk of
suicide should not routinely be placed in the segregation unit for reasons of
good order and discipline. I accept that the man did not become a risk until
after he was moved, but his location should have been considered as soon as
he was so identified. In addition, GSL’s comments disregard the fact that
segregation can be effected anywhere in the prison – including healthcare.
Section 4 of PSO 2700 says that the “crucial considerations” when deciding
on the type of accommodation in which to place at-risk prisoners are “the
degree of risk and the level of support (not just supervision) which is
available.” The distinction in the PSO between support and mere supervision
is an important one.
However, the evidence that has emerged suggests that, even if segregation
unit staff were able to offer an enhanced level of supervision – and this is by
no means certain – they had little time to offer support. (This was an
observation also made by HM Chief Inspector of Prisons.) Although the
superior staff to prisoner ratio in the segregation unit theoretically provided the
opportunity for greater individual contact, the reality that emerged from
evidence given to the police was of a busy unit with staff hard pressed to
complete the minimum necessary tasks, let alone offer meaningful support to
distressed prisoners.22
Regime
In any case, the potential for enhanced individual contact must be offset
against the more austere regime. There is little ongoing contact between
prisoners other than what can be achieved through talking through a wall, and
22 In their letter of 18 June, GSL took exception to my reference in the foreword to a “lack of
sensitivity and kindness (or worse), in the treatment of a vulnerable and broken man”. They
noted that it was “evident from the tragic outcome that the care provision for the man was
inadequate. More should have been done with regard to his deteriorating mental health and it
should have been done with a greater sense of urgency.” However, GSL said my comment
was emotive and sweeping and implicated all staff. They said it did “not give recognition to
the compelling weight of evidence from other sources of the caring and conscientious
approach of the overwhelming majority of our staff or the specific evidence that numerous
members of staff involved with the man demonstrated compassion and concern for him and
acted upon it.” They went on to list the various people who came into contact with him during
his time in the segregation unit – the Director, the duty director, healthcare staff, the
chaplaincy, custody officers. However, I do not suggest that there was no contact. My point
is that there was no meaningful contact with him. There was too little actual support. Various
people fulfilled their statutory duties, but very few actively engaged with him during that
contact.
35
time out of cell is limited to the completion of a few specific tasks (e.g. phone
calls, exercise, showers). There are no televisions in the cells and, whilst in
theory prisoners should be able to take with them their belongings, it seems
that the man had very few of his. His sole means of occupying his mind were
apparently his stereo and his bible. I understand that education staff visit the
segregation unit daily, but can find no evidence that there was any attempt to
engage him in some sort of educational activity. He had little therefore to
distract him from his thoughts of dying other than the occasional – and brief –
visits of various staff who spoke to him only from his cell door. The man’s
F2052SH care plan should properly have recognised and addressed the
dangers of the more restricted regime.
I recommend that the Director reminds staff that care plans should take
account of and address the specific conditions of the prisoner’s
location.
PSO 1700 says that:
“The regime for segregated prisoners … should be as full as possible
… In-cell education or work that could be done in cell (e.g. packing)
should be encouraged. Access to activities … should be comparable
to those for a prisoner held on normal location.”
I recommend that those authorising segregation be reminded of the
need to draw up detailed, constructive action plans to safeguard the
mental health of those located in the segregation unit. This should
apply even to relatively short term stays where the prisoner is identified
as being at risk of suicide.
Single cell
A further disadvantage of locating the man in the segregation unit was that it
only has single cells – the national suicide prevention guidelines state that
shared accommodation should be the norm unless the prisoner poses a risk
to others or is too disturbed to share. PSO 2700 says:
“4.1.2.3 Special consideration should be given to prisoners on an
open F2052SH who are segregated either under Rule 45 or who are
subject to an adjudication or have been located in the Segregation Unit
as a result of their adjudication hearing. The risk of locating the
prisoner in a single cell in these circumstances should be considered.”
The man was seen by a nurse within the prescribed time after a F2052SH had
been opened for him. However, the nurse does not appear to have
considered or consulted with others as to whether he should be in a single
cell. 23 It is quite likely that, had the matter actually been considered, the man
23 GSL commented, “This criticism does not appear to take into account the context of the
man’s removal to segregation.” They said he was segregated as a response to violent
behaviour and that, given that he was not considered to be a suicide risk at the time, the
question of single or shared accommodation would not have arisen. The next day, he
36
would have been judged a risk to others or too disturbed to share. However,
the reason for the prisoner to be in a single cell should be documented in the
F2052SH. It was not. I cannot be certain therefore that the matter was
addressed.
Bearing in mind that segregation need not be effected in the segregation
unit, I recommend that, even where a prisoner on an open F2052SH is
segregated, the Director should remind staff that consideration must be
given to accommodating him in a shared cell.
Given the man’s need for greater individual contact, staff might reasonably
have considered placing him in a cell near to the wing office where it would
have been easy for them both to keep an eye on and engage with him. I
accept that it might have been quieter for him upstairs, but I am not
persuaded the question was even considered. Certainly, when he was moved
on 22 March, he was simply put in an available cell.
72 hour review of segregation
The man’s segregation was reviewed on 23 March. An IMB Rule 45 – Review
Sheet (the only relevant documentation I have discovered) says:
“The man was not at all well! His condition appears to be induced by
taking drugs. Was signed up for 7 days, but an assessment by
healthcare was considered very necessary. This will take place today.”
The man’s F2052A Record of Events/Segregation History shows that the Duty
Director was concerned about the man’s state of mind and wanted to hold him
in segregation until he was checked over by healthcare. Even though the
Duty Director told the police that he made it clear to the man that, although he
was signing him up for a further seven days, this did not necessarily mean he
would remain segregated for the duration, I still question the decision. If the
Duty Director had concerns about the man’s mental health – and he clearly
did – the appropriate course of action would have been to seek his urgent
admission to healthcare.24
The Duty Director said he referred to the Healthcare Assistant in reaching his
decision, and that she had said there was no reason why the man should not
remain where he was. The Healthcare Assistant said she did not recall being
asked for her view on continued segregation, but added that she would have
been content for the man to remain where he was if she had been. However,
assaulted officers causing serious injury to one. The deterioration in his mental condition
became apparent only after that time and when he was already judged to be a serious risk to
others.
24
Worryingly, the Duty Director did not refer at all to risk of self-harm as such when
explaining his decision – only to general concerns about the man’s mental health. In fact, I
can find no evidence that the question of self-harm was actively and specifically considered in
reviewing his continued segregation. Equally, no mention of the Rule 45 review board was
made on the F2052SH.
37
she noted at the time that the man appeared confused, not aware of his
surroundings and not appearing to remember events of past few days and his
actions. I am not a healthcare professional, but a lay person might well judge
that how the man presented would be sufficient to warrant referral for an
urgent, full healthcare assessment before agreeing to continued segregation.
In her report the clinical reviewer criticised, “The failure of healthcare to be
represented at the segregation review board by a qualified nurse who had
made herself knowledgeable about the prisoner or prisoners to be reviewed.”
She viewed this as “a very significant missed opportunity”, adding, “It is not
acceptable practice in my view for this to be allowed to happen”. I agree.
I recommend that a qualified, informed healthcare professional should
attend all Rule 45 review boards. Where there are concerns about a
prisoner’s mental health, this professional should be a mental health
specialist.
There also appears to have been a failure of communication. Both the Duty
Director and the IMB member recalled that the Duty Director had asked the
Healthcare Assistant to ensure the man was seen by healthcare staff that
afternoon. (It is recorded in the F2052A that she was to arrange a visit by a
counsellor.) The Healthcare Assistant on the other hand said she saw
nothing about the man that warranted her referring him to healthcare
colleagues and that no segregation unit staff raised any concerns about him
with her. In the absence of a contemporaneous record, I cannot be certain
whether or not the Healthcare Assistant was asked to refer the man to
healthcare colleagues (although the balance of evidence suggests she was).
Suffice to say that he was not so referred, so the question of his continued
segregation was not urgently considered by those best qualified to make a
judgement. I accept that the man was to be seen the following day by a
visiting psychiatrist. By normal standards this is a swift response by visiting
mental health specialists. However, his case was urgent. He was dead
before the visit took place.
Segregation unit
In February 2005, the then Director at Rye Hill issued a notice entitled
Principles of the Management of the Segregation Unit and its Related
Services. This described the unit as “a compact special purpose residential
unit with a dedicated staff team led by a Segregation Unit Manager.” It said
staff working in the segregation unit would be “selected for their particular
competence in dealing with difficult situations and difficult people. Their
appointment as segregation officers will be confirmed personally by the
Director. All staff will be especially aware of the contents of PSOs 1700 and
1701.” The first stated purpose of the unit was to: “Hold all prisoners
segregated from normal location safely and securely and to treat them fairly
and with dignity.” The notice said that, “The regime of the Segregation Unit
will be ordered and disciplined at all time through the meticulous application of
decency and respect.” The manager should therefore: “Ensure that the
standard of cleanliness throughout the unit is an example to the rest of the
38
prison.” The manager should also, "Whenever feasible, seek and provide
prisoners with constructive activity in their cell. Materials for reading, for
certain hobbies and for educational purpose are examples.” The notice
concludes with:
“For the purposes of good management, safety and control in these
circumstances, it is of utmost importance that staff adhere strictly to all
security procedures and routines at all times. This is another area in
which the Segregation Unit will set an example to the rest of the
prison.”
Rye Hill’s policy at the time was that only staff with more than one year’s
custodial experience and who had demonstrated enhanced skills in dealing
with (difficult) prisoners should be detailed to work on the segregation unit.
They were required to be certificated for the role by the Director and on
appointment were given a letter which says:
“You are a certified PCO with a minimum of twelve months general
experience; you’ve demonstrated competence in dealing with difficult
situations; you’ve shown particular aptitude for managing difficult
prisoners; you’ve demonstrated sound knowledge of PSO 1700 and
other instructions and procedures relevant to the work of the
Segregation Unit ...”
It adds:
“You’ll be supported in this special work on a daily basis by the
appointed Segregation Manager and by visiting operational duty
managers. Further line support will be provided by Head of Custody
and a member of senior management.”
The sentiments, aspirations and underlying ethos of the Principles and the
letters to Segregation Unit staff are impressive and laudable. Unfortunately,
they were not matched by the reality.25
On the day the man died, the segregation unit was a busy place:
• A total of 32 adjudications were to be heard by the Controller and a
visiting district judge. The Controller dealt with his cases between 9:00
am and 10:10 am. The judge then dealt with the others.
• The escort of a troublesome prisoner (who had been involved in a
hostage taking incident earlier in the week) was also planned for that
day, and a number of extra staff had been deployed to deal with it.
They were present in the unit, kitted up ready to carry out control and
restraint. As a result, some senior managers were also present.
25 It is worrying that both the Segregation Unit Manager and a regular segregation unit officer
told the police they had not read PSO 1700 which governs segregation. The Segregation
Unit Manager also said he was unfamiliar with PSO 2700 on suicide and self-harm.
39
• Two prisoners (the man and another) were on SASH observations and
had to be seen six times during each hour.
In addition, the routine business of the unit - fabric checks, meals, cleaning
and the like - had to be carried out. This hectic schedule underlines the need
for effective and visible leadership.
The picture of the segregation unit that emerged from the police evidence was
of a unit with barely sufficient staff (notwithstanding the presence of the
additional staff for moving the hostage taker), and with little experience of
segregation between them (one had been a PCO for only a matter of weeks).
There appears to have been little management or organisation.26
The police evidence shows that four personnel were detailed to the
segregation unit (as opposed to being present for other reasons). Three
arrived on duty at about 7:00 am. The Unit Manager was not scheduled to be
on duty until 8:00am but then spent the first hour or so in the administration
block (where the LIDS27 terminal was) preparing for the day’s adjudications.
Thereafter he was fully occupied with the adjudications themselves. This left
the officers to get on with things. There appears to have been little by way of
formal handover (and certainly none by the Unit Manager) and no allocation of
duties. Staff simply got on with the job as they saw it. (Worryingly, and in
contravention of policy, no prisoners in the segregation unit had a SASH
watch indicated in the Occurrence Log on 24 March.) One of the officers was
a new PCO. He described being made to feel very unwelcome by his more
experienced colleagues and not knowing what he should be doing. He said
he simply took up a position at the bottom of the stairs and responded to cell
bells, lighting prisoners’ cigarettes etc.
I recommend that GSL introduces on every unit a system of formal
handovers between each shift attended by all unit staff. The purpose
would be to inform them about any particular issues and to ensure
priorities are clear.
Segregation of prisoners is a very serious matter. The additional deprivation
of rights and freedoms entailed in segregation means that it is an area of the
prison that must be particularly carefully regulated and monitored. It is critical
26 GSL commented that those who provided this evidence could not be considered to be
unbiased because of the circumstances in which they were giving evidence. They added,
“staffing on the units is determined in consultation with experienced prison managers having
backgrounds in both the private and public sectors. The staffing levels are in line with our
operating proposals which were evaluated by the Home Office prior to contract award and the
staffing patterns are similar to other very successful prisons that we operate. The prison
management team have discretion to put additional officers on duty in the segregation unit as
required.” Whilst I accept these points, it is worth noting that HM Chief Inspector of Prisons
had concerns about staffing levels at the prison and recommended they be reviewed. It is
also relevant to note that the prisoner profile at Rye Hill is a particularly challenging one.
Comparison with other GSL run prisons is therefore not necessarily appropriate. GSL also
said that, in the interests of balance, they referred me again to the positive account of the
segregation unit given by the Home Office Controller.
27 LIDS is a computerised prisoner information system and, amongst other things, provides
personal information relevant to the conduct of adjudications.
40
that procedures are followed to the letter and properly documented. This
needs effective hands-on management and appropriate direction of staff. I
would have expected a segregation manager in a category B prison to be on
duty in the unit first thing, and to remain there long enough to be certain that
everything was running smoothly.
I recommend that GSL develops training modules specifically for
Segregation Unit Managers and staff. This should include dealing with
particularly challenging prisoners and the possible effects of
segregation and how they can be ameliorated. The training should
incorporate enhanced suicide prevention training with emphasis on the
drawing up and implementation of detailed, effective support plans.
I recommend that the Segregation Unit Manager is given specific
responsibility for ensuring he has sufficient numbers of trained staff on
the unit at any one time.
I recommend that a LIDS terminal be placed in the segregation unit.
I recommend that responsibility for preparing for and co-ordinating
adjudications be given to a member of staff other than the Unit Manager.
I also understand from the Segregation Unit Manager’s evidence to the police
that the Unit Manager could be taken away from the segregation unit by the
requirement to act on a regular basis as Duty Security Manager, and
sometimes to take part in escort duties.
I recommend that the Segregation Unit Manager is not required to
undertake other duties and that, where this is unavoidable, an
experienced and certified manager is allocated to run the segregation
unit in his absence (this should apply seven days per week).
Cleanliness and hygiene
The man’s mother expressed concern that more dishes than were sufficient
for the two days her son was in the cell were found there after his death.
They suggested that he had been put into an unclean (as well as an unsafe)
cell. The evidence of two officers who moved the man on 22 March is that
they swept out all the cells themselves. I have no reason to doubt what they
say, especially given the level of disgust they expressed at what they found.
It was apparent that many cells had not been tidied or cleaned for some
considerable time. Some of them - including the man’s - smelled bad.28
It is evident from both the man’s mother’s evidence and that of staff to the
police that the man had also neglected his own hygiene.29 He claimed that he
28 I understand that the man would have been offered the opportunity to clean his cell, but this
is not the same thing as staff ensuring that the cell was clean.
29 This in itself should have been identified as a cause for concern (it is one of the warning
signs listed in Rye Hill’s policy on suicide prevention) - especially given that he had previously
been careful about his hygiene and appearance.
41
did not have a toothbrush (and none was found in his cell after his death). We
know he declined a shower on 21 March, and on 22 March he was unable to
take one (there was a problem with the power). An attempt to take him for a
shower on 24 March was aborted. Staff cannot of course force a prisoner to
wash, but they should have tried all measures open to them to ensure that the
man did so. One of the things certain to exacerbate depression is low self-
esteem. How must he have felt about himself in a cell that smelled and was
strewn with dirty dishes, and when he had not showered or brushed his teeth
for several days? Common decency dictates that prisoners should keep
themselves and their cells clean, but this assumes much greater importance
in relation to someone who has stated their readiness to die. It should have
been incorporated into his care plan as soon as staff became aware it was an
issue.30
I recommend that arrangements for ensuring the cleanliness of both the
prisoner and his environment should form part of any support plan
where there are indications that the prisoner is neglecting either or both.
There is evidence of poor management by the Segregation Unit Manager
which might in part explain the state of the cells.31 But responsibility does not
sit wholly with him. It is clear from his evidence to the police and following the
trial that the he felt unprepared and unsupported in his role. Segregation units
are rightly robustly regulated. Certain members of staff – including a
governor, a doctor and the chaplain – are required to attend on a daily basis
to ensure that all is well. The unit log shows that the requisite staff visited –
but I have to ask what use their visits were if they failed to identify basic
problems of hygiene or, having identified the problems, failed to act on them.
I recommend that GSL provides managers with additional training with
regard to their responsibilities in relation to the segregation unit.
SASH checks
No entries at all were made on the man’s SASH record whilst he was on the
visit on 22 March. Potentially key information could have been gleaned during
this time, as his mother has said that her son was distressed throughout the
visit. She also relayed her concerns to visits staff. The officer who went to
30 GSL said it was “too simplistic to say more should have been done to persuade the man to
co-operate, given the evidence of numerous failed attempts to engage with him.” However, I
have found no evidence to suggest that segregation staff had noticed either the state of his
cell before the two residential managers did on the evening of 22 March or the man’s own
unkempt appearance before the Duty Director did so on 23 March. Certainly, I am not
persuaded that they even tried to engage with him in these respects. GSL have said there is
clear evidence that he was offered and encouraged to have a shower and accept clean
clothes, but this did not happen until 24 March following the Duty Directors direction the
previous day.
Referring to the man’s mother’s allegation that her son did not have a toothbrush, GSL
commented, “We are not able to say if the man had or did not have a toothbrush. However,
what we can say is that a toothbrush would have been provided on request. It was clearly not
the case that he had not been able to brush his teeth or to wash. He had declined to do so.”
31 As noted at footnote 14 above, HM Chief Inspector of Prisons found that staff were
unwilling to challenge difficult prisoners.
42
collect the man for his visit told the police that segregation staff did not inform
the escorting officers that he was subject to SASH observations. Nor did they
give them the F2052SH on which to continue to record observations. This too
shows a lack of a co-ordinated approach to the management of those at risk
of self-harm.
I also recommend that he reminds staff that the F2052SH (now ACCT
form) must accompany the prisoner to whatever part of the prison he
goes.
(I note that visits staff responded to the man’s mother’s concerns by trying to
find a manager with whom she could speak. In light of what she told them
and the fact that they were not aware that the man was already on an
F2052SH, it is arguable they should have raised one themselves.)
On the day of the man’s death, no-one was specifically detailed to carry out
the SASH observations on either the man or another prisoner on an open
F2052SH. (The Segregation Unit Manager maintained that he had asked a
PCO to keep an eye on the man; The PCO said the Segregation Unit
Manager told him to keep an eye on the paperwork.) Nevertheless, it seems
that checks were carried out as they have been entered on the monitoring
sheet. (In saying this, I am conscious of statements from several prisoners
that no such checks were carried out and of evidence that records were
falsified in the man’s case as well as others.) In the period to 11:00 am, the
sheet was filled in by the PCO.
However, it is not clear whether the sheet was completed contemporaneously.
A PCO told the police that she had looked at the SASH records in segregation
on 24 March and found that there was about an hour’s worth of entries that
had not been completed for the man. (Since she said the man’s cell buzzer
was being used constantly whilst she was there, she must have noticed this
before 10:19 am.) However, she said she did witness a PCO answer the
man’s buzzer several times while she was there.
A PCO made his last check at 11:00 am. (This was corroborated not just by
the record but also by the Segregation Unit Manager who said the PCO
reported to him at this time that the man was once again asking for a shower.)
However, at 11:00 am, the PCO was asked to help out with adjudications.
No-one appears to have considered who would complete the SASH checks
thereafter, and the PCO did not mention them even though he had been
carrying them out alone for the previous hour. As a result, they were not
done. (The Duty Director denied that he had told the Segregation Unit
Manager that he would take care of the segregation unit regime whilst he (the
Segregation Unit Manager) was occupied with adjudications.)
During the police investigation, a PCO admitted that he wrote the four final
entries for the period between 11:00 am and 11:43am on the instructions of
the experienced PCO. This was after the Unit Manager had failed to get a
response from the man at 12:10 pm.
43
Unfortunately, the failure to carry out and record SASH checks was not
confined to the day of the man’s death. The Safer Custody Manager told the
police she had complained in writing over a long period that these were being
neglected regularly, and she had brought this to the attention of managers,
including the Segregation Unit Manager. In fact, she told the police she had
spoken to him about gaps in the SASH records. On 23 March, she had
spoken about the period the day before when no entries were made on any
SASH records between 1:15 pm and 5:45 pm.
A PCO also told the police that, about two or three days before the man’s
death, a new PCO had brought to her attention a SASH record where his own
entries had been changed to cover up a gap in the recordings earlier in the
shift. The PCO said she warned all the PCOs whom she saw in the
segregation unit about the importance of completing and documenting SASH
checks. She said she told the Segregation Unit Manager about two days
before the man’s death that he needed to get his officers to fill in the SASH
and keep it up to date. She said it was not the first time she had mentioned
this to him, but little improvement in the records had resulted.
I recommend that Unit Managers be required daily to sign the Unit
Special Watch Records to show they have checked them and also to
note any action taken to rectify identified problems.
I also recommend that Rye Hill considers placing the Unit Special Watch
Records outside the respective prisoner’s cell so that it can be
completed on the spot by the member of staff carrying out the check.
In view of the doubt over whether the checks were actually carried out and
indeed the need for the actions of segregation unit staff to be open to proper
scrutiny,
I endorse HM Chief Inspector of Prisons’ recommendation that CCTV
should be installed in the segregation unit.
The clinical reviewer pointed out that Rye Hill requires a six times an hour
watch on all prisoners identified at risk of suicide and self harm unless the
level is raised or lowered on the instructions of the weekly SASH meeting.
She suggested that this local procedure is not part of any national guidelines
and its application is indiscriminate. It is also in excess of the requirements
set out in PSO 2700 and places enormous demands on staff, especially
where more than one prisoner is subject to the arrangements. In this respect,
the policy may well have been set up to fail. Faced with an overly
burdensome task, staff are unlikely to carry out the checks, or be unable to do
so, or to record that they have done so.
It is also possible to envisage circumstances where any sort of watch would
not be appropriate. It is commendable that Rye Hill wishes to ensure the
physical safety of those identified as at risk from self harm, but this is both
labour intensive and may distract from the implementation of other measures
to support the prisoner and help him through the crisis. Such intensive
44
supervision may also be intrusive for the prisoner and tend to exacerbate his
state of mind rather than otherwise.
I recommend that Rye Hill reviews its policy with regard to observations
of prisoners identified as being at risk of self-harm.
Falsification of suicide watch record
One of the most troubling aspects of this case is that staff allegedly falsified
records in order to make it look as though the man had been properly
monitored. The Segregation Unit Manager admitted that, despite warnings
from the Safer Custody Manager about record keeping in the segregation unit
in relation to F2052SH, he had made four false entries in the man’s special
watch record on 23 March. In fact, he was involved in the man’s Rule 45
review during the period for which he signed the sheets. He admitted that no-
one else had made the checks.
The experienced PCO also admitted to the police that he had falsified entries
(although not in the man’s F2052SH) because he was too busy. He claimed
that he often checked prisoners without actually noting the fact at the time.
He also admitted telling a PCO to falsify the record for an hour during the
morning of 24 March (the hour during which the man probably died).
I also note that in several instances on the man’s F2052SH the checks have
been recorded on a computer, with the same entry being made repeatedly.
This of itself makes one question whether the checks were actually carried out
or if the form was simply filled in at some time during the shift.
I shall not say much more about this, as it has been the subject of a criminal
prosecution. What I can say is that it suggests that at least some staff knew
that they were supposed to carry out checks on prisoners at risk of self harm,
but did not truly appreciate the significance of the role. They appear to have
believed that it was important only to go through the motions and if that did
not happen, to make it look as though they had. Until the man’s death, there
appears to have been little appreciation that the measures they were required
to take were aimed at saving a man’s life. I hope the message has got
through and that details of this report are used in GSL’s training on suicide
and self harm.
The other key point to make is that, to paraphrase the title of a hugely
influential report issued by the then Chief Inspector of Prisons, suicide is
indeed everybody’s concern. It is not sufficient to say that there was not
enough time or that no instructions were given. Everybody has a duty to be
proactive and assume responsibility where self-harm and suicide is
concerned. This struck me most forcibly in reading the police interviews with
those who were charged with manslaughter. They make salutary reading.
I recommend that, subject to the views of the police, the transcripts of
interviews of staff by the police be used in some form during staff
training.
45
Self Harm and Suicide Prevention Policy and Procedures
Completion of F2052SH
In completing his section of the F2052SH, the Duty Security Manager advised
that the man should be offered “full support as per Rye Hill policies” and that
he should have counsellor support. This is a lazy way of formulating a care
plan and could be said to demonstrate a lack of care.32 It shows no
recognition that each prisoner at risk of suicide has individual needs that may
not fall into a ‘norm’. It shows no consideration of the man’s particular
circumstances and I have found no evidence that the ‘plan’ was ever
considered subsequently. Nor did it identify who was responsible for ensuring
the care plan (such as it was) was implemented.
Given that the man had apparently expressed his readiness to die, and in light
of his unwonted behaviour earlier in the day, I am surprised that the Duty
Security Manager did not make an immediate referral to healthcare. I am led
to wonder whether he actually saw the man for himself before making the
entry.
The doctor who saw the man at 7:20 pm on 20 March also does not appear to
have examined him, and there is nothing to suggest that he was aware of the
incident earlier in the day when the man stripped naked in the exercise yard.
All in all, I am struck by a lack of rigour and application in completing the main
body of the form.
Daily Supervision and Support Record
Rye Hill’s suicide prevention policy (paragraph 9.5.2) requires an entry in the
prisoner’s F2052SH at the end of each shift commenting on his behaviour and
demeanour. It states, “It is important to make valued and informative entries.”
PSO 2700 requires entries to “demonstrate meaningful interaction”. However,
the clinical reviewer has commented that in many instances the man’s
F2052SH contained just two entries a day – both by the night staff and not at
all meaningful – for example, “in bed reading” or “no problems”.
The clinical Reviewer judged that staff had failed to use the Daily Supervision
and Support Record in the F2052SH in any meaningful way. The clinical
reviewer has pointed out that the record should tell a story about the
prisoner’s behaviour and mood, and track the success or otherwise of the
support plan. Staff have completed the special watch to the detriment of the
support record. Very few staff other than shift managers wrote in the body of
the record and it was rarely meaningful. She has said that she expects
32 The Duty Security Manager’s instruction also pre-supposes that all staff would be familiar
with Rye Hill’s policies. Evidence given to the police suggests that they were not. Even the
Segregation Unit Manager, who might be considered to be in the lead with the man’s care,
told the police that he was not familiar with the suicide prevention policy document.
46
healthcare staff to write in the document each time they see a prisoner on a
F2052SH who is not an in-patient. At Rye Hill they did not do this. The only
people who wrote in the record other than unit staff were a Duty Director and
a chaplain.
The former residential manager spoke on two occasions to his mother.
Accounts differ as to the degree of detail given by his mother. She said she
mentioned her son’s injuries to the former residential manager, but this was
denied.33 However, the fact is that by the time of their second conversation in
particular, the man’s mother was extremely concerned. This should have
prompted the former residential manager to instigate an urgent review.
Certainly, she should have recorded the conversations in the F2052SH as
required by PSO 2700.
The Duty Director also spoke to the man’s mother when she apparently
expressed her concern about her son’s behaviour during visits and the effect
segregation was having on him. He did not make any entry about this on the
F2052SH.
I recommend that the Director reminds staff of the need to recall all
salient events in the Daily Supervision and Support Record and of the
need to make meaningful and informative entries at the end of each
shift.
In light of the man’s mother’s reported difficulties in speaking to someone to
relay her concerns and the doubt around what exactly was said,
I recommend that GSL establish a dedicated phone line for people to
contact in order to report concerns about prisoners. The line should be
manned 24 hours a day and calls recorded.
Unit Special Watch Record
PSO 2700, at paragraph 4.2.3, instructs that “supervision of the suicidal
should be active, involving supportive contact rather than mere observation.”
Of course, during the night when the prisoner is asleep only simple
observation would be appropriate. However, the entries generally at Rye Hill
show a lack of engagement with the man during the checks (this is not to say
of course that others did not engage with him at other opportunities) and
provide little, if any, insight into his present state of mind. It is worth noting
here that the form itself does little to encourage staff to provide any useful
information – there is space only for a very few words for each entry.
33 The former residential manager told the Deputy Ombudsman that she had told the man’s
mother when she would be available. She acknowledged that she made a comment that the
man looked better than he did previously, but a bit spotty (she said there was no mention of
moisturiser). As far as the man’s mother specifically mentioning marks to her, she said that
this was not the case. She said their conversation covered a range of topics, including
arranging for the man’s mother to visit, his brother’s birthday, property and staff corruption.
She added that, during the trial, the man’s mother said she could not be sure what she had
told the former residential manager.
47
I recommend that Rye Hill reserves its Unit Special Watch Record for
night time entries and requires staff to record daytime checks in the
Daily Supervision and Support Record.
Management oversight
The minutes for the Suicide Prevention Team meeting on 21 December 2004
record that part of the role of the newly appointed Safer Custody Manager
was to ensure all the F2052SH paperwork was correct. A marked
improvement in quality was noted. The minutes say that the Safer Custody
Manager was writing to individuals who had failed to carry out their duties
correctly by not filling in SASH paperwork. The minutes indicate that
disciplinary action would be taken against persistent offenders.
I welcome the close oversight of standards of form completion. The clinical
reviewer has commented that, in her experience, performance and record
keeping only improve if staff have evidence that managers are regularly
checking the F2052SHs and putting a note in each record. I was concerned
therefore to discover that Rye Hill’s pro forma for monitoring F2052SH records
includes columns for ticking where things have happened, but does not have
any section inviting comments on qualitative issues. This is a significant
oversight, since the actual carrying out of various functions is largely irrelevant
if the quality of the work is sub-standard.
I recommend that Rye Hill revises its management audit form for
F2052SHs to incorporate a space for qualitative comments.
However, the detail of the form is unimportant if it is not actually used. The
clinical reviewer noted that managers at Rye Hill Unit are required to do a
quality check of entries at least twice a week. She said there was no
evidence of this.
Not surprisingly, therefore, the minutes for the Suicide Prevention Team
meeting for 17 March 2005 record that, “The audit sheets are showing that the
main areas of concern for incomplete booklets is Unit Managers and the
general observations.”
Case reviews
PSO 2700 requires there to be a formal review of any prisoner on an open
F2052SH within 72 hours of the form being opened. Such a review was
therefore required before 4:30 pm on 22 March. It did not take place until 23
March (and it is a moot point that one took place in any meaningful sense
then). However, I believe an urgent review should have been convened much
earlier. The clinical reviewer noted that the local policy for Rye Hill lists a
number of warning signs for staff to look for to identify prisoners at risk of
suicide or self-harm. These include crying, mood swings, poor personal
hygiene, suicide notes. She commented that all of these applied to the man
but no action was taken.
48
This point is worth repeating. All of the potential warning signs were present
in the man, but no action was taken.
There were also a number of specific incidents that should have prompted an
urgent case review. The incident where the man stripped naked in the
freezing cold during exercise was one, as was the note he pushed under his
door saying he wished the Almighty would take him away. In light of his
general demeanour at the time, it is arguable that his asking to be hosed
down and refusing to move either backwards or forwards (though ultimately
not putting up any resistance when he was moved) might have properly
triggered a review.
I get no sense of staff truly engaging with the man’s situation and responding
appropriately. Some - notably members of the chaplaincy and perhaps a
PCO - made efforts to support him, but there appears to have been a
collective failure really to get to grips with his needs.34 It may be that they
were more preoccupied with the possibility of violence, or it might have been
that they set too much store on the assumption that he was coming down off
drugs and thought things would simply resolve themselves over time.35
72 hour case review
In the event, there was no F2052SH review until 23 March, when one was
apparently conducted following the man’s segregation review. The entry on
his SASH page 3 records that the Duty Director, the Segregation Unit
Manager and the Healthcare Assistant reviewed his case, but it is inadequate,
unsigned and undated. It advises that the man should receive full support
and that a counsellor should be made available. The form identifies that
segregation unit staff were to be responsible for the full support, but it does
not identify a single individual for making sure this happened. Nor does it
describe what form that support should take. There is also no mention of
referring him once again to healthcare, despite the conclusion of the
segregation review (conducted immediately beforehand) that he should
remain in the unit pending assessment by healthcare staff.
The Duty Director told the police he had never seen the form and it seems
likely that the Segregation Unit Manager completed it by himself after the Rule
45 review. This was plainly inappropriate. Whilst there might properly have
been cross-reference between the two reviews, they had quite different
purposes. A proper 72 hour review should also have been attended by a
34 The man was of course due to be seen by the visiting consultant psychiatrist on the
Thursday. This was a speedy referral, but staff should have been actively managing him in
the interim.
35 GSL commented, “We do not consider this to be a fair representation of the situation. First,
because it implies the members of the chaplaincy made the only noteworthy efforts to support
and engage with him, which is certainly not the case as we have detailed elsewhere …
Second, because when staff rightly consider the risk of violence it should not be assumed
they are incapable of making a professional judgement. Third because it is not correct that
the man had previously been involved in only one incident of violence. He had a poor
behaviour record in custody at Rye Hill and prior to his arrival here.”
49
chaplain (with whom the man had had significant contact) and a Registered
Mental Nurse.
50
Audit
Even following the man’s death and the various issues raised in relation to
SASH observations and form filling, an internal suicide and self-harm
prevention audit conducted in May 2005 noted a need for training for staff to
be followed through. The following weaknesses were identified:
• F2052SH log not up to date
• Entries on 2052SH lacked depth
• Some entries looked repetitive and entered all at the same time
• Support plans sketchy
• Photos missing from F2052SH
• Manager’s initial assessment not always filled out
• The 72 hour reviews not done on time
• Initiating officers’ comment not entered in 100 per cent of cases
• Segregation use of special accommodation paperwork not in place, log
not up to date
• Listener scheme not in operation [still]
• Multi-disciplinary teams but did not include the prisoner himself or any
external agencies.
I recommend that GSL bolsters its suicide prevention training to cover
all the shortcomings identified in the investigation into this case and the
audit and that refresher training is provided for all operational staff on a
frequent and regular basis.
Shoelaces
PSO 2700, at paragraph 4.4, instructs that, “Personal items including
shoelaces and belts must not be removed from at-risk prisoners as a matter of
course. The reasons for the decision to remove or return items must be
recorded in the prisoner’s F2052SH.”36 Removing belts and laces, even
when done with the best of intentions, can be counter-productive since it may
lower the prisoner’s sense of self-worth and make him feel even worse about
himself. Staff should only resort to removing articles of clothing when nothing
they are doing seems likely to prevent the prisoner from trying to kill himself.
However, the premise on which the instructions and guidance in the PSO is
based is that staff will take very good care of prisoners at risk of suicide and
self-harm. I cannot say that this was the case with the man. Worryingly, I can
find no record of the question of his retaining his shoelaces ever being
considered.
Ligature point
The cells at Rye Hill are designed to be safer cells. This does not mean that
they are ‘suicide proof’. It means that the opportunities for spontaneous acts
of self-harm are much reduced. The man hanged himself from a shoelace
36 It is worth mentioning here that, had the man been located in the healthcare centre, his
shoelaces would have been removed as a matter of course.
51
that he had threaded through a small hole on the door plate. The hole should
not have been there.
The plates securing the observation panels should be entirely smooth. They
should therefore be held in place by means of welding from the other (outward
facing) side of the door. However, in this instance, it seems likely that, when
the panel was replaced following some repair, it had been attached by means
of a rivet – or at least that this was the intention. Either a rivet had been
inserted at some time and then fallen out, or the rivet had never been put in.
As a result, a small hole was left in the plate and the corner of the plate was
capable of being eased away from the surface of the door. This provided an
easy and obvious ligature point.
I understand that cell doors should be separately examined (that is, quite
apart from the daily locks, bars and bolts checks37) every 13 weeks. The hole
had clearly been there for much longer than this as it had been painted over.
It is difficult to see how an examination could have failed to reveal the hole in
the door plate. This calls into question whether these important checks were
actually carried out, or if they were, to what standard?
I have considered whether the officers who re-located the man were negligent
in placing a man on an open F2052SH in a cell with a ligature point. Although
I would expect them to check that the cell was serviceable, I would not
ordinarily expect them to carry out a full fabric check. The hole was on the
back of the door and would not have been visible to someone standing in the
cell with the door still open. I cannot criticise them for not having noticed it.
Certainly, in their evidence to the police, the staff concerned suggested that
they were relying on the locks, bolts and bars checks having been carried out
properly.
I infer from the police evidence that staff were reluctant to enter the cells in
the segregation unit while the occupant was inside them. It could be that,
aside from poor management, this accounts for the lack of fabric checks. I
need hardly add that, if this is the case, it is extremely worrying.
I recommend that the Director impresses on managers the imperative
that all cells should be inspected daily, regardless of the occupant. (It is
particularly important that the cells of those considered to be at risk
should be examined closely to ensure no action has been taken to
facilitate self-harm.)
It is to be hoped that such inspections would also ensure there is no build up
of old food, plates and eating utensils.
37 There was no record of any locks, bolts and bars checks having been carried out in the two
weeks before the man’s death.
52
Response after the man was found behind his door
The Unit Manager said that, when she first saw the back of the man’s head
against the hatch, her first reaction was that he was playing up. Unable to get
any response from him, she apparently went back down the stairs
(remembering that his cell was located the furthest away from the office) and
spoke to the experienced PCO before returning to the cell. The experienced
PCO asked for the Duty Security Manager to attend, but no-one entered the
cell until he arrived. The officers involved said that this took a matter of
seconds, but in reality it must have been a matter of minutes. All in all,
several minutes must have passed between the time the Unit Manager first
went to the man’s cell and when the door was unlocked. (Worryingly,
although timings on statements cannot be taken as absolutely accurate, the
Unit Manager said she went to the man’s cell at 11:55 am and the Duty
Security Manager said he received the call at 12:10 am.) Such time loss can
be crucial in determining whether someone lives or dies.
I entirely understand staff’s concerns about unlocking potentially violent and
unpredictable prisoners without proper back-up (one of the officers concerned
said he had in mind a previous incident where a prisoner pretended to be ill
and then attacked staff who entered his cell to help him). I also appreciate
that the man had shown extreme strength in trying to exit his cell the previous
Saturday. Inevitably, staff would have heard about that incident and would
have feared a repetition. The police have suggested that, given that the man
was behind the door, staff could easily have closed it quickly had he reacted
when they opened it. However, this does not allow for the circumstance that
the prisoner remains still until the door is fully open and staff are inside the
cell.
Nevertheless, there were three officers present, with another one in the unit
office and the man was known to be a high suicide risk. My own view is that
an attempt should have been made to open the cell as soon as the three
officers were there. (I also believe that the threat posed by the man had been
over-stated, notwithstanding the incident on 19 March.)
However, it was a judgement call on the day and taken in the heat of the
moment. I do not think staff were wrong to be concerned about the potential
risk they felt they were facing.
Healthcare
I set out below the clinical reviewer’s examination of the issues and her
conclusions in relation to the healthcare afforded to the man. However, I first
have a couple of observations of my own.
Rye Hill’s Healthcare Policy states (paragraph 4, Policy and Procedures
PD10), “Only in exceptional circumstances will [mentally ill prisoners] be
located in the Health Care Centre.” I dislike this formulation. I accept that it
will not always be appropriate to locate mentally ill prisoners in healthcare
(just as it is not appropriate for every mentally ill person to be treated in
53
hospital outside prison). But the phrase “only in exceptional circumstances” is
too great an inhibitor. The clinical reviewer commented that it was probable,
bearing in mind statements by healthcare staff about the man’s unsuitability
for admission, that this guideline had resulted in a ‘closed door’ policy where
mentally ill prisoners were concerned at Rye Hill.
I recommend that the Healthcare Policy is amended to read that,
“Mentally ill prisoners should be located in the healthcare centre strictly
according to clinical need.”
The Healthcare Manager told the police that they tended not to accommodate
unpredictable or violent patients in the healthcare centre, as there were only
nursing staff there and they had no control over prisoners. In addition, such
prisoners might disrupt other patients. She said that if such a prisoner were to
be located in healthcare, then discipline officers would have to be brought
from the main prison to unlock the patient. Instead, healthcare staff treated
them on the wings.
I do not consider that this is acceptable. I am concerned that it also reflects a
more general reluctance to engage with prisoners who might be violent or
unpredictable. This is evidenced in part by the practice of interviewing and/or
assessing prisoners from their doorways – both the regular prison doctor and
the RMN assessed the man from his cell door. Of course the safety of
nursing staff is important. But the prison has a duty to look after prisoners
and their (mental or physical) health should override any other considerations.
This means that they should be located in an appropriate therapeutic
environment where their condition can be monitored round the clock,38 and
where it is possible for staff to engage meaningfully with them throughout the
day – not merely to check on physical safety during the SASH observations.39
If concerns about the man’s mental health on 23 March were such that it was
not considered appropriate to locate him on one of the wings, he should have
been transferred to the healthcare centre and appropriate additional staff
should have been detailed there as necessary.
The clinical reviewer commented that the healthcare centre at Rye Hill has a
policy for such circumstances. If the nursing staff had wanted to assess the
man in the healthcare centre but were concerned about the risk to
themselves, the Duty Director could have authorised custody officer support.
She added that, from the evidence in both policy and interviews, she did not
think Rye Hill had any experience of making such as decision.
38 The man appears to have suffered episodically, so that it was something of a lottery as to
what condition healthcare staff found him during their visits to the segregation unit. They
appear to have generally turned up during his calmer periods.
39 This is not to undermine the efforts of staff in the segregation unit. Several prisoners told
the police about staff spending time talking to the man when he was crying until he finally
calmed down. However, this is not the same as being able to focus attention on him rather
than finding time for him amongst the many other pressing tasks with which they were
charged.
54
Rye Hill’s inaugural Safer Custody Bulletin (March 2005) alerted staff to the
existence of a crisis suite in healthcare. It said the room was “for prisoners
who display a high risk of serious self-harm or committing suicide to spend
some time in an atmosphere that is calming.” Two Listeners would remain
with the prisoner in crisis. The man was clearly such a prisoner. It is difficult
to see why, given the note he had written, his express readiness to die, and
his bizarre behaviour, he was not moved into the suite. I can only conclude
that this did not happen because he was viewed as being too volatile. I am
not impressed by a suicide strategy that caters only for well behaved and
placid prisoners.
I recommend that GSL discusses with Primecare what needs to be done
by both parties to ensure all prisoners get the healthcare to which they
are entitled.40
I also recommend that GSL impresses on Primecare the need fully to
record all developments, assessments and treatments in the IMR and,
where the prisoner is at risk of self harm, the ACCT form (bearing in
mind the need for medical confidentiality).
(I have in mind here particularly, although by no means exclusively, the fact
that treatment was available for the man should his condition deteriorate, but
no-one - residential or healthcare staff - was aware of this.)
Assessment of the man’s mental health
The clinical reviewer commented that, quite apart from the symptoms of
mental illness manifested by the man following his segregation, PSO 2700
says:
“4.1.2.2 A mental health assessment must be undertaken by health
care staff of all prisoners at risk of suicide or self–harm who are placed
in a Segregation Unit, and the reviewed care plan implemented.”
She said the adjudication procedure provided an opportunity to medically
examine him. Records show that the Controller adjourned his outstanding
adjudications for medical reports. The clinical reviewer said it would have
been the responsibility of the Unit Manager to ensure this happened, thus
enabling the man to be presented for his adjudications in a timely manner.
However, despite the hearings twice being adjourned for the purpose, the
medical examination did not take place.
The clinical reviewer said that the Senior Nurse correctly reported her
concerns about the man on 21 March to her manager and to the regular
prison doctor. The clinical reviewer was struck that, notwithstanding the fact
that the Healthcare Manager, a psychiatric nurse, sought advice from the
visiting forensic psychiatrist following the Senior Nurse’s ‘referral’, she did not
actually go to see or assess the man herself. Similarly, the doctor (not himself
40 Healthcare provision at Rye Hill is sub-contracted by GSL to Primecare.
55
a mental health specialist) did not himself confer with the consultant
psychiatrist. (The clinical reviewer said she found this entire third party
consultation unsatisfactory. I agree.) The regular prison doctor visited the
man on 21 March and said he would review him later that day or tomorrow,
but there is no evidence that he actually did so.
An RMN visited the man in his cell at 10:15 am on 22 March. He found him to
be calm and rational and showing no psychotic symptoms. The man
apparently told him he felt well and had no problems. The RMN told the police
that his condition did not give him any reason whatsoever to suggest that he
should be removed from the segregation unit to healthcare.41 I note that this
interview was conducted from the man’s doorway.42 I do not consider that
this meets the requirement in the PSO for a mental health assessment. The
RMN told the police that, where he considered it warranted, he would ensure
that patients were taken somewhere private for assessment but he did not
consider this was appropriate here. I suggest this should happen in every
case.
I recommend that arrangements are made for all mental health
assessments to take place in privacy whilst ensuring the safety of the
interviewer. It is generally unacceptable for healthcare assessments to
be carried out in the doorway of the prisoner’s cell.
The man was due to see a psychiatrist on the day he died. But this was four
days after his behaviour first gave real cause for concern. In the interim,
whilst there was contact with mental health services, I am not persuaded that
he was properly assessed as required by the PSO.
The clinical reviewer noted that experienced psychiatric assessment might
have uncovered the level of risk the man’s distress presented. She also said
he might have been calmed by the administration of the prescribed diazepam
until the psychiatrist appointment. She was not critical that the olanzapine
was not given. To recommend such a drug on the strength of a telephone
conversation was surprising. The clinical reviewer commented that it would
have been preferable for the regular prison doctor not to have prescribed it
without speaking to the Forensic Consultant Psychiatrist himself. She added
that it would have been a benefit to the man if the psychiatric appointment
could have been arranged in less than four days (Monday to Thursday
interval). She surmised that there was no urgency attached to the request for
41 It was on the afternoon of 22 March that the man had his visit with his mother at which he
was very distressed and said he had been told his family was dead. This suggests two
things. It emphasises the episodic nature of his condition (and therefore the importance of
keeping him in healthcare where his state of mind could be constantly monitored by trained
professionals). It also calls into question the appropriateness and effectiveness of carrying
out a mental health assessment in his cell with numerous people around.
42 All the medical and nursing interventions appear to have been at the cell door or through
the observation flap. At no time was the man observed closely enough for his injuries to be
observed, yet his mother saw them straight away in visits on 22 March. No other staff saw
them either, despite him being unclothed from time to time in their presence.
56
an opinion because of the assumption that the man’s state was drug induced
and would resolve itself.
(I should say that I am surprised this suspicion was not formally tested at the
outset.
I recommend that where a prisoner’s unwonted behaviour is suspected
to be drug-induced, a ‘dip test’ be carried out immediately.)
GSL commented that,
“With the benefit of hindsight one may be critical of the quality and
timeliness of healthcare/ mental health provisions delivered to the man.
We accept there is justification for concluding that the very rapid
deterioration in hiss mental health was not properly diagnosed soon
enough or appropriately treated … However, we believe that in
engaging a specialist healthcare contractor the prison management
and custodial staff should be entitled to rely on the expertise of the
qualified professional healthcare staff. At this stage we have our
healthcare provision under review.”
I assume a copy of this report will form part of that review. However, to
ensure that the lessons of this investigation are not overlooked,
I recommend that a copy of this report is provided to the Chief Executive
of Primecare.
Throughout her report the clinical reviewer is critical of the failure by
healthcare really to get to grips with the man. I wholly endorse her comments.
There was a lack of thoroughness, engagement and effective follow-up in
their dealings with him. However, the fault does not lie entirely with
healthcare staff. Despite clear and recorded concerns about his condition,
and repeated references to his crying and ‘bawling’, no-one ensured that
healthcare staff took the situation seriously and gave more than a cursory
check. I can find no evidence that healthcare staff were kept fully in the
picture about his condition – that they were not informed, for example, about
the episode in the exercise yard, about his strange behaviour when taken for
a shower or about the extent of his evident distress. Above all, there is no
evidence that segregation unit staff (or others) pressed healthcare to become
more involved. As time went by, staff should have repeatedly asked
healthcare to assess the man and ensured that this happened. Despite their
own real concerns, they seem to have been too easily satisfied with
healthcare having visited and with the received wisdom that the man’s
condition was drug induced. (This should in any case have made no
difference to their response to him.) It is almost as though they considered
that their responsibility was discharged by the very fact that healthcare had
seen him. This was not the case, of course, and they should have impressed
on healthcare the need for thorough, in-depth checks. Medical expertise was
not necessary to know that there was something clearly (and medically)
wrong with the man – whether or not this was induced by drug taking. (The
57
post mortem toxicology report found no evidence of alcohol or drugs of any
description other than atropine, which the toxicologist suggested was probably
administered during the resuscitation attempt.) 43
The responsibility to ensure that the man received appropriate clinical care
was shared by all staff who came into contact with him. However, PSO 2700
places specific responsibility on the Unit Manager to consult healthcare staff
again if the prisoner’s condition deteriorates and requires further medical
assessment. The Segregation Unit Manager has left GSL’s employment, but
there is a lesson here for all Unit Managers.
I recommend that the Director at Rye Hill reminds all Unit Managers of
their specific responsibilities with regard to engaging healthcare staff
meaningfully in the care of prisoners at risk of self-harm and of sharing
with them current information about the individual.
Corruption allegations
The man’s mother suggested that her son might not have been properly
looked after because of the allegations he had made about staff at Rye Hill.
On 17 March 2005, the man alleged that four (named) officers were bringing
drugs and/or mobile phones into the prison. This allegation and its possible
ramifications formed part of the police investigation into his death.44
One of the PCOs named by the man was charged for being concerned in the
supply of drugs. He was found in possession of small amounts of
amphetamine and cannabis and was dismissed by the prison for the drugs
offence. He currently awaits trial for conspiracy to supply drugs. A second
officer was arrested but not charged. A third officer named by the man was
not arrested, although the police inquiry team spoke to him. The man’s
allegation gave no details and no intelligence supported the officer’s
involvement in these matters. The fourth ‘officer’ was identified as probably
being an orderly (that is, a prisoner), and could not therefore be charged as a
corrupt officer.
The police concluded that there was no direct evidence that staff mistreated
the man as a result of the allegations. However, the senior investigating
officer commented that:
“I can find no evidence that would indicate these failings and the
acts/omissions of individuals resulted from any motive associated with
43 GSL commented that, “it is apparent that certain officers failed to carry out their SASH
watch duties properly and to maintain records appropriately. There is justification to assert
that more should have been done and sooner about the man’s deteriorating mental health;
there were errors of professional judgement. That is very different from suggesting that the
majority of staff involved with him didn’t care.”
44 GSL said they had no evidence to support the man’s mother’s allegation that her son had
named five officers to police as being corrupt. They said, “We do know the context of police
involvement is that the prison management called in the police when the man allegedly tried
to corrupt an officer by handing him the note asking him to obtain drugs and a mobile phone.”
58
the man’s corruption allegations against staff. This is naturally at the
forefront of some family members’ views. Whilst I cannot substantiate
mistreatment as a result of his corruption allegations I find it equally as
challenging to rebut such a suggestion.”
I am similarly unable to make a finding either way. I should add that, despite
my concerns about the decision to keep the man in the segregation unit, I can
find no evidence that this decision was taken other than in good faith and with
his best interests at heart. Significantly, the IMB member who was present at
the review reported on the Duty Director’s genuine concern for the man and
the sensitive way in which he had treated him.
Racism
The man’s mother also questioned whether her son was treated differently as
a result of racism by staff.
She said that her son had complained to his solicitor and to the Commission
for Racial Equality about racism at Rye Hill. In addition, the police took
possession of two letters the man sent his girlfriend in which he alleged the
same thing. However, these letters did not apparently provide any detail of
why he considered the prison was racist.
A comment on the man’s wing history sheet shows that he complained that
there was no-one black to serve him meals, and claimed that this was racist.
Apart from this, there is no record of his having made a formal complaint of
racism within the prison.
The man’s behaviour at Rye Hill was challenging. Some 29 SIRs were
submitted in which he was named. Amongst other things, these contained
allegations that he threatened or abused staff and was involved with drugs.
There appears to have been no attempt by either wing managers or other
senior staff to investigate and regulate his behaviour through advice or
counselling, or by use of the formal discipline reporting system. Certainly staff
do not appear to have dealt with him heavy-handedly – quite the reverse.
(Indeed, in light of the number of SIRs, there seems to have been a failure to
challenge him. One possibility is that staff felt intimidated and not in control.)
The police inquiry asked all those giving statements for any evidence of
attitudes, behaviour or comments made to or about the man of a derogatory
nature. None alleged any impropriety. The police concluded that the
evidence to hand did not justify suggestions of racism in respect of his
treatment, but they would remain open-minded. I can only endorse that
conclusion.
Contact with the family
The man’s mother complained that it was her sister-in-law rather than she
who was contacted following her son’s death. I understand that the prison
chose to phone the man’s aunt because she and her husband were due to
59
visit the man that afternoon. However, any parent would wish to know
immediately and at first hand that their child had died and not rely on a
message conveyed through a third party. I can only imagine how this must
have added to his mother’s distress. I appreciate that the prison wished to
prevent the man’s aunt and uncle arriving for the visit only to be told that their
nephew was dead. But surely it would have been possible to tell both parties
simultaneously or within a short time of each other. If, as the man’s mother
suggested, the prison told her that they could not find her number for her, I
agree that this was totally unacceptable. All the more so, given the number of
calls between her and the prison during the period 19 – 24 March.
I recommend that Rye Hill’s contingency plans include an instruction
that the next of kin be informed first hand and immediately of a death.
I am also saddened that the visit she made to Rye Hill actually added to her
distress. It would not have been appropriate for a category B prison simply to
have suspended all its security measures for the visit. But it is self-evident
that the visit by next of kin following a death in custody must be arranged and
conducted in as sensitive a way as possible. In particular, it can reduce the
shock if families are warned beforehand exactly what will happen on their
arrival (as suggested in PSO 2710, Family Liaison Officer guidance).
I recommend the Director at Rye Hill reviews arrangements for ensuring
visits from bereaved relatives are handled as sensitively as possible.
Finally, I note that the man’s mother said she had not received a letter of
condolence from Rye Hill. This is a shoddy, not to say heartless omission. It
is hard not to see it as symptomatic of every other failing revealed in this
report.
I recommend that, even at this late stage, the Director should write to
the man’s mother to offer her an apology for the omission and his
condolences over her son’s death.
I recommend that a requirement to send a letter of condolence to the
next of kin is incorporated into Rye Hill’s contingency plans.45
45 GSL said: “The evidence presented by the man’s is very distressing and she has my
sincere sympathy for the loss of her son in such tragic circumstances. The omission by the
prison management to write a letter of condolence to the family is a serious failure and is
contrary to our practice and operating procedures in our prisons when there is any death in
custody whatever the circumstances. It was either a serious oversight or a wrong judgement
at the time that such a letter would have been considered inappropriate in the circumstances
of the investigation into the death and the allegations made by the man’s mother. The
director has now written to her as you recommend and we will take steps to ensure our
procedures in this regard are followed.” I am very grateful to the Group Managing Director for
his frank acknowledgement and prompt action.
60
PART VI - CONCLUSION
Very few people who came into contact with the man during his last days
emerge from this investigation with any credit. They include the Duty Director
(who described the man as being ‘unbalanced and paranoid’, yet took no
action) and the most junior PCOs and Healthcare Assistants. Few reacted
with any urgency to the distress the man was showing. Many appear simply
to have gone through the motions of observing the suicide prevention policy.
Some did not even do that.
The impression is that the man was treated primarily as a violent,
unpredictable prisoner coming down off an illicit drug, rather than as someone
desperately in need of support. Staff did not engage with him in the way they
should with all at-risk and vulnerable prisoners – that is, face to face, in
privacy and without time constraints. More often than not, they spoke to him
from the ‘safety’ of his doorway. Ultimately, the perception that he was a
danger to staff rather than to himself also led to a delay in opening his cell
door when he was found slumped behind it. (I have no reason to suppose the
delay was material in the particular circumstances, however.)
The so-called care plan on the man’s F2052SH was simply hopeless. The
interface between discipline and healthcare staff appears to have been fragile
and remote. And there was a failure by all concerned to take personal
responsibility for looking after him and really getting to grips with his care.
I have not sought to hide the shortcomings of individuals where they have
been revealed in this investigation. However, many of the individuals of
whom I am most critical are no longer employed by GSL and it would be
wrong to scapegoat those responsible for lesser failings and omissions. In
addition to providing the man’s family with an authoritative account of what
happened, the purpose of my investigation has been to ensure that the
company and the prison learn the lessons from this tragedy. Systemic failings
– the operation of the suicide prevention policy and the interface between
healthcare and operational staff, for example – and weaknesses in training
and management must be robustly addressed.
Solicitors acting for the man’s mother commented on a draft of this report that
she was “somewhat surprised and disappointed at [my] reluctance to
recommend that GSL or Primecare bring any of their employees to account”.
They said:
“Given the depth of your investigation and the level of disapproval you
express regarding specific individuals, (relying in addition on the
findings of the clinical reviewer in her report) common sense and our
client’s legitimate expectations dictate that such individuals should be
held accountable in some way, including through disciplinary action. In
your own words, the majority of the officers appeared to have ‘simply
gone through the motions’ when dealing with her son and several did
so when they clearly should have done more and should be held
accountable for their serious lack of professionalism and care.”
61
The solicitors go on to list those individuals whom they suggest should be
subject to disciplinary action.
I have considered this matter further, but on balance am not minded to
change my original view. Those who manifestly did not do their job have
already been disciplined and no longer work for the company. In addition, I
understand that the healthcare team has been replaced with a new one, albeit
still under the auspices of Primecare. As for the others listed by the solicitors,
they do not emerge very well from my investigation but I do not consider their
actions are such as to warrant disciplinary action. Their conduct left much to
be desired, but the fact they did not go beyond the minimum expected of them
does not constitute a disciplinary offence. In addition, the death itself, the
ensuing criminal proceedings and my report will all have a salutary effect.
GSL acknowledged in their letter to me of 18 June, “that there were failures in
systems and safeguards and that on occasions procedures were not adhered
to. As a consequence some members of staff faced the unsuccessful
prosecution and internal disciplinary measures; our procedures and the
management systems to ensure compliance have been reviewed and
strengthened and we are implementing further changes some of which are in
line with your draft recommendations”. I welcome this response.
Nevertheless,
In light of the individual and systemic failings revealed in this report,
copies should be sent to the Minister, to the Chief Executive of the
National Offender Management Service and the Chief Executive of GSL
for their consideration.
62
LIST OF RECOMMENDATIONS
1. I recommend that the Director reminds staff that care plans should take
account of and address the specific conditions of the prisoner’s
location.
2. I recommend that those authorising segregation be reminded of the
need to draw up detailed, constructive action plans to safeguard the
mental health of those located in the segregation unit. This should
apply even to relatively short term stays where the prisoner is identified
as being at risk of suicide.
3. Bearing in mind that segregation need not be effected in the
segregation unit, I recommend that, even where a prisoner on an open
F2052SH is segregated, the Director should remind staff that
consideration must be given to accommodating him in a shared cell.
4. I recommend that a qualified, informed healthcare professional should
attend all Rule 45 review boards. Where there are concerns about a
prisoner’s mental health, this professional should be a mental health
specialist.
5. I recommend that GSL introduces on every unit a system of formal
handovers between each shift attended by all unit staff. The purpose
would be to inform them about any particular issues and to ensure
priorities are clear.
6. I recommend that GSL develops training modules specifically for
Segregation Unit Managers and staff. This should include dealing with
particularly challenging prisoners and the possible effects of
segregation and how they can be ameliorated. The training should
incorporate enhanced suicide prevention training with emphasis on the
drawing up and implementation of detailed, effective support plans.
7. I recommend that the Segregation Unit Manager is given specific
responsibility for ensuring he has sufficient numbers of trained staff on
the unit at any one time.
8. I recommend that a LIDS terminal be placed in the segregation unit.
9. I recommend that responsibility for preparing for and co-ordinating
adjudications be given to a member of staff other than the Unit
Manager.
10. I recommend that the Segregation Unit Manager is not required to
undertake other duties and that, where this is unavoidable, an
experienced and certified manager is allocated to run the segregation
in his absence (this should apply seven days per week).
63
11. I recommend that arrangements for ensuring the cleanliness of both
the prisoner and his environment should from part of any support plan
where there are indications that the prisoner is neglecting either or
both.
12. I recommend that GSL provides managers with additional training with
regard to their responsibilities in relation to the Segregation Unit.
13. I also recommend that he reminds staff that the F2052SH (now ACCT
form) must accompany the prisoner to whatever part of the prison he
goes.
14. I recommend that Unit Managers be required daily to sign the Unit
Special Watch Records to show they have checked them and also to
note any action taken to rectify identified problems.
15. I also recommend that Rye Hill considers placing the Unit Special
Watch Records outside the respective prisoner’s cell so that it can be
completed on the spot by the member of staff carrying out the check.
16. I recommend that Rye Hill reviews its policy with regard to observations
of prisoners identified as being at risk of self-harm.
17. I recommend that, subject to the views of the police, the transcripts of
interviews of staff by the police be used in some form during staff
training.
18. I recommend that the Director reminds staff of the need to recall all
salient events in the Daily Supervision and Support Record and of the
need to make meaningful and informative entries at the end of each
shift.
19. I recommend that GSL establish a dedicated phone line for people to
contact in order to report concerns about prisoners. The line should be
manned 24 hours a day and calls recorded.
20. I recommend that Rye Hill reserves its Unit Special Watch Record for
night time entries and requires staff to record daytime checks in the
Daily Supervision and Support Record.
21. I endorse HM Chief Inspector of Prisons’ recommendation that CCTV
should be installed in the segregation unit.
22. I recommend that Rye Hill revises its management audit form for
F2052SHs to incorporate a space for qualitative comments.
23. I recommend that GSL bolsters its suicide prevention training to cover
all the shortcomings identified in the investigation into this case and the
audit and that refresher training is provided for all operational staff on a
frequent and regular basis.
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24. I recommend that the Director impresses on managers the imperative
that all cells should be inspected daily, regardless of the occupant. (It
is particularly important that the cells of those considered to be at risk
should be examined closely to ensure no action has been taken to
facilitate self-harm.)
25. I recommend that the Healthcare Policy is amended to read that,
“Mentally ill prisoners should be located in the Health Care Centre
strictly according to clinical need.”
26. I recommend that GSL discusses with Primecare what needs to be
done by both parties to ensure all prisoners get the healthcare to which
they are entitled.
27. I also recommend that GSL impresses on Primecare the need fully to
record all developments, assessments and treatments in the IMR and,
where the prisoner is at risk of self harm, the ACCT form (bearing in
mind the need for medical confidentiality).
28. I recommend that arrangements are made for all mental health
assessments to take place in privacy whilst ensuring the safety of the
interviewer. It is generally unacceptable for healthcare assessments to
be carried out in the doorway of the prisoner’s cell.
29. I recommend that where a prisoner’s unwonted behaviour is suspected
to be drug-induced, a ‘dip test’ be carried out immediately.
30. I recommend that a copy of this report is provided to the Chief
Executive of Primecare.
31. I recommend that the Director at Rye Hill reminds all Unit Managers of
their specific responsibilities with regard to engaging healthcare staff
meaningfully in the care of prisoners at risk of self-harm and of sharing
with them current information about the individual.
32. I recommend that Rye Hill’s contingency plans include an instruction
that the next of kin be informed first hand and immediately of a death.
33. I recommend the Director at Rye Hill reviews arrangements for
ensuring visits from bereaved relatives are handled as sensitively as
possible.
34. I recommend that, even at this late stage, the Director should write to
the man’s mother to offer her an apology for the omission and his
condolences over her son’s death.
35. I recommend that a requirement to send a letter of condolence to the
next of kin is incorporated into Rye Hill’s contingency plans.
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36. In light of the individual and systemic failings revealed in this report,
copies should be sent to the Minister and to the Chief Executive of the
National Offender Management Service for their consideration.
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