Individual at The Mount

Investigation into the circumstances surrounding the
death of a man at HMP The Mount
in October 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
July 2008
This is the anonymised version of a report of an investigation into the death of
a man who was found hanging in his cell at HMP The Mount on 7 October
2007. The man was a life sentence prisoner and was 35 years old. He had
been in custody for six years and at The Mount for two.
I offer my sincere sympathies to the man’s family, friends and all those
affected by his loss.
The investigation was conducted by two of my senior investigators. The
Deputy Ombudsman, accompanied my investigators on one of their visits to
The Mount. A clinical review into the care received by the man while he was
in prison was undertaken by an Independent Health Clinician for the West
Hertfordshire Primary Care Trust (PCT). I am grateful to the clinical reviewer
for conducting this. I must also thank the Governor and staff of The Mount for
their assistance and co-operation with the investigation process.
I am pleased to say that the man received a high level of individual care and
support at The Mount, and I commend the staff for this. However, my report
includes six recommendations. In particular, I refer to the design of the cells
where the man was discovered. A further recommendation refers to the
possible extent of illicit alcohol brewing at the prison.
My report also raises concerns to whether the man was the subject of bullying
to pay for drug debts. I note from The Mount’s own document, Safer Custody
Research Findings 2007, that drug and debt related problems represent by far
the most frequent causes of bullying. Few prisoners said they would report
this to staff. They felt staff either did not care or would do nothing about it.
This could give some insight into the position the man might have found
himself in.
Stephen Shaw CBE
Prisons and Probation Ombudsman July 2008
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CONTENTS
Summary 4
Investigation process 5
HMP The Mount 6
Key findings 10
Issues raised in the investigation 25
Conclusion 29
Recommendations 30
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SUMMARY
The man arrived at HMP The Mount in October 2005, having been in custody
since 2001. He was on a life sentence and had transferred from another
prison to continue with rehabilitation programmes. Alcohol, drug misuse and
a propensity for violence were all risk factors in his offending.
The man had had two episodes of self harm in 2001 and 2002. On both
occasions a self harm form (F2052SH, later replaced by the Assessment,
Care in Custody and Teamwork (ACCT) document) was opened, and he was
monitored accordingly.
No more risks were identified until September 2007 when the man harmed
himself by cutting his wrist. An ACCT document was opened immediately.
The man later disclosed that he did not feel suicidal and had cut himself out of
frustration because he had not been given the right amount of medication
prescribed for depression.
I judge that the man received a great deal of support and care from staff to
manage his frustrations. At the time he was on Dixon wing, which staff and
prisoners alike describe as busy and noisy. As part of the man’s ACCT care
and support plan, he transferred to the newly built Narey wing on 17
September 2007.
The man’s ACCT document was closed on 19 September. He attended the
review meeting along with wing staff, a representative from healthcare and the
safer custody officer. It was noted that his mood had much improved. Staff
also commented on how well he seemed to be doing on the new wing.
No further concerns were raised about the man’s wellbeing. He was last seen
alive when he was checked by the night patrol officer shortly after 8.30pm on
6 October 2007, and gave no cause for concern. However, during roll check
the following morning, the man could not be seen in his cell through the door
observation panel. It was first thought that he was in the shower area, which
was obscured from sight. However the night patrol officer received no
response after repeatedly banging the cell door and calling out. The alarm
was raised, and other staff attended the wing and entered the man’s cell
where they found him hanging in the shower cubicle area. Resuscitation was
not attempted as rigor mortis had already set in. The paramedics formally
pronounced his death.
After the man’s death, evidence suggested that he might have been in debt
for receiving drugs from other prisoners. This could have resulted in his being
bullied, although he himself never reported it.
My report includes six recommendations.
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THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by one of my
investigators on 10 October 2007, when he visited The Mount. He met
the Governor and the deputy governor. Notices of the investigation and
terms of reference had already been sent to the prison and invited
anyone with any information to contact my investigators. Two prisoners
subsequently came forward and were interviewed, as were members of
staff.
2. During his initial visit, my investigator also met representatives of the
local branch of the Prison Officers’ Association (POA) and the Head of
Healthcare. My investigator visited Dixon and Narey wings, where the
man had been located, and met separately with a representative of the
Independent Monitoring Board (IMB) who raised concerns about the new
cell design on Narey wing. My investigator, accompanied by a second
investigator and Deputy Ombudsman, returned later to the prison to
conduct interviews.
3. A clinical review was commissioned from West Hertfordshire Primary
Care Trust (PCT) to assess the man’s medical care. Unfortunately,
there was some delay in the completion of this review, partly because
the PCT was unable to find a suitable clinician. The PCT eventually
appointed a clinical reviewer, to whom I am most grateful. However, I do
hope that the PCT has now put in place a system better designed to
facilitate any future requests for clinical reviews.
4. One of my family Liaison Officers made contact with the man’s mother to
tell her about our investigation. On 18 December 2007, my family liaison
officer and investigator visited the man’s mother and sister at their home.
The man’s mother raised the following questions in relation to her son’s
death, and I hope I have addressed them fully in my report:
• They had sent the man a considerable amount of money (more than
£500) over an approximately three month period whilst he was at the
Mount. The man had not told them why he needed the money.
• The family suspected the man was involved in drugs and debt and
this might have been worrying him. They are concerned that it was
not noticed by the prison because the large amounts of cash enabled
him to pay any debts.
• The family wondered whether he was having trouble with someone
on Dixon wing who was then moved to Narey wing.
• The man had told them that he had three more years to serve in
prison.
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HMP THE MOUNT
5. The Mount is a category C training prison, five miles from Hemel
Hempstead. It opened in 1987 as a young offender institution and
changed its role to that of an adult establishment in 1990. The Mount’s
operational capacity is 764 prisoners.
6. Healthcare is open from 7.45am to 5.15pm on weekdays. Prisoners can
report sick either first thing in the morning or at lunchtime. During these
times they can be seen by the nurse or the pharmacist. A range of
healthcare resources is accessible for prisoners, but there is no inpatient
facility. Two doctors from a local NHS practice hold clinics every
weekday morning. Prisoners can report ‘special sick’ at any time and
another doctor visits the prison in the afternoon for ‘special sick’ and new
receptions. Out of hours cover is provided by an on-call doctor. An in-
house pharmacist is employed on a full time basis.
7. The Mount has eight wings. The man was initially located on Dixon
wing, which is a normal residential wing and houses short and long term
prisoners on enhanced and basic incentives and earned privileges
scheme (IEP) levels. Prisoners on this wing also have their own cell
keys. Narey wing, where the man was later located, is a new build wing.
Long term and life sentence prisoners were being relocated to Narey
wing at the time of this investigation.
8. An unannounced inspection of The Mount by HM Chief Inspector of
Prisons, Ms Anne Owers, was carried out in September 2006. In relation
to doctor and nurse appointments, Ms Owers noted: “The appointment
system worked well, although there were some delays in appointments
because of the mass movement system for prisoners. However,
prisoners were seen quickly and without due delay. Prisoners who
requested appointments with the GP or nurse were generally seen at the
next available appointment, usually the following day”. Ms Owers’ report
also noted that The Mount had made very impressive progress since its
previous announced inspection in October 2004.
Adjudication
9. An adjudication is an internal hearing into breaches of prison discipline.
Assessment, Care in Custody and Teamwork (ACCT)
10. As at all prisons, ACCT has been introduced at HMP The Mount to
monitor and support prisoners assessed as at risk of suicide or self
harm. (The previous system was known as the F2052SH procedure.)
Once placed on ACCT, the prisoner is observed at pre-determined
intervals according to the perceived level of risk.
11. Each prisoner is assessed within 24 hours and then reviewed further at
intervals decided on an individual basis. The ACCT guidance says that,
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to be effective, the review should involve the people who know the
person at risk or are involved in their care.
12. Amongst other things, the ACCT guidance states that prisoners should
be cared for in a safe environment. It is for the case review team to
decide the most appropriate place to locate an individual prisoner.
Canteen
13. Prisoners can obtain various foodstuffs and other items as canteen from
the prison shop. They also have access to a water boiler and are
provided with a weekly tea pack, bread and other food items. Prisoners
use money from their prison cash account to purchase canteen items.
Counselling, Assessment, Referral, Advice and Throughcare (CARATS)
14. Organisations specialising in the treatment of substance abuse have
drugs workers based in most prisons. CARATS workers can run
programmes, and offer counselling, support and referral to rehabilitation
centres to prisoners and on release. Access to CARATS is voluntary.
Incentives and Earned Privileges Scheme (IEPS)
15. The IEPS was introduced to encourage and reward good behaviour in
prisons. There are three levels - Basic, Standard and Enhanced.
Incentives include access to in-cell television, more private cash to
spend, wearing own clothes, more time out of cell, and community visits.
The man was on the enhanced IEP level.
Induction
16. Having gone through the reception process, prisoners at The Mount are
located onto the New Arrivals and Assessment Centre (NAAC), Howard
Induction wing. Prisoners receive their induction here and the facilities
and the regime of the prison are explained. After a suitable period on
the induction wing, they are re-allocated to a regular residential wing.
Insiders and Listeners
17. As is the case at most prisons, The Mount relies on experienced
prisoners as Insiders and Listeners. Insiders welcome new prisoners,
highlight any concerns and explain the processes the newcomers will
encounter in the early days of custody. Listeners assist those prisoners
who require additional support at any time in their period in custody.
They are provided with training from the Samaritans to support them in
this role. Confidentiality is a main feature of this role.
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Lifer manager
18. Prisoners on an indeterminate or life sentence are assigned a lifer
manager to work with them through their sentence, and to assess and
meet their different needs. This will include target setting, sentence
planning and preparing reports for parole hearings.
Medication management in prison - In-possession medication (IP)
19. Prisoners should be provided with a health service that is equivalent in
quality and range to that in the wider community. Prison Service
Instruction 028/2003, A Pharmacy Service for Prisoners, provides that
medicines in use, together with associated monitoring and administration
devices, should normally, and as a matter of principle, be held in the
possession of the prisoners themselves. Each prison should have a
policy and risk assessment criteria for determining on an individual basis
when medicines may not be held in possession.
Mental health in-reach
20. The in-reach team offers a mental health service for all prisoners who
have enduring mental illness. They also treat and support prisoners in
crisis situations. They also support prisoners who are on ACCT
documents, and attend most ACCT review meetings.
Release on licence (Parole)
21. Prisoners may be released early on licence subject to the decisions of
the Parole Board. The Board makes its decisions on the basis of reports
by prison and probation staff. The decision to grant or not grant release
on licence is based on an assessment of the extent of their risk and the
way in which it can be managed. This is informed by the nature of the
prisoner's offence, their home circumstances, their plans for release, and
their behaviour and engagement in rehabilitative programmes in prison.
Personal officers
22. Every prisoner is assigned a personal officer. Their role is to meet with
the prisoner on a regular basis and to discuss any issues or concerns
the prisoner may have.
Roll check
23. The roll check is the physical count of the number of prisoners on each
wing within a prison. Roll checks occur on a number of specified
occasions during the day and night, and staff must sign that the roll is
correct
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Private cash / private spends
24. Prisoners are not allowed to retain notes or coins in their possession.
Money may be sent to the prisoner, preferably by postal order or cheque
made payable to the Governor. There are no limits on the amount of
private cash a prisoner can have but, since the introduction of IEPS,
there are limits on how much can be spent. The following currently
applies to The Mount:
• There is no 'cap' but all single amounts over £100 are reported to
security.
• There is no limit on how much money a prisoner can send out.
• The weekly automatic transfer of money to the spend account for
enhanced prisoners is £23. Prisoners can accumulate up to 10 times
this amount in their spend account before private cash ceases to be
transferred into it (earnings are unaffected).
• There is no limit on how much of their spends a prisoner can use
each week in the canteen.
25. My investigator identified that the man received around £470 from his
family between April and October 2007. In addition, he received weekly
earnings of approx £13. The prison has a record of all the transactions
he made during the period. Including his canteen and telephone credit,
this amounted to approximately £580.
Violence Reduction Strategy
26. The Prison Service has a specific policy on reducing violence which also
incorporates policy on dealing with bullying. The policy states that
everyone has the right to feel safe and free from physical, emotional or
psychological intimidation and all prisons are required to have in place a
local Violence Reduction Strategy. This strategy must make clear that
all forms of violence, including bullying, will be challenged and there
should be monitoring systems in place to record all incidents of violence
(including bullying) and identify any emerging patterns.
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KEY FINDINGS
Prior to the man’s arrival at The Mount
27. In December 2000, the man was arrested and charged with committing
two violent offences. In June 2001, he admitted to the offences at court.
Because he had committed a similar offence and been convicted in
1991, the man met the criteria for a discretionary life sentence. The
court sentenced him to life imprisonment with a tariff (minimum period) of
three years and seven months. That minimum period would expire in
July 2004. The court identified that alcohol, drug misuse and a
propensity for violence were contributory factors to the man’s offences.
28. Following his conviction, the man was transferred to HMP Wormwood
Scrubs. He went through the normal prison reception screening
process. The man was interviewed by the healthcare nurse and
disclosed that he had recently taken opiates and cocaine. He was
referred to CARATs for substance misuse advice. He was also referred
to a psychiatrist for a mental health assessment because his mood was
low and he had difficulty managing his anger. A F2052SH document
(later replaced by the ACCT) was opened and he was transferred to the
detoxification unit for a period before being moved on to a normal
residential wing in a shared cell.
29. The man was seen by the outreach team and it was agreed that he
should continue to see CARATs workers and the outreach team every
week. During his time at Wormwood Scrubs, The man was seen by
healthcare regularly to review his medication of chlorpromazine (an anti-
psychotic drug) and amitriptyline (most commonly used for the treatment
of depression). Both medications were prescribed to help his mood and
to improve his sleeping.
30. In March 2002, the man transferred to HMP Swaleside where he would
start his offence related rehabilitation programmes. He went through the
prison reception screening process and was later located to a shared cell
in a normal residential wing. The man disclosed that he had no present
thought of self harm.
31. The man’s behaviour at Swaleside was reported by staff as generally
satisfactory. He participated with the rehabilitation programmes, was on
the voluntary drug testing unit and had produced negative test results,
and was on the enhanced level of IEPS. However, he did subsequently
incur two adjudications, one of which was for possessing fermenting
liquid (hooch).
32. The man continued to receive medication for his low mood and sleeping
problems, and attended the Community Psychiatric Nurse (CPN) clinic
regularly for reviews. He later had two episodes of self-harming. The
first occurred in August 2002. He said it had occurred because he was
miserable and depressed. The second, in October 2002, was carried out
10
whilst under the influence of alcohol. On both occasions the man used a
blade to make cuts to his forearm. A F2052SH document was opened to
monitor and support him on both occasions.
33. When the man attended the CPN review clinic in November 2002, it was
noted that his mood was much more stable. He continued to receive
repeat medication of chlorpromazine and amitriptyline. The man
seemed more settled and expressed no more thought of self harm. This
continued for the rest of his time at Swaleside, although he attended
healthcare for a number of physical ailments.
34. As part of the man’s life sentence plan to address his offending
behaviour, he completed a number of rehabilitation programmes and his
progress was continually assessed. By January 2005, the Parole Board
recognised that he still needed to be assessed for the Cognitive Self
Change Programme (CSCP) or the Controlling Anger and Learning to
Manage it (CALM) course, for lifer victim awareness, and the alcohol and
drug awareness programme. The latter two courses were not available
at Swaleside, and so it was recommended that the man progress to a
category C prison to complete the remaining courses. As a
consequence, when the man’s Parole Board Review was held in April
2005, release or moving to open conditions was not recommended.
The man’s arrival at The Mount on 4 October 2005
35. The man was transferred to The Mount on 4 October 2005. He again
went through the normal prison reception screening process. Here he
said that he was feeling much better, was not depressed and had not
self harmed for three years. He disclosed that he had lost some weight
and was fully aware of healthy eating. He was now only taking the
prescribed amitriptyline, which he said was keeping him well. The man
was later located to Howard wing, the induction wing for new prisoners.
36. Only a day later (5 October 2005), the man moved to Dixon wing, a
normal residential wing. The following day, the reception officer had a
long chat with the man because he was quiet and seemed a little
disorientated. The man told the reception officer that he felt his move
from Swaleside had been too rushed. He also felt pressurised at being
moved so quickly from Howard to Dixon wing. It felt to him as if his
induction programme was being hurried. During their conversation, the
man mentioned that he had had a history of self harm and depression,
although he said he currently felt free of any such thoughts. The man
declined the reception officer’s offer of a referral to the healthcare unit,
saying he had no need to see them.
37. The reception officer suggested to the man that his induction be put on
hold until he had settled in at The Mount. Later that afternoon, the
reception officer spoke to the wing manager. The wing manager spoke
with the man later that day and told him she had arranged for his
induction to be deferred until 17 October to give him time to settle. The
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man was happy with this and the wing manager arranged to speak with
him again in a week’s time. The next day (8 October), the wing manager
noted in the man’s wing history sheet that he had been polite to her and
appeared to be much more settled.
38. A mental health in-reach referral meeting took place on 7 October at
which the team discussed the man. He was currently stable on his
medication and it was agreed that he should receive support through
Primary Care, and that it was not necessary for the In-reach team to take
any further action with him at this time.
39. On 12 October, staff had cause to speak to the man. He was upset
because healthcare had refused to issue his medication. Wing staff
discovered that the man was not due further medication for another day.
This was explained to him and he soon calmed down. Over the coming
months, the man settled into the prison regime. He raised no particular
concerns with staff and was often described as a quiet.
40. The man had previously complained of having abdominal pain and a
subsequent ultrasound examination showed that he had gallstones. On
5 September 2006, he attended day surgery at a local hospital for a
medical procedure. When he returned to prison, staff allowed him to use
the office telephone to contact his mother to reassure her that he was
okay. He was checked hourly overnight by the night duty officer and
made an uneventful recovery from his operation.
41. On 26 September, the man was referred to healthcare after reporting
that he had felt depressed since having his operation. He said he was
neither eating nor sleeping well, although had no thoughts of self harm.
He was seen by the prison doctor who referred him back to the In-reach
team.
42. The man was later seen and assessed by the In-reach team manager,
on 10 October 2006. The in-reach team manager told my investigators
that the man was not interested in engaging with him at that particular
time. He recorded that the man was worried and depressed by his
present circumstances and his uncertainty about getting released on
licence. The man told him that he had been refused parole, had been in
prison for about six years and was still without a release date. The man
also complained about the high level of noise on Dixon wing. He said
that both these issues made him feel stressed.
43. The man also mentioned to the in-reach team manager that, when his
family came to visit, it sometimes made him feel worse because he was
not able to be there to support them outside. The In-reach team
manager told my investigators that the man categorically said he had no
suicidal intentions or thoughts of self harm. He noted the man was still
taking amitriptyline 75mg at night, and recommended that he be referred
back to the Primary Care team for a review of his dosage. He also made
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a referral for the man to see the prison doctor to be assessed for a
relaxation group.
44. The man’s mood was assessed by the doctor the following month on 8
November. His medication dosage was increased to 100mg at night.
When the man attended the doctor’s clinic for a review approximately
four weeks later, his mood was better, he appeared stable and said he
was happy on the new dosage.
45. On 15 December 2006, the man attended healthcare with a small
testicular lump and was referred for an ultrasound scan. The ultrasound
examination took place on 19 January 2007 and a diagnosis of a cyst
was made. No treatment was required and reassurance was given.
46. The man attended healthcare regularly over the following months for
reviews of his anti-depressant medication and for other minor healthcare
problems. This included him being risk assessed for in-possession
medication (IP). He was trusted to take his medication as prescribed
and given seven days medication at a time.
47. At the beginning of March 2007, the man learned that his father had
died. The Chaplain delivered the news and offered him bereavement
support. The man was later permitted to attend his father’s funeral which
was held on 8 March. No concerns were reported regarding the man’s
behaviour throughout the ceremony. The Chaplain told my investigators
that the man was pleased to be able to attend his father’s funeral, and he
continued to offer support to the man after this period.
48. A fellow prisoner on Dixon wing, told my investigators that he got to
know the man quite well whilst they were on the wing. He said he felt
that there was a change in the man’s mood after his father had died.
The man seemed depressed, agitated and withdrawn. The prisoner also
believed that the man had got himself into debt on the wing by buying
heroin from other prisoners. This was brought to the prisoner’s attention
because, as a consequence, the man would borrow his canteen when he
had used his own to pay back debts.
49. A second prisoner also told my investigators that the man had borrowed
canteen from him on occasions. The second prisoner said he believed
that the man had got himself into debt due to being given heroin by other
prisoners.
50. Many of the comments in the man’s wing history sheets throughout
2006/07 show that he was a polite and well behaved individual.
Comments included: “another good week from the man, polite to staff”
and “always on time at lock up and maintains excellent behaviour”.
There are no records to indicate that the man approached any member
of staff to disclose any concerns or issues. Staff continually noted his
helpfulness around the wing.
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51. The man was interviewed on 12 April 2007 by the prison psychologist
regarding a recent psychology report (disclosed to him in December
2006) and his forthcoming parole review hearing. The man said he was
happy with the report.
52. On 9 May, the man attended his Parole Board Hearing. This was his
third review. On this occasion the Board acknowledged the good
progress he had made at The Mount. He had remained free of
adjudications and enjoyed enhanced status. He had completed a
number of courses and programmes, although he had not undertaken
any offence related work on violence. The next available course was the
CALM programme, which was scheduled to take place in June. The
Parole Board therefore deferred until November 2008 a decision on
whether the man would be moved to open prison conditions or released
on licence. The Board would then review the progress he had made.
53. The wing manager told my investigators that the man was disappointed
at this outcome, but did not appear angry or devastated. The wing
manager explained that if a prisoner was refused parole once they
reached their tariff, further review dates were set by the Ministry of
Justice Lifer Section. In general terms, Parole Board hearings took
place every two years. She also confirmed that the man had spent a
considerable time in prison and was fully aware of how the parole
system operated.
54. The man commenced the CALM course in June 2007. On 26 July, a
wing officer told my investigators that she spoke with the man because
he appeared very quiet and withdrawn. The man said that he was
approaching the end of his CALM course and had been finding it difficult.
His tutors were aware of this and had allowed him extra time to complete
the work. The wing officer also offered her support and told my
investigators she kept an extra eye on the man after this point.
55. The wing officer said that the man was always polite, worked in the
servery and was generally quite a happy person. He had a few selected
friends and tended to socialise with other lifers. He liked a laugh, and
was quite a funny person who had gained the nickname “Asbo” from
other prisoners on the wing. The wing officer said that, if the man was
not happy, staff would soon know just because of the type of person he
was. For example, there were days when the man asked to be locked
up early because he said he had had enough of socialising with other
prisoners. Throughout her contact with him, the wing officer also said
that the man showed no sign of taking drugs or being bullied.
56. On 29 July, the man was the subject of a random mandatory drug test
(MDT). He tested positive for opiates and was placed on a disciplinary
report to face adjudication. He later wrote as part of his written
representation for the adjudication that he had taken what he thought
were painkillers that were given to him by another prisoner. He wrote
that he was truly sorry for his actions.
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57. After the discovery of the man’s positive MDT, he was referred to see a
CARATs worker. The man met with the CARATs worker on 7 August.
She introduced herself and explained her role in reference to the man’s
MDT failure. The man told the CARATs worker that his positive MDT
was due to being on prescribed co-codomol. He said he had appealed
against the charge and his solicitor was dealing with the matter.
58. The CARATs worker and the man discussed the courses he had already
completed. They now included the alcohol and offending behaviour
course and the CALM course, of which he was two sessions away from
completion. The man said he was enjoying the CALM course although it
was difficult at times. In interview, the CARATs worker described the
man as quiet throughout the meeting and said that he raised no
concerns. It was agreed that they would meet again to review his
progress in November.
59. The man successfully completed the CALM course on 11 August. The
wing officer noted in the man’s wing history sheet that he appeared
relieved at this and was now looking forward to moving to Narey wing,
the new wing for life sentence and long term prisoners. A week later (19
August 2007), it was noted that the man’s mood was low and he
remained in his cell a lot of the time. When asked, the man said he was
worried about his forthcoming adjudication.
60. On 25 August, the wing officer again commented that the man was
looking forward to moving to Narey wing. She noted in his wing history
sheet, “I think the man’s had enough of Dixon.” The man told the wing
officer that the reason he wanted to leave Dixon wing was because it
was too noisy for him. The wing officer said in interview that the man
was anxious to move to the new wing, which was originally supposed to
have opened at the end of July. The opening had been continually
delayed, adding to the man’s frustration.
61. The wing manager was also the lifer manager and so she had frequent
contact with the man. He spoke to her about his past alcohol abuse, and
how he was feeling better now so that it was not an issue. He later told
her that he was fed up and stressed and could not wait to move to Narey
wing. Although the wing manager said that the man did not want her to
“make a fuss of him”, he told her that he had pinched the insides of his
arms a few times as a self-harming mechanism to release his stress.
With the man’s knowledge, the wing manager spoke with the safer
custody senior officer and arranged for her to speak to the man. The
man was shown some techniques to use to help him relieve stress,
including some relaxation CDs. The wing manager also arranged for the
man to attend relaxation classes. The man later told the wing manager
that he found all of this helpful.
62. In a bid to alleviate some of the man’s frustration, the wing officer made
a tentative arrangement with the senior officer on Fowler wing for him to
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be temporarily relocated there for a couple of weeks until Narey wing
opened. When this was broached with the man, he refused saying that
he wanted to remain on Dixon as that was where his friends were. He
said that he was happy to remain there until Narey wing opened.
63. The man’s adjudication took place on 1 September. The charge of
providing a positive MDT for opiates (heroin) was proven and resulted in
14 days cellular confinement, stoppage of earnings at 60 per cent, loss
of canteen and loss of association. All the punishments were suspended
for four months.
64. On 6 September, the man collected his medication from healthcare.
When he returned to his cell, he discovered that there were four tablets
missing. He immediately informed a wing officer who reassured him that
the shortfall would be made up if an incorrect quantity had been given.
The healthcare unit was contacted and, following discussion with the
head of healthcare, it was agreed that as the man was considered a
trusted prisoner he would be issued the four tablets. In the meantime,
apparently in reaction to the thought of being without some medication
for a day or so, the man returned to his cell and self harmed by cutting
his left wrist.
65. A senior officer told my investigators that sometimes it was difficult to
judge the man’s mood because he spent a lot of time alone in his cell.
Generally he was in a good mood, but staff often relied on other
prisoners to tell them when he was not. When the man returned to his
cell on this occasion, it was a prisoner who told the senior officer that the
man had self harmed. The prisoner actually dressed the man’s wound
first and then alerted staff. The man was subsequently taken to the
healthcare unit.
66. A nurse treated the man in the healthcare unit. It was a superficial
wound which he cleaned, glued and steri-stripped. The man told the
nurse that he had self harmed for three reasons. First, because he had
not received the right amount of medication. The second issue was that
the man was finding it difficult to cope on Dixon wing because it was very
rowdy and there were problems on the wing. Lastly, the man disclosed
that he had some family problems, although he would not elaborate on
them.
67. Following the man’s act of self harm, an ACCT document was
immediately opened and the man attended an ACCT assessment
interview. He said that when he informed staff that four tablets were
missing from his medication, he was made to feel as if he was lying.
This caused him to cut his wrist out of frustration. He also said he felt
anxiety at the thought of just having two days worth of his medication.
However, the man said that he had no intention of taking his life.
68. Afterwards, the man was returned to his cell, and hourly observations
and staff interaction began. Access to the phone was arranged should
16
he wish to use it. The man was also reminded of the services of the
Listeners who were available to talk with him at any time. As the man
was in a single cell, staff arranged for a good friend of his to speak with
him to help his mood.
69. The next day (7 September 2007), an ACCT review took place. The
man was present together with a senior officer, the Safer Custody Officer
and the In-reach manager. The in-reach manager told my investigators
that the man said he had self harmed as an emotional release, which he
had now achieved. The man had said he was adamant that he had no
further thought of self harm, did not want to commit suicide and wanted
the ACCT document to be closed. The man said he was still generally
unhappy on Dixon wing, and was waiting for his transfer to Narey wing.
70. The staff at the review meeting noted that the man now appeared in
quite a cheerful mood. He disclosed that there were times when his
mood was low, especially after visits from his family, but he was always
cooperative with staff. He had attended the first week of his Relaxation
Course and agreed to attend for the next three weeks. A computerised
cognitive behavioural therapy (CCBT) training course, Beating the Blues,
had also been arranged for him to attend. (This is a computer based
confidential course designed to help individuals reduce their stress and
anxiety levels.)
71. The outcome of the man’s ACCT review was thought to be positive.
Although the ACCT document was to remain open, it was to coincide
with his pending move to the new wing. His observation levels were
reduced to one in the morning, afternoon and evening, and three times
during officer patrol state. The man was reminded again of the services
of the Listeners and the In-reach team.
72. On 9 September, the wing officer spoke with the man who again said he
had had enough of Dixon wing, describing it as loud and containing dirty
and angry prisoners. There was no doubt that the man was anxious to
leave the wing.
73. The chaplaincy plays an active role in checking prisoners who are on an
open ACCT. The Chaplain, who had met the man before, spoke to him
to see how he was and to offer support. The man told him that he
wanted to leave Dixon wing where he was unhappy. He gave no
particular reason why he wanted to move. The Chaplain said he would
try and expedite matters on the man’s behalf by speaking with the wing
manager.
74. In order to try to keep the man active and to improve his mood, the wing
officer obtained permission for him to assist with the last minute
preparations for the new wing. There were a number of items of
furniture to be taken from various parts of the prison and a selected
group of staff and prisoners were chosen to do this. The wing officer
thought this would be a good motivation and give the man something to
17
do, as well as taking him out of Dixon wing except for lunchtime. The
safer custody officer told my investigators that she spoke to the man
whilst he was doing the work. He was thoroughly enjoying being a part
of setting up the new wing. The wing manager described the man as
much like his old self whilst doing the work.
75. On 17 September, the man was eventually relocated to the new Narey
wing. Because of his good behaviour and assistance in getting the wing
up and running, he was allowed to choose which cell he would occupy.
He was located next door to a third fellow prisoner, whom the man
considered to be a good friend. No more concerns were noted about the
man’s well-being.
76. A further ACCT review took place on the morning of 19 September
attended by In-reach community psychiatric nurse, the wing manager,
the safer custody manager and the man. Other than the man, none of
them had attended the previous ACCT review. The In-reach community
psychiatric nurse told my investigators that, although the In-reach team
do not normally attend ACCT reviews, they like to take an active role in
supporting safer custody and to work together as a team.
77. The In-reach community psychiatric nurse said that the man appeared
very well, bright and cheerful at the review. He was happy to be on
Narey wing and invited the staff to see his new cell. He said that his cell
had a nice view and he had his own shower. He also said he had no
more thoughts of self-harm and wished to continue his Relaxation and
CCBT courses.
78. The review agreed that the man’s ACCT document should be closed and
it was noted:
“ACCT closed – he is much more positive in his state of mind no
thoughts of self harm, happy to continue with relaxation classes.
Arrangements have been made with workshop 8 for the man to
resume work from 24/9/07. The man intends to take up the CBT
when he has completed relaxation classes. Happy that there
are staff he is comfortable approaching with any issues.”
As is normal, a post closure ACCT meeting was scheduled (for 17
October) to see how the man was progressing.
79. The Chaplain visited the man on Narey wing after the review. He
described the man as more positive and chatty than when they last
spoke.
80. On the following day (20 September), the man collected his week’s
supply of medication as usual, doing the same on 27 September and 4
October.
18
81. On 21 September, it was noted that the man was now working in the
servery, was polite and cooperative, and no concerns were identified.
Because of the design of Narey wing, the acoustics were quieter and the
man was said to be integrating with other prisoners. A week later, on 28
September, he was presented with a certificate of achievement for his
completion of four sessions of the Relaxation course for dealing with
anxiety, problem solving and assertiveness.
82. The man wrote a letter to his mother on 1 October. This was disclosed
to my investigating officers after his death. He explained that he had not
made any telephone calls to his family because he felt it was easier for
them, as well for him, if no contact was made. This extended to his
visiting rights. The man said that he felt he would not be released from
prison within the next three years. He claimed he was drug free but had
no money, was in debt and felt like a tramp. As a result, the man said he
had borrowed things off other prisoners.
83. On 4 October, the man spoke to the safer custody officer. The man was
out on association and said that he was really enjoying being on the new
wing. He joked with the safer custody manager and said he had no
issues or concerns. This was of course in contrast to what the man had
written to his mother just days earlier.
The night of 6 - 7 October
84. The prisoner in the cell next door to the man was his friend. This
prisoner told my investigators that he last spoke with the man around
6.00pm on the evening of 6 October. He said the man seemed fine and
they had spoken about Christmas. The last thing the man asked was
whether the wing manager had checked his observation panel, which he
confirmed. The prisoner said that, after lock up, he and the man tended
to continue their conversations, although on this particular evening the
man was quiet. The prisoner said this did not concern him, and he
believed that the man might have taken his medication early which was
not unusual.
85. A prison officer commenced his night duty shift at around 7.45pm on the
evening of 6 October. He told my investigators that he relieved the day
staff after the roll check had been completed. The Night orderly officer
also commenced his night duty at the same time, and they received a
handover from the senior officer on the day shift. The two officers
completed a roll check around the prison, double locking prison gates for
security reasons. Throughout the night, the prison officer on night duty
said he would be on hand to assist the night orderly officer in carrying
out any duties around the prison.
86. An Operational Support Grade (OSG) began his night duty shift at
8.30pm. He told my investigators that one of his first tasks is to
complete the roll check of the wing. (The roll check would also be
repeated the following morning between 5.00am and 6.00am.) When
19
the OSG arrived at the man’s cell, he looked through the observation
panel where he saw the man seated on the floor watching television.
The cell light was off. He knocked on the door and asked the man how
he was. Although the man acknowledged the OSG’s presence by
looking at him, he did not respond. The OSG said that everything looked
normal within the cell. As the man was no longer on an ACCT
document, the OSG had no reason to make any further checks on him
throughout the night. There were no concerns reported on the wings
that night.
87. The officer on night duty told my investigators that, from around
10.00pm, he and the night orderly officer checked all the wings at regular
intervals to make sure that everything was calm. With regard to Narey
wing, the officer said no concerns were reported by the OSG.
The morning roll check on 7 October, cell C1 Narey Wing
88. Having had a quiet night, the OSG commenced the morning roll check at
around 5.30am. He started from wing A through to B and C and so on.
When he arrived at the man’s cell, he looked through the observation
panel but could not see the man on his bed which had lots of pictures
scattered on it. The OSG knocked on the door and called out the man’s
name to get a response but did not receive one. He knocked repeatedly
but obtained no reply.
89. The OSG told my investigators that it was not unusual for a prisoner to
be in the shower area. It was not possible to see into the showers on
Narey wing from the cell observation panel. The OSG said that
prisoners at times sat on the toilet and would not reply to calls from staff.
90. The OSG also confirmed to my investigating officers the procedures in
regard to entering a cell during the night time period. He said that, if he
could see a prisoner was trying to harm himself or was in a life
threatening situation, he would go into the cell having considered the
risks to himself and security of the prison. Before doing so, he would
inform the control room to gain permission. The OSG night patrol staff
do not hold keys to cells but carry a sealed pouch with a cell key which is
only to be used in emergencies.
91. The OSG decided to continue with his roll check, and to return to the
man’s cell after a minute or so to recheck. He returned and knocked on
the cell door several times but the man was nowhere to be seen or
heard. The OSG immediately made his way to the office to telephone
the control room and inform them.
92. The night orderly officer told my investigators that it had been a fairly
quiet night. He confirmed that at around 5.50am, whilst in the gate
house, he received a phone call from the OSG who informed him that he
had got no response from cell C1. The night orderly officer told the OSG
to make as much noise as possible to try to get a response from the
20
prisoner inside. Having carried out this instruction, the OSG still
obtained no reply from the man.
93. The night orderly officer told the OSG that he should wait for him to
arrive on the wing before going into the man’s cell to check on his
wellbeing. The night orderly officer was still concerned about the safety
implications of one officer being alone on the wing and entering the cell
unaccompanied. The night orderly officer and the two officers on night
duty made their way immediately to the man’s cell on Narey wing. This
took no more than two minutes.
94. When they arrived, the night orderly officer looked through the
observation flap and banged on the cell door. He could see through the
observation panel that the bed was straight ahead and that, to the right,
the shower door was open. The night orderly officer asked the second of
the officers on night duty to unlock the door. The second officer went
into the cell followed by the night orderly officer and the first officer on
night duty. All three officers and the OSG had had first aid training,
although the second officer on night duty and the night orderly officer last
completed their training over four years previously.
95. As the officers looked into the shower cubicle, they saw the man
hanging. The ligature was attached to a metal bar that went across the
top part of the shower cubicle. The night orderly officer immediately
used his radio to contact the control room and raise the alarm and call
for an ambulance. In the meantime, the second officer on night duty and
the night orderly officer supported the man’s body and the first officer
used his fish knife (a specifically designed cut down tool) to cut the
ligature. The man was wearing his boxer shorts and tee shirt. He was
laid on the bed by the officers. The first officer on night duty told my
investigators that the ligature looked as if it was a white thin shoe lace.
The pictures on the man’s bed appeared to be of his family members.
96. The night orderly officer said that their initial reaction was to commence
cardio pulmonary resuscitation (CPR). The second officer first examined
the man for signs of life. He told my investigators that the man’s “torso
lacked colour, his body was bloodshot” and rigor mortis had set in. He
described the man’s body as stiff, cold and clammy. The night orderly
officer concurred that the man showed no signs of life.
97. The officers then left the cell to await the ambulance and police. The
ambulance arrived at the prison at 6.16am and the two paramedics were
escorted by the first prison officer to the man’s cell. Following their
examination, the paramedics pronounced the man’s death at 6.30am.
After the man’s death
98. The prison’s death in custody contingency plan was activated and the
man’s cell was sealed to await the arrival of the police. All the necessary
agencies were informed and the first officer on night duty was given the
21
role of log keeper for the cell. The OSG and the first officer returned to
the wing office and started to trace the details of the man’s next of kin.
The Governor, Deputy Governor and Independent Monitoring Board
were also informed.
99. The police arrived at 6.48am and examined the man’s cell. They found
a note written by the man in which he appeared to indicate that he
intended to take his own life. Arrangements were made for the man’s
body to be removed from the prison by the undertakers.
100. The Staff Care Team and the Chaplain were deployed and immediately
began supporting staff who were on duty.
101. A hot debrief meeting for the night duty staff was conducted at 8.50am
by the Deputy Head of Operations. A few staff were absent because
they were being interviewed by the police. Staff present spoke about the
events of the morning. A number commented on the lack of visibility in
the new cells on Narey wing. Staff were reminded about the support
mechanisms in place, and all involved when the man was discovered
were offered taxis home if they did not wish to drive. (The latter was
especially good practice that I draw to the attention of the Prison
Service’s Safer Custody and Offender Policy Group.)
102. As the time for the general unlock of prisoners was approaching, the
deputy head of operations and the wing manager spoke individually to
each prisoner on Narey wing to inform them of the man’s death. The
prisoner who was the man’s friend was the first to be told and was very
shocked to learn the news. An officer was left with him for support whilst
the deputy head of operations and the wing manager continued telling
other prisoners.
103. Later in the day, all prisoners on open ACCT documents were
interviewed and offered further support. A member of the healthcare
team and chaplaincy attended each review. The deputy head of
operations conducted a further hot debrief at around 5.45pm to ensure
that staff were aware of the events of the day and to identify any
concerns.
104. The wing manager informed my investigators that she was approached
by a Narey wing prisoner after the man’s death. He told her that the man
had been in debt to other prisoners on Dixon wing, and they had been
sending messages to the man on Narey wing demanding payment. The
wing manager passed this information to the prison security department.
The wing manager did not know the reason for the debts.
105. The deputy governor arrived at the prison at 8.20am, having already
been told of the man’s death. He immediately gathered information
about the man’s next of kin. Together with the Chaplain, he left the
prison at 9.30am and drove to London to break the news to the man’s
family. They arrived at the man’s mother’s house at 10.30am but got no
22
response. They decided to go to the man’s sister’s address, which was
only minutes away. The news was broken to the family who were given
relevant information about what would happen next. The chaplain also
offered to return to see the family at any time to offer support.
106. Throughout my investigation, the chaplain continued to offer support to
the family, which included conducting the man’s funeral. A memorial
service was held within the prison at a later date that was attended by
the man’s family. The Chaplain also arranged for the man’s personal
possessions to be returned to the family.
107. From prison records and intelligence, it was found after his death that
the man had arranged for three separate payments (totalling £182.90) to
go to a woman. The payments were noted on the prison records as
going to his sister’s new baby, but the man’s sister confirmed to my
investigators that she had not received any money. The information was
subsequently passed to prison security and the police liaison officer who
are looking into the matter separately from this investigation.
Post mortem and toxicology report
108. The post mortem and toxicology report confirmed that the cause of the
man’s death was hanging. The examination also found that the man
was not under the influence of any common recreational drugs.
However, he had a blood alcohol level of approximately 180 milligrams
per 100 millilitres, which is associated with drunkenness in a person with
average tolerance to alcohol. The man had also taken amitriptyline and
chlorphenamine (an antihistamine).
109. The clinical reviewer has confirmed that the man commenced
chlorphenamine in May 2007. Chlorphenamine is antihistamine used for
the treatment of allergic reactions such as hay fever, insect bites and
food allergies. The man was prescribed this for urticaria (a skin
condition) on his arms. He was prescribed 4mg (one tablet) three times
a day. He was given seven days supply each week, with the last issue
of 21 tablets given on 4 October. The recommended dosage of this
medication is 4mg every four to six hours with a maximum of 24mg daily.
110. The port mortem report states that alcohol, amitriptyline and
chlorphenamine are all depressant drugs and will have a sedative effect.
When present in the bloodstream at the same time, the drugs interact
causing an increase in the level of sedation.
The design of the cells in Narey wing
111. My investigator visited Narey wing and confirmed that it was not possible
to see within the shower area by looking through the observation panel
from outside the cell. A number of staff told my investigators that, prior
to the opening of Narey wing, they had raised concerns about the
absence of a sight line into the shower. The safer custody manager also
23
expressed her disquiet with senior management. The concerns were
also raised at a security meeting before the wing was opened.
112. The safer custody manager told my investigators that, as a
consequence, a protocol was put in place that any prisoners on open
ACCT documents would be reassessed to establish whether the new
wing would be the appropriate location. The man met this criterion as he
was on an open ACCT. However, it was considered a major part of his
ACCT careplan to be moved to the new wing as this was expected to
reduce his risk of self harm. These cells however are not designated
safer cells.
113. My investigators contacted the Prison Service’s Safer Custody and
Offender Policy Group concerning the design of Narey wing. (The Mount
played no part in its design, which was managed by the Prison Service
centrally.) The Safer Custody and Offender Policy Group subsequently
reported that the design of the wings had now evolved and the metal bar
in the shower had been designed out.
114. In respect of the existing accommodation at The Mount, Safer Custody
and Offender Policy Group have said that there are resource implications
of changing the existing accommodation. It is said not to be possible to
change it at the current time.
Additional hot debrief meeting
115. The deputy head of operations held a further staff debrief meeting on 5
November 2007 to allow those who were not present previously the
opportunity to raise any concerns. The police liaison officer reported that
around four pairs of shoe laces were found in the man’s cell. He
described this as unusual. No other concerns were raised, but again
staff were offered the support of the Care Team.
24
ISSUES RAISED IN THE INVESTIGATION
Clinical Care
116. The man was in prison continuously between 4 January 2001 and 7
October 2007. He had frequent contact throughout with healthcare
professionals both for his physical and mental healthcare needs. In
addition, he had contact with CARATs workers at all three prisons where
he was held.
117. The clinical review generally endorses the view I have formed that the
man was well supported at The Mount by wing and healthcare staff who
provided a high standard of care. None of the professionals identified
concerns about alcohol or misuse of prescribed medication.
118. The man had a history of self harm including the incident in September
2007 when he cut his wrists. The man attributed this to anxiety,
frustration and depression. At no time did the man directly express
suicidal thoughts.
119. After the man self harmed, an ACCT document was opened, an ACCT
careplan was put in place, and he was monitored accordingly. He
continued to receive his weekly repeat prescriptions. Given that one of
these medications was for depression, a risk assessment should have
been carried out to determine if it was safe for him to hold his own
medication in possession.
The Governor and PCT should ensure that prisoners on ACCT are
reassessed before they are allowed to retain their own medication.
Induction
120. Induction is fundamental to ensuring that prisoners settle into the prison
regime and are made aware of the care and support mechanisms that
are in place. The Mount has clear induction procedures. These state
that prisoners should spend a suitable amount of time on the induction
wing. Unfortunately, this did not apply to the man as he was moved off
the induction wing to a normal residential wing within 24 hours of arrival.
Although I do not believe this was connected to his death, the Governor
will wish to review arrangements to ensure that all prisoners receive an
adequate induction.
Why did the man believe that he would serve another three years in
prison?
121. In the man’s letter to his mother of 1 October 2007, he was despondent
about his life in prison and when he would be released. At his parole
hearing in May 2007, he was told that his position would next be
reviewed in approximately 18 months. There is no evidence to suggest
that he had been told a timeframe of three years would apply.
25
The man’s MDT history whilst at The Mount
122. The man was randomly drug tested four times during his time at The
Mount. The tests were on 5 October 2005 (reception test), 16 June
2007, 16 July 2007 and 2 October 2007. The only failure was the test on
16 July and the man later admitted that he had taken heroin. His use of
heroin corroborates evidence elsewhere in my report that the man was
using drugs, although the extent of his use is unknown. Given that he
tested negative at an MDT five days before his death, and that no drugs
were found in his body at post mortem, it is possible he used drugs as a
coping mechanism whilst on Dixon wing. His use of drugs seems to
have ceased once he moved to Narey wing, although he had already
accumulated debts.
The man’s use of alcohol at The Mount
123. Alcohol was one of the factors identified by the court when he was
sentenced as contributing to his offending behaviour. But throughout my
investigation, there was no evidence to suggest that the man had drunk
alcohol or been observed as being under the influence. However, on
receipt of the post mortem results that showed alcohol in his
bloodstream, my investigators contacted The Mount’s security
department. They reported that there was no further information or
intelligence relating to the man and the brewing or use of alcohol.
124. Although alcohol was not an identified concern during the man’s time at
The Mount, the fact that he was able to consume a considerable amount
of alcohol in the hours before his death raises both safety and security
issues. I have recorded elsewhere in this report that the man received
an adjudication at Swaleside early in his sentence for fermenting liquids
(hooch), so he was obviously familiar with how to make it. But there is
no evidence that it was he who brewed the alcohol found in his
bloodstream.
125. The manufacture of hooch is an age-old tradition amongst prisoners.
However, its potential for encouraging disorder, debt and illness need no
elucidation.
The Governor should investigate the extent of alcohol
production at The Mount and establish a plan to deal with the
findings.
Was the man being bullied?
126. In his final letter to his mother, the man wrote that he had no money and
had borrowed things off other prisoners. Peer evidence suggests that he
had got into debt to pay for drugs. I think it probable this was one of the
reasons the man was so anxious to move from Dixon wing to the new
Narey wing. Having said that, he was offered the opportunity to move
26
temporarily from Dixon wing but declined. Furthermore, he gave no
indication to staff that he did not get on with any prisoners on Dixon
wing. Nor was there evidence to suggest the man was unhappy after
moving to Narey wing.
127. The man made extensive use of his earnings as well as that money sent
in by his mother. Prisoners do not handle cash, but whether the man
used his canteen purchases as currency is not known. However, it is a
possibility that cannot be ruled out. Prisoners frequently swap their
personal belongings or use them as barter.
128. The man had frequent interactions with staff. They observed him in both
low and high moods. On no occasion did he express concerns to staff
about being bullied, but this is not to say that it did not occur. The
Mount’s own document, Safer Custody Research Findings 2007,
suggests that problems relating to drugs or to debt represent by far the
most common causes of bullying. It is important that staff try and build
an environment where prisoners feel safe and confident to approach
staff with any concerns.
The Governor should remind both staff and prisoners about the
prison’s violence reduction policy.
First Aid
129. Although two of the officers who first arrived at the man’s cell had not
had first aid refresher training for over four years, this did not affect the
initial care that the man received as other staff were present.
130. In respect of the number of staff who are first aid trained, the deputy
head of operations has confirmed that a first aid training programme,
including refresher training, was in the process of being rolled out at the
time of this investigation.
Care and Support
131. My report indicates that staff had built up a fairly good rapport with the
man. This was evidenced by the support offered throughout his time in
prison, and in particular when he felt anxious whilst undertaking the
CALM course and waiting for Narey wing to open. The chaplaincy also
played an important role in offering support to the man before his death,
and to his family afterwards. The latter was confirmed by the man’s
mother when my investigators and FLO visited her.
The Governor should commend relevant staff for the care and
support they offered to the man throughout his time at The Mount.
132. Senior staff on duty and the Care Team played an active role in
addressing staff needs following the man’s death. As I have noted
earlier, this thoughtfully included arranging transport for staff who were in
27
shock following the discovery of the man hanging. I commend the prison
for the care and support that was offered. This included holding a further
debrief meeting.
The Governor should commend senior colleagues and the Care
Team for the care and support offered to staff. I was particularly
impressed by the kindness shown in arranging transport for those
staff most affected.
The design of Narey wing
133. The new Narey wing is a modern design with in-cell shower facilities that
are not present in the older wings. I fully acknowledge the importance of
privacy, and en-suite shower facilities provide a benefit of particular
value for long-term and life sentence prisoners. However, as presently
configured, the result is an area of the cell that is partly obscured to staff
when looking through the observation panel. Self-evidently, there is a
balance to be drawn between privacy and propriety and the needs of
security and safety. It is essential that those prisoners allocated to
Narey wing are appropriately risk-assessed.
134. In addition, the shower frame in the cells in Narey wing has a metal bar
across the top to which the man tied the ligature. The flaw in this design
was highlighted by staff before the wing was opened, and measures
were put in place to risk assess any prisoner on ACCT who was to be
located on the wing.
135. I am aware that the Prison Service’s Safer Custody and Offender Policy
Group has already taken forward the matter of the cell design, and I am
pleased to learn that it will not form any part of future building
specifications. I would, however, welcome feedback on what action, if
any, can be taken as regard to the current situation at The Mount - in
particular, whether the metal bar can be designed to be collapsible.
Whilst I am aware of the financial constraints facing the Prison Service,
and that most prison cells contain many other potential ligature points,
the metal bar across the shower frame is a weakness in the design of
Narey wing that should be addressed as a matter of some urgency.
The Governor should ensure the continued risk assessment of
prisoners on Narey wing, giving due consideration to the cell
design. The Area Manager should review whether the metal bars in
the shower frame can be removed or re-designed.
28
CONCLUSION
134. This investigation has shown that staff offered good support to the man
throughout his time at The Mount and tried to manage his anxiety and
depression. On the whole, this appears to have worked well.
135. The man’s frustrations stemmed from his concerns about how much of
his indeterminate sentence he would serve and what seems likely to
have been the accumulation of debts for drugs. According to the man’s
peers, these drug debts resulted in him being bullied, although this was
not something he ever brought to the attention of staff.
136. Although the man had a history of self harm, there is no evidence to
suggest that he had ever threatened to take his own life. When he did
self harm in September 2007, an ACCT document was opened
immediately along with a careplan to support him. One of his major
hopes was to be located to the new Narey wing, and this was addressed
by staff and was soon followed by the closure of the ACCT.
137. The man’s alcohol consumption, mixed with his prescribed medication,
may possibly have had a negative effect on his mood.
138. I do not think that staff had any reasonable grounds for thinking the man
was at particular risk at the time it appears he took his own life.
However, the design of the new cells in which the man was located does
present a risk both to safety and to security. Resources and other
priorities allowing, I hope this can be addressed by the Prison Service.
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RECOMMENDATIONS
1. The Governor and PCT should ensure that prisoners on ACCT are
reassessed before they are allowed to retain their own medication.
2. The Governor should investigate the extent of alcohol
production at The Mount and establish a plan to deal with the
findings.
3. The Governor should remind both staff and prisoners about the
prison’s violence reduction policy.
4. The Governor should commend relevant staff for the care and
support they offered to the man throughout his time at The Mount.
5. The Governor should commend senior colleagues and the Care
Team for the care and support offered to staff. I was particularly
impressed by the kindness shown in arranging transport for those
staff most affected.
6. The Governor should ensure the continued risk assessment of
prisoners on Narey wing, giving due consideration to the cell
design. The Area Manager should review whether the metal bars in
the shower frame can be removed or re-designed.
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