Individual at Swaleside

The death in custody of a man
at HM Prison Swaleside in January 2005
Report by the Prisons and Probation Ombudsman
for England and Wales
January 2006
This is the report of an investigation into the circumstances surrounding the death of a
man at HM Prison Swaleside in January 2005. He was found dead in his cell at
6.55am. A bed sheet had been fashioned into a noose and was wrapped tightly around
his neck.
A post mortem examination performed on 13 January at Medway Maritime Hospital
found that the cause of death was suspension.
I offer my sincere sympathy and condolences to the family of the man who have
suffered the tragic loss of a much loved and important member of their family. The staff
at Swaleside shared the sense of loss. They knew him well and remember him with
affection.
Mr Ron Tasker, assisted by Mr Tom Wright, carried out the investigation on my behalf.
As part of their investigation they commissioned an independent review into the clinical
management of the man. I am grateful to Dr Stephen Lawrence who carried out the
review on behalf of the Medway Primary Care Trust.
My thanks also go the Governor and all Swaleside staff. I appreciate their willing
cooperation, which has enabled the investigation to be both thorough and to be
completed in a timely fashion.
The man’s continued use of drugs in prison was likely to have influenced the Parole
Board’s consideration of his possible release or moves to less secure accommodation.
The man was also concerned about his son’s health and had told his sister he was in
debt to a fellow prisoner to the tune of £120. However, what was actually on his mind at
the time of his death is necessarily unknowable. He had given no indication either to
staff or to his fellow prisoners of any intention of taking his own life.
I make two recommendations.
In deference to the views of the man’s family, I have edited out significant parts of my
original report. As a consequence, this anonymised report is much shorter and much
less detailed than is my normal practice.
Stephen Shaw CBE
Prisons and Probation Ombudsman September 2007
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Summary
The man was born in July 1967. His early life was straightforward and he left school
with a good set of examination results. At the time of his death the man had two
children.
The man arrived at Swaleside in September 2001. He was serving a life sentence
imposed in October 2000 for offences of wounding. A short tariff of three-and-a-half
years gives some indication of the trial judge’s anxiety and hope. Anxiety because
drugs had played a part in the offences, and hope that the man would seek help in
prison and be able in the near future to be drug-free and secure his early release.
Apart from periodic temporary transfers to other prisons nearer home to receive visits
from his family, the man had been continuously at Swaleside where he was well known
and liked by staff and prisoners.
Progress through the prison sentence had been variable. On the one hand the man
was a good all round member of the prison community. He chose his friends carefully
and worked hard in the prison wing or the workshops. He had completed successfully
social skills and other courses. He had enrolled and attended drugs courses and he
had subjected himself to voluntary drug testing. On the other hand, the man’s drug use
continued throughout his sentence and despite his best efforts he was unable to kick
the habit. This drug use led the Parole Board in April 2004 to defer a decision on his
future. Although the Board marked some progress, they hoped to see a sustained drug
free period by the time of the next hearing which was set for March 2005.
At the time of his death, the man had two recent positive findings for drug use. He
would have been worried that the parole hearing scheduled for March would take a poor
view of this. Furthermore, he had told his sister that he was in debt to another prisoner
as a result of borrowing a mobile phone which had been smuggled into the prison. It is
probable also that he was worried in respect of his elder son’s undiagnosed illness.
The man was in good health and the clinical review revealed a fit young man whose
minor ailments from time to time had been treated appropriately. There was no history
of depression and to all intents and purposes he was in good health and in good spirits.
The man had not previously harmed himself and his demeanour in the period leading to
his death appeared normal. Staff could not possibly have seen this coming. As our
investigation took shape their shock and disbelief spoke for itself.
It is impossible to say what the man’s intentions were when he wrapped a bed sheet
round his neck or what motivated his actions. In spite of Swaleside’s excellent facilities
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to help people with drugs problems, and notwithstanding the man’s own very creditable
efforts, it may be that he decided the problems were too big for him to solve.
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Investigation methodology
The investigation was opened on 12 February 2005 when Mr Tasker and Mr Wright met
with the Governor and his deputy at Swaleside. They were given a comprehensive and
very helpful briefing on the events leading up to and after the man’s death.
Ombudsman’s notices were issued to staff and prisoners, identifying the scope of the
investigation and inviting anyone who wished to see the investigators to make
themselves known. Staff and prisoners in key positions or locations were identified and
were invited for interview. All responded willingly and fully. The local branch of the
Prison Officers’ Association were briefed. They were helpful and offered constructive
comment and advice.
Local police were contacted and provided all the information at their disposal, as did the
coroner’s officer.
The chair of the Independent Monitoring Board was interviewed, as was one other
member of the Board.
The investigators commissioned an independent clinical review. Dr Stephen Lawrence
conducted this on behalf of Medway Primary Care Trust.
Mr Tasker, together with my family liaison officer, Lucy Phelan, met the man’s family at
home. They were made to feel very welcome and his mother added a great deal to
their knowledge and understanding.
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Conclusions
The man could not break free from the drug habit which had direct relevance to the
offence for which he had received his life sentence. He would have known that the
forthcoming parole review would hear evidence of his current drug taking, and that the
Parole Board might say they were unable to note any significant progress over the last
year. The man may have thought that release was as far away as ever.
Life had become further complicated through worry about the health of his son.
Problems are often magnified in prison and, despite regular information and
reassurance from his family, he may have imagined all sorts of things which he could
not help sort out.
It also seems that he was in debt to another prisoner. He told his sister that he owed
£120 for the use of an unauthorised mobile phone, and he had no way to pay back the
money.
When Mr Tasker and Ms Phelan met the family they said they knew that the man was
worried about the health of one of his sons, and that he owed money to another
prisoner. But they considered it unlikely that these things would have troubled him to
the extent that he would want to take his own life.
However, all of this is in the realms of speculation. The man had given no indication
that he might harm himself and we cannot know what was in his mind when he attached
a ligature around his neck. In the end the problems may have been too big for him to
solve, even with the support of his family, staff and fellow prisoners.
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Recommendations
The Governor should arrange for notices in foreign languages to be posted in prisoners’
telephone booths to advise non-English speaking prisoners how to contact the
Samaritans.
In the light of the family’s experience, the Governor should remind staff of the
importance of returning personal effects to next of kin in a timely and considerate
manner.
It is pleasing to know that the Area Manager and Governor accepted and agreed to
implement the two recommendations at the time of the draft report, rather than waiting
for the final report.
Good practice
My investigators highlighted two areas of good practice at Swaleside:
The care team has refurbished an old building in the grounds of the prison. They have
spent wisely, and have bought carpets, soft furnishings and paintings, and they have
made a small kitchen. The area is used for counseling, for informal conversations and
for time out for staff that are, for any reason, feeling low. The care team is proud of their
work. Most of them are veterans of many years and events. The team does not confine
its activities to working within an office. They are present throughout the prison, on
telephones and they visit staff at home. This example of good practice is one that
others might emulate. My investigators are aware that many prisons have good care
teams. The one at Swaleside, in their view, stands out as the best.
A monthly bulletin is published in the prison. It provides a regular summary of the
prison’s activity and it highlights how the prison and its population are performing. It
describes each wing and identifies both good things about the establishment and things
causing anxiety. This easy to read digest is an example of good practice.
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