Individual at Shrewsbury

Circumstances surrounding the death of
a man in August 2004
at a hospital whilst in the custody of HMP Shrewsbury
Report by the
Prisons and Probation Ombudsman
for England and Wales
October 2005
CONTENTS
Page
CONDUCT OF THE INVESTIGATION 3
HMP SHREWSBURY 4
HER MAJESTY’S CHIEF INSPECTOR OF PRISONS 4
THE MAN 7
THE EVENTS OF 16 AUGUST 2004 8
DISCOVERY OF THE MAN 13
CONTACT WITH THE MAN'S FAMILY 16
CONCLUSIONS 17
COMMON ISSUES EMERGING FROM
THE THREE DEATHS IN AUGUST/SEPTEMBER 2004 19
(i) Detoxification 19
(ii) Clusters of three deaths 21
(iii) F2052SH procedures at Shrewsbury 22
(iv) Action taken at Shrewsbury following the three deaths 23
RECOMMENDATIONS 25
1
During the afternoon of 16 August 2004 the man was found hanging in cell A1-19 at
HMP Shrewsbury. He was the sole occupant of the cell and had arrived at the prison
from Shrewsbury Magistrates’ Court just three hours previously. He was taken to the
Royal Shrewsbury Hospital where he died on 19 August 2004. This is a report into
the circumstances leading to his death.
In the following fortnight, two other prisoners were found hanging in their cells at
Shrewsbury.
Shrewsbury is a small local prison and a cluster of apparently self-inflicted deaths
occurring within such a short space of time was profoundly shocking for prisoners and
staff. My investigators have studied the individual cases of each death with great
care, but I have also examined the possibility that there are connections between
them. I have additionally set these three deaths in the context of other recent fatalities
at Shrewsbury.
Factors which appear to be common to the three deaths are:
• the very short time between reception at Shrewsbury and death
• the part of A Wing where all three deaths occurred
• significant drug use in the community by each man, coupled with
Shrewsbury’s detoxification procedures in the late summer of 2004.
These themes are explored in greater detail later in this report. Necessarily, some of
the text, findings and recommendations overlap with those in the reports into the
other two tragedies.
I offer my profound condolences to the man’s family. I thank the acting Governor at
Shrewsbury Prison throughout the latter half of 2004 and his staff for their constant
courtesy and practical support to my investigation team. I also thank the Shropshire
County Primary Care Trust (PCT) and the Section Head of Prison Health at the
Department of Health in London, for the vital contribution they have made to the
investigation. Three colleagues from my office conducted this investigation on my
behalf.
The conclusions and recommendations in this report – as in the other two – require
no extra words from me. I simply record that I was very pleased to learn that a new
detoxification regime was introduced at Shrewsbury on 1 February 2005. I am aware
that a new Medical Officer has also recently taken up post.
This version of my report, published on my website, has been amended to remove the name
of the deceased and the names of staff and prisoners who were involved in my investigation.
STEPHEN SHAW CBE October 2005
Prisons and Probation Ombudsman
2
CONDUCT OF THE INVESTIGATION
1. The investigation team are all investigators working for the Prisons and Probation
Ombudsman. They visited Shrewsbury on a number of occasions in August and
September 2004. They were given access to all the documentation held by the prison
on the man.
2. The man’s father requested that contact with him be maintained via his solicitor.
3. Taped interviews were held with prison staff and prisoners who had important
contacts with any of the three men who died. Notices to Staff and Prisoners were
issued at Shrewsbury, inviting anyone with relevant information to make contact with
the investigation team. All staff were offered the opportunity of being accompanied by
a friend or trade union colleague whilst being interviewed.
4. The investigation team maintained regular contact with the West Mercia Constabulary
investigation led by an Acting Detective Inspector and a Detective Constable. I am
extremely grateful to our police colleagues for their cooperation and helpfulness at all
stages of the investigation.
5. My investigators wrote to Shropshire County PCT requesting a clinical review of the
three deaths. The review was led by the Trust's Commissioner for Substance Abuse. I
am greatly obliged to him and his colleagues for their professional advice on the
clinical factors in these three cases.
6. My investigators also wrote to the Section Head, Substance Misuse, Prison Health at
the Department of Health in London. I am very grateful to him for supplying expert
written comments on the clinical management of the substance misuse of the three
men who died.
7. My investigators made available to the Medical Officer at Shrewsbury from 1992 until
31 August 2004 copies of the documents produced by the PCT and the Section Head
of Substance Misuse, Prison Health. In response, the Medical Officer has written an
eight page letter putting on record some observations that he feels may be pertinent
to the investigation.
3
HMP SHREWSBURY
8. There has been a prison on the present site since 1793 but the main prisoner
accommodation currently in use dates from the 1870s. The site offers little room for
expansion or structural change.
9. Shrewsbury is a local prison for adult male prisoners. It houses unconvicted and
convicted men, mainly from the Magistrates' and Crown Courts in the Shrewsbury,
Mid Wales and Stoke on Trent areas. In the 12 month period prior to this
investigation, the population had fluctuated between 290 and 350 prisoners. The
certified normal accommodation of the prison is 182 but the operational capacity
(maximum permitted number of prisoners) at the time of the three deaths was 350.
10. The cells at Shrewsbury are on A and C Wings. A Wing has a certified normal
accommodation of 160, with an operational capacity of 307. C Wing has a certified
normal accommodation of 22, with an operational capacity of 43.
11. A Wing cells are located on four Victorian galleried landings. The wing has one anti-
ligature cell and two constant observation cells. C Wing is used for vulnerable
prisoners with special needs and it has one anti-ligature cell. A Wing's role is both
complex and wide-ranging. It accommodates a broad mix of prisoners, both
remanded and convicted. The wing holds prisoners subject to every level of the
Incentives and Earned Privileges Scheme, those detoxifying from various substances,
and prisoners requiring support with issues such as mental health and learning
difficulties. Newly admitted prisoners are generally housed on the ground floor of A
Wing, which is known as A1.
HER MAJESTY’S CHIEF INSPECTOR OF PRISONS
12. The most recent full inspection at Shrewsbury by Her Majesty's Chief Inspector of
Prisons took place in November 2001. Remarks in the preface to her report are of
considerable relevance to the present investigation. The first paragraph of her preface
observes strikingly:
"Shrewsbury Prison has no inbuilt advantages. It is one of the oldest, most
overcrowded and cramped local prisons in the country. It has to manage the great
majority of its 330 prisoners on one wing, with no inpatient healthcare, limited training
space and no outdoor recreation facilities."
13. However, in the second paragraph of her preface, the Chief Inspector remarks:
"Yet it has among the best staff/prisoner relationships of any prison we have
inspected. From the Governor down, staff were visible and approachable."
14. The issue of self-harm also appears on the very first page of her report. She writes:
4
"One area that urgently needs addressing is the risk of self-harm in the early days of
imprisonment. This is very strongly linked to the absence of proper detoxification
facilities, which itself reflects inadequate medical cover. 60% of those identified as at
risk of self-harm were in the process of detoxification. The prison's only recent suicide
was a recently admitted drug user, and the majority of self-harm incidents had taken
place in reception and induction cells within the first few weeks in the prison.
Listeners (Samaritan/Trained Prisoners) and staff were in effect having to support
those with substance related needs. It is to the credit of the Governor and
management that they had identified this dangerous gap, and were seeking advice
from other local prisons in order to identify the risks and deal with them more
appropriately."
15. In the section of her report dealing with Substance Use, she writes:
"Apart from a recently written alcohol detoxification protocol, there were no current
detoxification protocols for substance users. We were told that the normal practice
was to prescribe up to three days of dihydrocodeine, diazepam and zimovane. Staff
and prisoners verified this. The general opinion among them was that ‘the detox is
crap.’ We agreed that the current detoxification practice was inadequate."
16. The Chief Inspector further records:
"The most recent death in custody had been in August 2000. There had been an
inquest in April 2001. The Governor of another prison had carried out an internal
investigation and had reported that the prisoner belonged to that group of drug users
who appear to be at risk in the first week or so after reception. He commented that
these were prisoners who were voluntarily coming off drugs or unable to renew
medication and also said that they should merit special attention from the policy
makers on suicide awareness and self-harm."
17. She then recommends: "The Prison Service should ensure that the observations and
recommendations of an investigation into a death in custody at HMP Shrewsbury
(2001) are addressed and reflected in policy throughout the service."
18. The Inspectorate made an unannounced inspection of Shrewsbury between 9-11
August 2004, the week before the man’s death. The inspection report was published
in December 2004. One of the central purposes of this unannounced inspection was
to check on progress made at Shrewsbury in response to recommendations made by
the Chief Inspector after her previous visit in November 2001.
19. In the introduction to the unannounced inspection report, the Chief Inspector
observed with pleasure that Shrewsbury had retained the very good staff/prisoner
relationships and the commitment to continuous improvement that had impressed her
on the previous inspection. She remarked that the great majority of her
recommendations had been achieved and important areas of the prison had
significantly improved "even though Shrewsbury has the dubious accolade of being
the most overcrowded prison in an overcrowded prison system".
5
20. However, in the same introduction, she indicated that some weaknesses needed
attention and she highlighted the issue of detoxification:
"In our last report, we expressed great concern about detoxification procedures, and
these remained defective, in spite of the fact that nearly two-thirds of prisoners
admitted to having injected heroin in the period immediately before imprisonment.
More analysis of patterns of suicide and self-harm was needed, in a prison that had
experienced three self-inflicted deaths that year (and has since had three more)."
21. Section 2 of her unannounced inspection report is headed Progress Since the Last
Report. This sets out the earlier recommendations and notes progress made in
implementing them. In relation to substance use, the first recommendation was that
the medical officer should undertake training in working with substance users, so that
he might provide the services set out in Prison Service Order 3550. The
unannounced inspection report observes that this recommendation was not achieved
and that the GP in post at the time of the unannounced inspection was due to leave at
the end of that month. The Chief Inspector accordingly made a further
recommendation as follows:
"The replacement medical officer should receive adequate training in working with
substance users to support and complement the work of the substance misuse
nurses and the specialist medical officer from the Newhouse Shelton Psychiatric
Hospital."
22. The concluding paragraph in the Substance Use subsection of her unannounced
inspection report records the earlier recommendation that a work plan for developing
a comprehensive detoxification programme for prisoners should be developed in
consultation with the area drugs strategy coordinator and the clinical adviser to the
Prison Service Drugs Strategy Unit. The Chief Inspector writes:
"Two specialist substance misuse nurses had been recruited to work with prisoners
who needed detoxification drugs. However, the large percentage of prisoners whose
main drug use was heroin were not prescribed any medication on the first night. Wing
staff said that such prisoners, especially those experiencing their first time in prison,
were therefore under additional stress through not knowing how to cope with the
initial withdrawal of drugs."
6
THE MAN
23. He was born in August 1974. He was arrested by West Mercia Police on Saturday 14
August 2004. He spent the weekend of 14 and 15 August 2004 in police cells in
Telford and Shrewsbury. On the morning of Monday 16 August 2004 he appeared at
Shrewsbury Magistrates' Court where he was sentenced to 94 days imprisonment.
24. The man arrived at HMP Shrewsbury at 1:05 pm on the afternoon of 16 August. He
was the first prisoner to be received at Shrewsbury that day and therefore the
reception procedures were completed relatively swiftly. He was transferred from the
Reception area of the prison to the ground floor level of A Wing shortly after 2 pm. At
approximately 2:15 pm, he had a conversation in his cell with an officer with whom he
had had previous contact when she worked for the private company which supplies
custody staff at Shrewsbury Magistrates' Court. His behaviour at that time caused the
officer no concern.
25. The same officer conducted a roll check on A1 landing shortly before 4 pm. When she
looked into his cell at approximately 3:55 pm, she saw him lying on his bed. She is
absolutely certain that he was alive at that time.
26. At approximately 4:10 pm, staff were alerted to an emergency in his cell when a
prisoner came running to the staff office at the other end of A1 landing to inform them
that a prisoner was hanging in his cell.
27. Staff ran down the landing and were directed to cell A1-19 by another prisoner. When
they opened the cell door they saw him hanging by a bedding sheet from the window
bars at the back of his cell. Determined efforts were made to revive him in his cell and
he was transferred by ambulance to a nearby hospital at 4:43 pm. He died in the
hospital on the afternoon of Thursday 19 August 2004.
28. He was an intravenous heroin user. He told the Addictions Nurse who conducted his
Reception Health Screen at the prison that he used heroin and methadone on a daily
basis and had last used these drugs on 14 August. He was suffering heroin
withdrawal symptoms on the afternoon of his arrival at Shrewsbury. He was due to
see the prison doctor on the evening of 16 August but that standard evening
appointment was overtaken by the events of the afternoon.
29. He had been held in custody at Shrewsbury on a number of occasions prior to his
death. On one of those occasions, in January 2003, a Self-Harm at Risk form was
opened because he told staff that he felt suicidal. The form was closed three days
later and there is no evidence that a similar form was opened on any of the
subsequent occasions when he was received at Shrewsbury. He was not perceived
as being a suicide risk when he arrived at Shrewsbury on 16 August. During the
afternoon he had dealings with a number of staff and prisoners and none of them
observed any indication that he was contemplating self-harm.
7
THE EVENTS OF 16 AUGUST 2004
30. Before 9:00 am on the morning of Monday 16 August 2004, the man was transferred
from Monkmoor Police Station, Shrewsbury to Shrewsbury Magistrates' Court.
Responsibility for his care and custody transferred at that point from West Mercia
Police to the custody staff who manned the cells area at the Magistrates’ Court. The
police had already opened a Prisoner Escort Record (PER). This document is used to
highlight any information of importance about a prisoner who is being transferred from
one agency to another. The outside cover of the PER form states that there were no
known medical or security risks in relation to him. In the final column of the Risk
Categories Section of the document the police ticked drugs/alcohol issues and in
section 5 of the document they made reference to a Cannabis Resin entry on their
Police National Computer. There was no reference to his heroin addiction and the
police were not aware of any suicide/self-harm risks so they did not tick that particular
box on the form.
31. Part B of the PER form indicates that he came back down from court to the cells area
at 10:53am after being sentenced to 94 days imprisonment. He received a short legal
visit and then the next entry of note comes at 12:15 pm when he refused his lunch. At
12:47 pm, he began the short journey from the court cells to Shrewsbury Prison, with
the prison's gate book showing that he arrived there at 1:05 pm. Twenty-three
prisoners were received at Shrewsbury that afternoon and evening but he was the
first to arrive.
32. The procedure at Shrewsbury, as in all local prisons in England and Wales, is that
newly arriving prisoners are processed in the Reception area before being transferred
to the residential part of the prison. Shrewsbury is a smaller than average local prison
and the vast majority of prisoners there are held on A Wing with a much smaller
number on C Wing, which is reserved for vulnerable prisoners.
33. On the afternoon of 16 August, he was coming straight into Shrewsbury Prison from
the outside community so he had to be given a new prison number. The list of
prisoners received in the Reception area at Shrewsbury that afternoon confirms that
he was the first prisoner to be received and was allocated his new prison number of
HG8838 at 1:13 pm. The reception process at Shrewsbury Prison would have been
very familiar to him as he had been held at the prison on several occasions
previously.
34. The three main components of the reception process at Shrewsbury are:
i. a series of contacts with three or four prison staff who work in the Reception
area;
ii. an interview with a nurse in the Reception area so that the First Reception
Health Screen document can be completed;
iii. the last part of the process is that the prisoner sees the First Night Officer
whose task is to settle the new prisoner as effectively as possible, complete
the Cell Sharing Risk Assessment document and arrange the new prisoner's
transfer from the Reception area to a cell in the residential part of the prison.
8
35. A helpful explanation of the duties undertaken by the prison officers working in
Reception is contained in the interview with an Officer, recorded on 10 September
2004. He explained in interview that the usual complement of staff in the area is a
Senior Officer and three prison officers. He outlined their respective duties as follows:
“The Senior Officer will accept the prisoners in and check the warrants and make sure
that we can legally hold them, take their money, check the money and those kind of
things. The first officer will be doing what is called the page 1 which is all personal
details, height, weight, address and that sort of thing. The second officer would list the
prisoner’s property and canteen and that kind of thing and the third officer’s job would
then be to do fingerprints and strip searching and then handing the prisoner over to
the First Night Officer.”
36. The officer was responsible for completing page 1 of the man’s prison record
(Personal Summary Sheet). The officer’s name and signature appear at the bottom of
the page. The Addictions Nurse had signed the Prisoner Escort Record to indicate
that she saw the man for his health screen at 1:15 pm, so it is probable that she
completed her brief confidential medical and psychiatric history of him before the
Officer recorded the page 1 details.
37. The information recorded on the Summary Sheet by the officer includes the fact that
the man was single and had two children. The address where he had been living in
Oswestry was recorded, but when he was asked for the name and address of his next
of kin he supplied no information. Similarly, when asked for the name and address of
any other persons to be notified in an emergency, he supplied no information. Near
the bottom of the form are what the officer called the D boxes and in box D4 he wrote
"States not suicidal". In interview, the officer explained that his normal procedure is to
ask three times in three different ways if a prisoner feels he will self-harm. The officer
always looks the person in the eye and, in the man’s case, he remembered that "he
obviously caused me no reason for concern and he reiterated that he felt fine and
was adamant that he was not going to hurt himself". The man also told the officer that
he had last been in prison custody in September 2003 when he was discharged from
HMP Liverpool, after serving a three months sentence.
38. When the officer was asked whether there were any issues that concerned him in
relation to the man, he replied:
"No, definitely not, I remember him being chatty and he seemed to have no
problems."
39. When asked if the man was "rattling" (suffering physical consequences) as he
withdrew from heroin, the officer replied as follows:
"He looked thinner than he did as I recall last time I saw him but that is pretty
standard, he certainly was not shivering or he did not have any sort of major
withdrawal symptoms at that point."
40. When asked to sum up his overall impression of the man following approximately ten
minutes of contact with him that afternoon, the officer replied:
9
"I had no concerns, the only reason that it has actually become a feature is the fact of
how fine he was, how normal and chatty that he was….. it was just a normal run of
the mill processing of the man."
41. The man’s health screen in the Reception area was conducted by the Addictions
Nurse. On the second page of the screen, she wrote that he had been homeless in
the past year and on the next page she recorded that he had seen a doctor in the last
few months for heroin abuse. The Addictions Nurse noted that he had been receiving
120 milligrams of methadone a day for the last four months of his life. On page 4 of
the form she wrote "Nil of note" in response to a question about his physical
appearance.
42. In the Substance Use section of the form, she recorded the man’s admission that he
had used drugs in the past month. He told the nurse that he used heroin and
methadone on a daily basis and had last used both substances two days previously.
The urine test conducted by her gave a positive result for both substances. He
confirmed his intravenous drug use. At the bottom of page 5, the form requires the
nurse to refer a prisoner to a doctor or nurse-led drug service if a prisoner is using
drugs more than once a week or supplies a positive urine test. The man fell into both
categories and she duly referred him to both the doctor and the drugs service in the
Planned Action section of the form at page 8.
43. In the Mental Health section of the health screen form he was asked if he had ever
received medication for any mental health problems. He said he had not. I have
discovered that, when receiving his First Reception Health Screen at HMP
Shrewsbury on 25 January 2003, he had told the Registered Mental Nurse (RMN)
that he had received anti-depressants, although he had taken none for two weeks
previously.
44. The man told the Addictions Nurse that he had never tried to harm himself but in
January 2003 he told the RMN that he had cut his right wrist eight months previously.
He told the RMN that he had suffered from depression in the past, that he felt like
hurting himself at the moment (in January 2003) and that he often contemplated
suicide.
45. In January 2003, the RMN opened a F2052SH (Self-Harm At Risk Form) because the
man seemed withdrawn and depressed and admitted contemplating suicide prior to
imprisonment. On 16 August 2004 he did not reveal such information to the
Addictions Nurse so she did not refer him for a mental health assessment nor did she
consider opening a F2052SH. Her recorded impression of his behaviour and mental
state was "Nil of note" because she was not aware of information to the contrary.
46. The last officer to see him before he was transferred to his cell on A Wing was the
First Night Officer. Another experienced First Night Officer explained the purpose of
the First Night task thus:
"I may need to make sure the new prisoner is reasonably calm and if he is not, he is
nervous, try and calm him down a bit, especially new prisoners and also give him
information which will help him settle into the prison and then I will locate him onto the
10
landing, onto the Wing. Most days when I am doing it I will actually go to the cell with
him and check his cell as well, make sure the cell is reasonably clean and show him,
especially if he is brand new, where the light switches are, the kettle, the television
and allow him a phone call."
47. Another job conducted by the First Night Officer is to complete sections 1 and 2 of the
Cell Sharing Risk Assessment and the First Night Officer also signed section 4 of that
document. In interview, she explained that her colleague the Addictions Nurse
completed section 3 of the risk assessment in which she indicated there were no
concerns that the man might harm himself. In section 1 of the form, the First Night
Officer put a tick to say there was no current F2052SH. At question 6 of section 2,
she wrote that the man was currently dependent on drugs. She said that, although he
was "rattling", he did not seem as bad to her as other prisoners she had seen coming
through reception. At the seventh question, she ticked the box indicating that he did
not have an open F2052SH and the No box was again ticked at question number 8
which asks: "Is there evidence of the prisoner having a previous F2052SH?" The
man, as indicated at paragraph 62, had indeed been on F2052SH for a few days in
January 2003 but the First Night Officer was not aware of that information at this time.
He told the officer that he would prefer to share a cell with another prisoner who was
“rattling”.
48. The First Night Officer described him as buoyant when she interviewed him. She said
that he was chatting to her and to the Reception orderlies as well:
"He was laughing and joking with them at the same time as he was doing a
discussion with myself. He seemed buoyant and quite uplifted in his mood, he
showed no concerns to myself of being upset or down in any way."
49. Shortly after her discussion with the man, the First Night Officer accompanied him to
A Wing and located him in cell A1-19. She could not be precise about the time when
she moved him to A1 landing, but she thought it was approximately 2:30 pm. Another
officer is fairly confident that her discussion with him in cell A1-19 occurred at around
2:15 pm so it is quite possible that he was located on A Wing more promptly than the
First Night Officer remembered subsequently.
50. The man cannot have spent much more than two hours on A Wing during the
afternoon of 16 August, but during that two hour period he had contact with at least
one member of staff and at least two prisoners. The first known contact was with an
officer at approximately 2:15 pm. In interview, she explained that she became a
Prison Officer at Shrewsbury in September 2003 and prior to that was a Custody
Officer at Shrewsbury Magistrates’ Court. In that job she met the man on a number of
occasions because, according to her, "He always seemed to be in and out". She
knew that he was a heroin user and remembered that sometimes when she saw him
in court he was quiet and subdued due to his withdrawal from the drug. At page 9 of
her interview, she recalled that "Under no circumstances did I think there was
anything wrong with him… we were having a laugh and a joke".
51. The last prisoner to occupy cell A1-19 before the deceased was interviewed. He
recalled that when he was returning from a gym induction session at about 2:30 pm or
11
2:40 pm he was told by an officer to go into his cell (A1-19), gather up his belongings
and move to a new cell on A2 landing. When he went into the cell he had occupied for
the previous four days, he found the man already there and the two men had a
conversation for 10 or 15 minutes. The man was lying on the bottom bunk bed in the
cell and he seemed very relaxed to the other prisoner.
52. When asked to describe the man’s behaviour and attitude at this time, the prisoner
said:
"He was very relaxed, lying on the bed and me taking my belongings and he said that
it was not the first time he has been in prison so you know in my head I felt he was
here before, he knows the system. In my opinion he was very relaxed about it."
53. After what he described as a normal conversation, the prisoner left cell A1-19 and all
the available evidence strongly suggests that the man remained alone in the cell until
the time when he was discovered hanging later in the afternoon.
54. A conversation took place between the man and his friend at approximately 3:45 pm.
His friend asked to see the investigation team and explained that they were friends
outside prison. He had last seen the man about two months previously in Oswestry,
and he said they had also lived together in Shrewsbury. The man told his friend that
he had been in police custody since Saturday (two days earlier). He said that the
medication he had been receiving at the police station had been stopped on his
arrival at HMP Shrewsbury.
55. He asked his friend about others from Shrewsbury who were in the prison at that
time. The friend knew that on the last occasion when the man was in Shrewsbury he
had asked to be segregated from other prisoners for his own protection.
56. The friend explained that the man had been worried about another person who was in
the prison at the same time. The friend did not know the identity of that prisoner, but
he knew there was some problem between the two men in the outside community
and that the man did not wish the problem to carry on in prison. On the previous
occasion, he had felt "a bit intimidated" so he had thought it better to put himself on
protection.
57. My investigators have studied the records relating to the two separate periods of
imprisonment that the man served in 2003. The more recent prison sentence was
imposed at Shrewsbury Magistrates' Court on 16 October 2003 and there is no record
that he asked for protection on that occasion. However, on 3 June 2003, he was
sentenced to three months imprisonment by Shrewsbury Magistrates' Court. He was
received at HMP Shrewsbury the same day. On 5 June 2003, he wrote a statement to
the prison Governor as follows:
"I wish to apply for VP (Vulnerable Prisoner) status due to the fact that 3-4 lads have
made threats and I fear for my safety."
58. An entry on his prison record on 5 June 2003 states that he was granted C Wing
status and a further entry on the same date confirms that he was received onto C
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Wing, being located in cell C2-8. C Wing is a small unit at Shrewsbury which holds
those who have asked to be kept separate from the main body of prisoners on A
Wing. A further entry on his prison record indicates that he spent less then two weeks
on C Wing because, on 17 June 2003, he was transferred from Shrewsbury to HMP
Stafford.
59. The friend stood at the flap outside the man’s cell door and reassured him that he
would have no problems on this occasion. He explained that there were no prisoners
who would cause him any trouble. There were only a few Shrewsbury men in the
prison at the time and his friend described them as "good lads".
60. The man’s friend asked him how long he was serving. He replied that it was 92 days
so he would not need to spend long in prison. The man’s friend promised that he
would try to get some sugar and tobacco for him. His friend then left and went to his
job of cleaning the Visits area.
61. The investigator asked the man’s friend if he had any concerns at that time about him.
He replied:
"No, I would not have said you are going to commit suicide myself, it was the furthest
thing from my mind because he did not seem depressed…. to my reckoning he did
not look like committing suicide, even if I were an officer I would not have been able
to say you know put you on a watch because you are depressed or whatever, I would
not have been able to tell that, and I am his friend."
62. An officer was the last person to see the man alive. She did a roll check on A1
landing and she is confident this check began at around 3:55 pm because she
distinctly remembered looking at her watch as she started the task. When the officer
looked inside cell A1-19 to ensure that the man was there, she saw him lying on the
bottom bunk bed. He was awake, his eyes were open and he was facing towards the
cell door. They did not speak to each other at this time but in interview the officer was
absolutely certain that he was alive.
DISCOVERY OF THE MAN
63. At approximately 4:10 pm on the afternoon of 16 August 2004, most of the prisoners
on A Wing were locked in their cells They were not due to be unlocked until the
evening meal was served at approximately 4:45 pm. Two prisoners were outside their
cells at the time and they shouted to another prisoner, whose job was to do general
cleaning duties on A1 landing, that a prisoner was hanging in his cell. At the time, the
cleaner was on A1 landing four or five cells away from the emergency. He shouted for
an officer straightaway. A number of officers were gathered in or outside the wing
office at the opposite end of the landing from the man’s cell.
64. An officer’s account states that he was A1 Landing Patrol at the time and at
approximately 4:10 pm he was in A1 landing office when a prisoner came running to
the window of the office to raise the alarm.
13
65. He ran down the landing and another prisoner directed him to Cell A1-19. The officer
opened the cell door and saw the man hanging by a bedding sheet from the window
bars at the back of the cell. He was almost directly facing staff as they ran into his
cell.
66. The officer grabbed him around the top of his legs in order to lift him up while a
prisoner tried to remove the noose from around his neck. The prisoner had jumped on
to the top bunk bed in the cell and in interview he explained that he used his hands to
remove the noose. The officer said the noose was tied with "like a slip knot" but he
eventually managed to slip the noose up over the top of the man’s head. Once the
noose had been removed, the officer and a colleague placed the man on his back on
the cell floor and the prisoner left the cell.
67. At the time that the man was found hanging the Staff Nurse was also on A1 landing.
Her job at the time was to administer medication to the queue of prisoners who came
to the window of her office on the landing. She became aware of a number of people
running towards the office. Two prisoners shouted that another prisoner was hanging
in Cell 19. She immediately closed her medication bag and went to the incident.
68. When she got there, she found the man on the floor in the recovery position. An
officer felt for a pulse in the man’s wrist and the Staff Nurse felt for a pulse in his
neck. She noticed that the pupils of his eyes were fixed and dilated. She touched his
eyes to try and get a response but there was none so she and the officer commenced
resuscitation. He placed a facemask over the man’s mouth and gave him mouth-to-
mouth resuscitation. The Staff Nurse administered chest compressions. The officer
was rapidly relieved by another officer who maintained mouth-to-mouth and the Staff
Nurse continued with chest compressions until she was relieved by the Addictions
Nurse. When the Staff Nurse was relieved she rang the Healthcare Centre and asked
for a defibrillator to be brought to the cell. (The defibrillator is attached to a patient's
chest and administers an electric shock to the heart in an effort to restart it.) Prior to
the arrival of the defibrillator, the Senior Officer had taken over from the officer at the
man’s head. The Senior Officer and the Addictions Nurse jointly administered
cardiopulmonary resuscitation (CPR).
69. The Addictions Nurse had recently been trained in the use of a defibrillator. The
machine indicated that a shock should be administered to the man and she duly did
so. Then the machine told staff to commence CPR so they resumed chest
compressions and mouth-to-mouth.
70. At 4:13 pm, the prison's control room had been notified of a Code Brown Emergency.
This is a code used at Shrewsbury to indicate a hanging. An ambulance was called at
4:14 pm and arrived at the prison at 4:22.pm. When paramedics arrived at the man’s
cell they checked his airway. The paramedics put a mask back over his mouth and
gave him oxygen.
71. The Addictions Nurse later made an entry in the man’s medical record, in which she
noted the arrival of the Sister and the paramedics at approximately 4:25 pm. She
wrote that, after a period, the paramedics managed to feel a carotid pulse in his neck
14
but his larynx was in spasm and they were unable to intubate him. The paramedics
continued to ‘bag’ him. (The Addictions Nurse explained that was a reference to an
ambu bag which is attached to oxygen and squeezed to supply artificial breaths to a
patient.)
72. The prison's control room log states that the ambulance left the prison at 4:43 pm
bound for the Accident and Emergency Department of a nearby hospital. The man
remained in hospital until his death.
73. His medical record indicates that medical staff at the prison maintained regular
contact with the hospital in order to check on his condition. The Sister’s entry in the
medical record at 8:45 am on 17 August states that she contacted the High
Dependency Unit and was told that he remained on a ventilator, heavily sedated but
showing signs of spontaneous breathing.
74. A further entry in the record at 10 am by the Sister refers to a lengthy phone call she
had with the man’s father who was enquiring as to what had happened.
75. An entry in the record at 8:40 am on 18 August states that the Sister had visited him
in hospital the previous evening. The report on the morning of 18 August was that his
pupils had been reactive but they had since become fixed and dilated. He was
unresponsive to painful stimuli. He died in hospital on 19 August 2004.
15
CONTACT WITH THE MAN’S FAMILY
76. He gave no next of kin information when he was received at Shrewsbury in the early
afternoon of 16 August. The authorities subsequently found it difficult to establish
contact with his father.
77. As there was no information about next of kin or any other persons to be notified in an
emergency, the prison authorities asked West Mercia Police to make the necessary
contact. My investigators were told by the Detective Inspector in charge of the police
investigation into the man’s death that the police found this a very difficult task.
78. His Inmate Medical Record indicates that the Sister in the prison's Healthcare Centre
contacted the High Dependency Unit at the hospital where he was being cared for at
8:45 am on 17 August. The HDU stated that they had been in contact with his father
and that the family had been advised to contact Healthcare staff at the prison for
updates. The Sister then had a lengthy telephone call with the man’s father at 10 am
the same morning.
79. A letter of condolence was sent to his parents by the prison's acting Governor and
appropriate information notices were published to both staff and prisoners following
his death.
80. On 7 September 2004, his father formally requested that all parties involved in regard
to the investigation into the death of his son liaise directly with his solicitors. His
wishes in this matter have of course been respected.
81. On 4 October 2004, the solicitors wrote to my investigator raising two questions from
the man’s father. The questions were:
i. Should his son’s cell not have been opened around 4 pm for him to receive
medication?
ii. "the acting Detective Inspector has advised the family that the man was
checked at 4 pm and at 4:07 pm was found hanging."
One of my investigators commissioned a note from the Head of Healthcare at
Shrewsbury, who explained the procedure for the issue of medication in a
memorandum of 3 November 2004. At the time of his death, the man had not been
prescribed medication in the prison so his cell was not due to be opened at 4 pm on
16 August.
82. In a letter to the solicitors on 25 November 2004, my investigator explained that he
had no information at all that the man was found hanging at 4:07 pm. Since then no
further information has come to light which could place the discovery that he was
hanging at any time before 4:10 pm at the very earliest.
16
CONCLUSIONS
83. All the available evidence clearly suggests that his death was self-inflicted. There is
no evidence whatsoever that any other person was involved. He left no note behind
and therefore the reason for his action is not known. He gave no indication to either
staff or prisoners that he was contemplating self-harm. He was withdrawing from
heroin at the time of his death
84. He had previously been on an F2052SH at Shrewsbury for three days between 25
and 28 January 2003. He had returned to the prison in February, June and
September 2003 but was not placed on F2052SH on those occasions. There is no
robust system for identifying prisoners who have previously been on Self-Harm at
Risk Forms as they arrive in Reception for a new period of custody.
85. A number of training needs have been identified in the course of this investigation.
These include first aid training, especially for Healthcare staff; substance misuse
training, especially for addiction nurses; defibrillator training; and systems for calling
support to a clinical emergency. There is no evidence that these training needs
contributed to his death.
86. He was held at Shrewsbury for such a short time that he was not seen by the doctor
on the evening of his reception. In view of his many periods of incarceration at
Shrewsbury, he would have been well aware that symptomatic relief was not routinely
available to prisoners withdrawing from heroin during their first night in custody.
87. At his own request he had been segregated from other prisoners in June 2003 prior to
his transfer to HMP Stafford. There is no evidence that he was similarly segregated
when he returned to Shrewsbury in September 2003. When he arrived on 16 August
2004 he was reassured by his friend that there were no men in the prison at that time
who would give him any trouble.
88. He was found hanging in his cell at some time between 4:10 pm and 4:13 pm. The
prison's control room called for an ambulance at 4:14 pm and an ambulance arrived
promptly at 4:22 pm.
89. When the alarm was raised, the Staff Nurse arrived almost immediately as she was
already on the wing dispensing medication to other prisoners. There was a slight
delay in bringing the defibrillator to his cell, but the Addictions Nurse had recently
been trained in the operation of that equipment and used it effectively.
90. The noose around his neck was removed by a prisoner who performed cleaning
duties on A1 landing. It is clear that the ligature was removed very rapidly and he
should be commended for his important contribution.
91. Reports after previous apparently self-inflicted deaths at Shrewsbury have
recommended the introduction of anti-ligature knives.
92. Both Healthcare and prison officer staff made determined but unavailing efforts to
revive the man. He died in hospital at 1:55 pm on 19 August 2004.
17
93. The authorities experienced considerable difficulty in establishing contact with his
father, as there was no current next of kin information on his son’s prison record.
94. My investigator discovered that page 6 of open F2052SHs was not being completed
when he conducted a survey of all such documents. This page should be completed
by the doctor when a prisoner is returned to residential accommodation after medical
examination. This observation is not a criticism of the locum doctor, whose
contribution to the work of the prison in the last four months of 2004 has been praised
by the Governor. Rather, it helps identify a training requirement to ensure there is
effective cooperation between medical and non-medical staff in the drive to prevent
both suicidal and self-harming behaviour.
95. Examination of the minutes of the Suicide Prevention Meeting indicates that work of
good quality is taking place. If the Suicide Prevention Coordinator worked full-time or
had more hours dedicated to his work, he would be able to present more helpful
information to this meeting and to the Senior Management Group about underlying
trends in relation to suicide and self-harm at Shrewsbury. There was also evidence of
a need to improve the quality of entries in open F2052SHs so that there is dialogue
and interaction rather than mere observation.
96. At the end of the First Reception Health Screen, the Addictions Nurse appropriately
referred him to both the doctor and the drugs service because of his substance use.
He told her that he was using heroin and methadone daily, but declared he had never
tried to harm himself. She was not to know that he gave a different answer to the
same question in January 2003 when he told the nurse conducting his First Reception
Health Screen that he had cut his wrist eight months previously, and that he
contemplated suicide often.
97. Two separate Prisoner Escort Records (PER) were raised by West Mercia
Constabulary on 14 August 2004. The PER that was not sent to Shrewsbury Prison
identified drugs issues, and stated at section 5 that he was a heroin user who was
prescribed methadone. The PER form that was received at the prison and signed by
the Addictions Nurse referred only to cannabis resin, which significantly understates
the nature and severity of his drug dependency. It is true that the first entry on part B
of the same form describes him as a drug addict, but that entry does not have the
same prominence as section 5 of part A of the form.
18
COMMON ISSUES EMERGING FROM THE THREE DEATHS IN
AUGUST/SEPTEMBER 2004
98. There are some significant linkages between the three deaths in August/September
2004. A striking feature is that each hanging occurred so soon after reception at the
prison. All three men were dead less than a week after their arrival at Shrewsbury.
The man was found hanging before he had received his first meal at the prison.
99. All three deaths occurred in cells facing west on A1 and A2 landings. The amount of
natural light in these cells was severely restricted by the proximity of metal sheeting
erected by contractors engaged in rebuilding work on the site. I commend the
Governor for his prompt identification of this issue, and I note that the Area Manager
agreed to take the cells out of commission in response to the Governor’s suggestion.
It would not be surprising if prisoners held for prolonged periods of time in such dark
cells suffered adverse psychological consequences. However, as indicated, the three
men who died spent only brief periods of time in their respective cells. All of them had
been held at Shrewsbury before. The man and one of the others had been there on
several occasions.
(i) Detoxification
100. The most important connection between the three men was that they all used heroin
in the community and all three were withdrawing from their drug use as they entered
Shrewsbury. I have paid particularly close attention to the detoxification arrangements
that were in place at Shrewsbury in August/September of last year. The advice I have
received on this matter is contained in the reviews conducted by Shropshire County
PCT and the Section Head, Substance Misuse, in the Prison Health team at the
Department of Health in London.
101. The Clinical Review Panel (CRP) appointed by Shropshire County PCT commented
as follows in its reviews of the deaths of all three men:
“The CRP believes that any individual withdrawing from opiates is at an increased risk
of self-harm or suicide, noting that individuals withdrawing from opiates often
experience symptoms of depression and can have rapid and unpredictable mood
swings.”
102. The CRP was told by the Healthcare Manager at HMP Shrewsbury that at the time of
the three deaths:
“the prescribing of medication to relieve the symptoms of opiate withdrawal between
admission and the commencement of detoxification was not available”.
103. She also explained that prisoners did not start a detoxification programme until the
day after their arrival at the prison. In response, the CRP recommended that:
The prescribing of medications for the symptomatic relief of the effects of opiate
withdrawal be made routinely available especially in the period between reception
and the commencement of detoxification the next day.
19
104. The CRP also noted that the detoxification regime in place at HMP Shrewsbury at the
time of the three deaths in August/September 2004 did not follow recognised clinical
guidelines for the management of substance misuse problems. The standardised
Shrewsbury prison detoxification programme consisted of the prescription of
dihydrocodeine 90 mg twice a day for three days, dihydrocodeine 60 mg twice a day
for three days, dihydrocodeine 30 mg twice a day for three days and Mirtazepine 15
mg at night for nine days. The CRP accordingly recommended that:
A detoxification programme, which is in line with national guidelines, should be
introduced at HMP Shrewsbury as soon as is possible.
105. The Section Head of Substance Misuse, Prison Health, reports that “dihydrocodeine
detoxification is not recommended by the Department of Health”. He refers to
guidelines issued by the Department of Health in 1999 in the document Drug Misuse
and Dependence – Guidelines on Clinical Management. The guidelines state at Page
38 that codeine-based drugs, such as dihydrocodeine, are not licensed for use for the
treatment of drug dependence and the same page of the document adds:
“The product licence for dihydrocodeine does not include the treatment of opiate
dependence and there is concern amongst practitioners about its widespread use.”
106. He also observes that contrary to Prison Service Order 3550 the dihydrocodeine
protocol at HMP Shrewsbury shows no evidence of the involvement of the local NHS
Substance Misuse Specialist.
107. In relation to the man, he observes there is no evidence that his clinical substance
misuse management was a factor as he died so soon after arriving at Shrewsbury.
“That said, in my opinion the standard prescribing regime at Shrewsbury would not
have been adequate to manage satisfactorily the severe opiate dependence
experienced by the man.”
108. He concurs with the Panel’s conclusion that prisoners withdrawing from opiates
without the assistance of medication are at a heightened risk of suicide. He therefore
recommends that,
As part of a first-night reception, prisoners reporting a current problem with opioid
drugs should be given a brief assessment using the Short Opioid Withdrawal Scale,
or a similar measure. A moderate score on this scale would occasion symptomatic
prescribing and a more acute problem should indicate medical examination on the
first night.
20
109. He further recommends:
The PCT and the prison should consider the establishment of a clinical withdrawal
management unit where drug-dependent prisoners would stay for the first few days of
custody, until their symptoms stabilise.
110. Prison Service guidance on detoxification and related issues is set out in the Prison
Service Order entitled Clinical Services for Substance Misusers issued in December
2000. The introduction to the Order requires all Governing Governors “to ensure that
effective treatment of substance misusers is delivered by evidence-based services
which identify, assess and treat substance misusers in line with Department of Health
guidelines (1999”)”
111. The Order contains a checklist on the clinical management of opiate misusers which
requires the following mandatory action:
“Each prison will have a detoxification service for opiate misusers, developed in
conjunction with (a) local NHS consultant using evidence-based guidelines in line with
those of Department of Health (1999)”.
112. The prison’s Drug Strategy document was most recently reviewed on 1 March 2004.
Detoxification does not figure prominently in the document. A number of treatment
options are listed at Pages 26 and 27 of the document, with the commentary on
detoxification stating:
“Detoxification is carried out in line with the agreed protocol and complies with HCS8
[Prison Healthcare Standard 8]/NHS Guidelines in place.”
113. New, improved detoxification procedures began on 1 February 2005. I accordingly
recommend that the prison’s Drug Strategy document be urgently revised if this has
not already happened, and that detoxification arrangements are given greater space
and prominence in the new document.
(ii) Clusters of three deaths
114. I contacted the Prison Service’s Safer Custody Group (SCG) seeking information
about clusters of apparently self-inflicted prison deaths in recent years. I am grateful
to a member of staff of SCG for his detailed response to my investigator.
115. He has supplied a table showing all cases since 1978 where three self-inflicted
deaths have occurred in less than 30 days. This table shows the Shrewsbury cluster
as being the third worst in Prison Service records. At HMP Manchester, three deaths
occurred within two days in 1982, and at HMP Leicester three deaths occurred within
11 days in March/April 2000. At HMP Gloucester, another relatively small local prison
like Shrewsbury, three deaths occurred within 18 days in February 2004. In his e-mail
he observes that: “only local prisons seem to experience significant clusters” and that
“the risk of having additional suicides does increase after an initial death”.’
21
(iii) F2052SH procedures at Shrewsbury
116. None of the three men who died between 19 August and 1 September 2004 was on
an open F2052SH at the time of death, but the investigation team examined suicide
prevention procedures at Shrewsbury. My investigators discussed these matters with
the Suicide Prevention Coordinator at Shrewsbury. On the day of our discussion, six
prisoners were on an open F2052SH. He told my investigators that they were mainly,
but not exclusively, located on A1 landing near the staff office. He indicated that these
documents were mainly opened by Healthcare staff, but the prison was not easily
able to provide detailed information about reasons for opening F2052SHs or
significant statistical trends. I understand that such information is starting to be
collected for Suicide Prevention Committee Meetings and I recommend the support of
such an initiative. The SPC task at Shrewsbury is not presently full-time and I strongly
recommend to the Governor and West Midlands Area Manager that consideration be
given urgently to the appointment of a full-time coordinator. Although Shrewsbury is a
small local prison, the case for a full-time post seems a strong one in view of the
number of recent apparently self-inflicted deaths, the need for more refined
information to be collected and presented to management at the prison, and the need
to improve the quality and amount of staff training on this crucial subject.
117. The Suicide Prevention Coordinator said he was eager for anti-ligature knives to be
issued to staff at Shrewsbury. The senior governor who investigated the
circumstances of a death at Shrewsbury on 4 March 2004 made a recommendation
that anti-ligature knives should be issued to members of staff with appropriate
training. I recommend that this recommendation should now be implemented without
delay.
118. The lead investigator audited F2052SH procedures on 23 September 2004 when five
booklets were open. Two prisoners were on intermittent watch and three were on
hourly watch. With one exception, all the men on F2052SH were in single cells. The
explanation given was that it was not considered appropriate for them to share a cell
with another prisoner. Regular reviews had taken place but no entries had been made
on page 6 of the document by the Medical Officer. This was perhaps not completely
surprising because a doctor had taken over at short notice as locum Medical Officer
on 1 September 2004. I recommend, however, that any new or locum Medical Officer
at Shrewsbury receives training in F2052SH procedures within a week of taking up
post in view of the importance of exchanging sufficient information between
healthcare staff and prisoner officers, especially when prisoners at risk are being held
on normal location.
119. On the day of the audit, it was noticeable that an officer had been detailed to
F2052SH duties but the entries over several days in all the booklets examined
suggested observation of the men at risk, rather than much interaction with them. My
investigators were informed by staff that it was rare for booklets to be opened on men
located on the second and third levels of A Wing, and rarer still on the fourth (topmost
level) of the wing. I am well aware that the staff at Shrewsbury have already been
22
exhorted to write inter-active entries in at-risk documents but it may well be that
further training is required, backed up by regular and vigorous management checks.
120. My investigators also observed that the prison did not have readily accessible
information about prisoners who had previously been subject to Self-Harm at Risk
Procedures. I was informed that such information generally disappeared from the
LIDS computer system 12 weeks after a man left the prison. Reference to previous
F2052SHs seemed a matter of chance or the good memory of a particular officer or
nurse in Reception who happened to remember that such and such a prisoner had
previously been on a F2052SH. The opening of a F2052SH does not of itself ensure
that a potentially suicidal prisoner will remain alive, but it is most desirable that staff
be aware of recent periods when prisoners were thought to be at risk as they make
decisions about men who have returned to custody.
121. In the man’s case, he said on 25 January 2003 that he felt suicidal when he arrived at
Shrewsbury and accordingly a F2052SH was opened by a nurse on that date. Three
days later, the form was closed because there were no immediate concerns over self-
harm and the assessment was that the man was "coping well at the moment".
122. He was released from prison but by 7 February 2003 he was again received at HMP
Shrewsbury. On this occasion, page 1 of his prison record includes a statement by
him that he was not suicidal and a Self-Harm at Risk Form was not opened. There is,
however, no reference that my investigators have discovered to the closure of the
previous at risk form just ten days before. The absence of "organisational memory" in
respect of prisoners who have previously been on a F2052SH is disturbing and I draw
this issue to the attention of the NOMS Safer Custody Group. It is not desirable that
the only source of information about a prisoner's recent history should be the prisoner
himself, so I recommend that the Governor at Shrewsbury attempts to devise a more
reliable and robust system for retaining information about previous Forms 2052SH. I
do not know how soon the Prison Service at national level will possess computer
systems of sufficient sophistication to capture such information.
(iv) Action taken at Shrewsbury following the three deaths
123. The Prison Service's Director of Operations requested an urgent review following the
deaths of the man and the other two prisoners. This review was undertaken on 2
September 2004 by the West Midlands Area Principal Psychologist and the Outreach
Support Cooordinator for Safer Custody Group. Their brief was to review urgently the
recent incidents in order to identify any common issues that could be acted upon
immediately.
124. A report entitled Common Themes and Learning Points from Recent Deaths in
Custody at HMP Shrewsbury was completed by them on 2 September 2004. They
examined Reception, First Night Centre and induction procedures at the prison. They
also included a section on drug strategy and detoxification, pointing out that the
establishment did not have a dedicated drug detoxification unit. They quoted a staff
member who felt there was not a proper system for drug detoxification. They noted
23
that other staff members "stated how the system at HMP Shrewsbury is improving,
but they constantly struggle due to lack of resources".
125. Their review made eight recommendations. On 14 September 2004, the Acting
Deputy Governor at Shrewsbury wrote to them to provide an update on some of the
recommendations they had highlighted.
126. In the First Night Centre section of their report, they refer to the impression that A
Wing is poorly lit with little natural light. The Governor at Shrewsbury had written to
the West Midlands Area Manager on 14 September 2004 to say that he had
consulted widely across the establishment following the recent deaths and that one
recurring theme deserved the Area Manager's consideration. He wrote that cells
facing west on A1 and A2 landings looked directly towards the fencing that had been
erected around the demolished gymnasium site and new education block extension:
"The prisoners believe the lack of light is oppressive and has contributed to the
depression that led to all three suicides. The fencing is less than a metre from the
cells. Prisoners located in the A1 cells cannot see anything but the fence, irrespective
of where they stand."
127. The Governor suggested to the West Midlands Area Manager that cells A1-12 to A1-
20 should be taken out of commission and that affected cells on A2 landing should be
occupied by prisoners on the Enhanced Level of the Incentives and Earned Privileges
Scheme as such prisoners are confined to their cells for shorter periods of time. The
Governor’s suggestion was duly accepted by the Area Manager.
128. The Governor’s initiative in writing to his Area Manager mirrored concern expressed
to my investigators by a prisoner at Shrewsbury. He asked to see my investigation
team and said he had identified a possible cause as to "why they are committing
suicide". He said he had noticed that the people who were committing suicide (his
expression) were on the side of A Wing where all the windows had been covered up
by sheeting outside. He understood that all the windows on one side of the wing were
covered with corrugated sheeting because "the gym was supposed to be falling down,
there's been structural damage or something, so they have had to knock the building
down".
129. He also expressed a view that the number of deaths at Shrewsbury could be
diminished if prisoners on induction spent more time out of their cell. He agreed there
was an induction programme for new receptions but said that prisoners spent the
remainder of their time in their cells, apart from association periods on a Wednesday
evening and a weekend morning or afternoon.
24
RECOMMENDATIONS
CLINICAL REVIEW
I endorse the six recommendations made by the Clinical Review Panel established by
Shropshire County PCT. I attach particular weight to the recommendations calling for the
prescribing of medication for the symptomatic relief of the effects of opiate withdrawal on the
first night of custody, and for the introduction of a detoxification programme at HMP
Shrewsbury in line with national guidelines.
The recommendations made by the Clinical Review Panel were:
1. The Clinical Review Panel believes that any individual withdrawing from opiates is at
an increased risk of self-harm or suicide noting that individuals withdrawing often
experience symptoms of depression and can have rapid and unpredictable mood
swings, we therefore recommend that all prisoners received at Shrewsbury are
considered at risk until they are more fully assessed and commenced upon an
appropriate detoxification or maintenance programme.
2. The Clinical Review Panel recommends that the feasibility of using an IT system to
flag prisoners with a previous risk history be considered.
3. That all prison healthcare staff and discipline staff should receive first aid and life
saving skills training and regular update and refresher training.
4. That the protocol for calling support to a clinical emergency be reviewed and that any
communication makes the nature of the emergency clear and that appropriate life
saving equipment is taken by nurses responding to the call.
5. That the prescribing of medications for the symptomatic relief of the effects of opiate
withdrawal be made routinely available especially in the period between reception
and the commencement of detoxification the next day.
6. The Clinical Review Panel recommend that a detoxification programme that is in line
with national guidelines should be introduced at Shrewsbury as soon as is possible.
SUBSTANCE MISUSE REVIEW.
I endorse the two recommendations made by the Substance Misuse specialist from the
Department of Health. If they are accepted by the Area Manager and PCT then I recommend
that an expanded Action Plan be drawn up as soon as possible. The recommendations made
by the Substance Misuse specialist were:
1. As part of a first night reception, prisoners reporting a current problem with opioid
drugs should be given a brief assessment using the Short Opioid Withdrawal Scale,
or a similar measure of withdrawal symptoms. The results from this scale would
highlight the need for medical management on the first night: a moderate scoring from
the scale would occasion symptomatic prescribing; a more acute problem should
indicate medical examination on the first night.
2. The Primary Care Trust and the prison should consider the establishment of a clinical
withdrawal management unit, where drug-dependent prisoners would stay for the first
few days of custody, until their symptoms stabilise.
25
OPERATIONAL
1. A training needs analysis should be undertaken to include the training needs
identified in the course of this investigation and the clinical review.
2. Anti-ligature knives should be introduced to individual members of staff.
3. The Governor should meet with senior police and escort contract colleagues with the
aim of improving the quality of information recorded on Prisoner Escort Record forms.
4. Consideration should be given to the appointment of a full-time Suicide Prevention
Coordinator.
5. Any new or locum Medical Officers at Shrewsbury should receive training in F2052SH
procedures within a week of taking up post.
6. A more reliable and robust system for retaining and retrieving information about
prisoners previously on F2052SH should be introduced.
26