Individual at Wandsworth

Investigation into the death of
a man at HMP Wandsworth in
February 2005
Prisons and Probation Ombudsman for England and Wales
September 2005
This is the report of an investigation into the circumstances surrounding the death of a
man at HM Prison Wandsworth in February 2005. The man was found dead in his cell
at 11.55 am that day.
A post mortem examination was performed in hospital on 15 February and it was found
that there were no signs of restraint or injury. The ligature marks found on his neck
were consistent with hanging.
I offer my sincere condolences to the family of the man who have suffered the tragic
loss of a loved one. Prisoners and staff at Wandsworth who knew the man expressed
their sense of shock and sadness at his death.
The investigation was carried out on my behalf by my investigators. The local Primary
Care Trust were invited to undertake a review of the clinical care the man received.
However, they declined as they had no direct commissioning responsibility at that time.
My Deputy Ombudsman who is BSc RGN qualified has reviewed the medical record
and found nothing of note.
My thanks also go to the Governor and all Wandsworth staff. I appreciate their willing
cooperation which has enabled the investigation to be thorough, and to be completed in
a timely fashion.
I make four recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman
September 2005
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Contents
Summary
Wandsworth Prison
Investigation
Prison history
Discovery of the death
Examination of the issues
Conclusions
Clinical Review
Recommendations
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Summary
This is the report of an investigation by the Prisons and Probation Ombudsman into the
tragic death on 14 February 2005 at Wandsworth Prison of the man who was in prison
serving a sentence under a different name.
The investigators reviewed the man’s records and spoke to a number of staff and
prisoners.
The man had been in custody since 20 January and at Wandsworth prison since 21
January. He was not considered to have been a suicide risk at any time during this
period. He was found hanging from the window of his cell at approximately 11.55 am
on 14 February by his cellmate. The prison staff who gave immediate help, and
paramedic staff later called to the scene, were unable to revive him and he was
pronounced dead at 12.40 pm.
This report reviews the care that the man received while in prison custody and the
events leading to his death.
A letter written by the man gave an insight into the man’s situation at that time and his
state of mind prior to his death.
On 23 December 2003, the man entered the United Kingdom illegally using a false
identity. It is understood that he had used a number of aliases of which the name he
used in prison was one. The name he used in prison was the one that he used to gain
employment in this country.
On the morning of 13 February 2005, after a number of attempts made while at
Wandsworth, the man finally made contact by telephone with his girlfriend who knew
him by the name he was using in prison. He had made it clear in earlier
correspondence that he wanted to marry her, and two telephone calls to her included
attempts by the man to try to persuade her to do so. He also spoke with someone in
Ghana. This conversation included a discussion of arrangements to be made to
accommodate his return there at the end of his sentence.
The report describes in detail the actions taken by staff following the man being found
hanging. I note that the duty doctor was delayed in attending the scene. I also
comment on the fact that there was no hot debrief following the incident. We have also
investigated an allegation that a C wing cell call alarm was ignored on the morning of
the incident, and that a spoof notice was put up on the wing about a memorial service
for the man. No evidence was found during the investigation to substantiate these
allegations.
The man’s next of kin is his cousin. It is understood that he reported that both his
parents were deceased. It is possible to route communications to his other family
members in Ghana through his cousin. The prison has been in contact with her and
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funeral arrangements were made. A memorial service for Vincent was held at
Wandsworth prison on 18 February.
I conclude that, on the basis of the evidence I have seen, the man’s death could not
have been predicted or prevented.
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Wandsworth Prison
7. Wandsworth Prison was built in 1851 and has been extensively refurbished in
recent years to include integral sanitation for prisoners. It houses a large number
of drug users and prisoners with mental health problems. It is leaving behind an
image of being a jail where staff despite a somewhat forbidding reputation have
little interaction with prisoners. This death and a similar incident four days earlier
were the first in over a year and came as a huge disappointment to the Governor
and his staff. A subsequent safer custody audit resulted in a score of 85%.
8. The prison was last visited by the HM Inspectorate of Prisons approximately nine
months ago and it was noted that there was a continuing shortfall in staff
numbers. The Chief Inspector also recorded her “serious concern” that
Wandsworth was not meeting the standards required of a healthy prison.
9. Wandsworth has a CNA of 1,173 was with an operational capacity of 1,462. It is
understood that the prison always functions at or near this figure which is the
maximum population level.
10. Wandsworth is one of the first prisons to be using the new ACCT system for
caring for those prisoners thought to at risk of suicide. Information received from
senior managers at Wandsworth indicate that only 63 staff had suicide
prevention or awareness training and eight staff were trained in ACCT
awareness from December 2004 to February 2005 and 15 to March 2005. There
have been 11 case managers and a similar number of ACCT assessors trained
since the system was introduced.
11. There is currently an extensive building programme underway to provide in cell
electricity to the cellular accommodation, thus enabling prisoners to have access
to televisions and mains operated radios. I commend this project as a positive
step to improving the environment.
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Investigation
12. The investigation was opened on 18 February 2005 when my investigators met
with the Governor and the head of safer custody at Wandsworth. They were
given a comprehensive and 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 was briefed. They
were helpful and offered constructive comment and advice.
13. Local police were contacted and provided all the information at their disposal, as
did the coroner’s officer.
14. A member of the Independent Monitoring Board was interviewed, as was one
other member of the Board.
15. The investigator requested an independent clinical review from the local PCT.
However, the PCT declined to undertake this as they had no direct
commissioning responsibility at that time.
16. My investigator, together with one of my family liaison officers, met with the
man’s cousin, at her home. They were made to feel welcome and the man’s
cousin was able to add to their knowledge and understanding of the events
leading to the man’s death.
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Prison history
Number Prison Number Name
DOB 26 April 1972
Sentence six months imprisonment / detention order
Release date 20 April 2005
Sentenced 21 January 2005
At South Western Magistrates Court
Offence 1 deception
Offence 2 illegal immigration
17. The man was received into Wandsworth on 21 January and underwent the First
Night process that is designed to assess new prisoners, needs. He was seen
while in reception by staff who established that, among a number of other things,
he was fluent in English and that he had not been identified as being at risk of
self harm. He was also seen by the chaplain who gave his name to the foreign
national orderly and Listener. The Listener spoke to the man and they
immediately realised that they were fellow Ghanaians and therefore had much in
common. They discussed the man’s situation and the Listener offered himself as
a friend and as counsel. Later, after he had been put onto C wing, the man
asked to see him in his capacity as a Listener. This was at about 9.50 pm and
the conversation lasted until approximately 10.30 pm. This was the only time
that the man asked for a Listener during his time at Wandsworth and his motive
for doing so on this occasion may have been to speak again to a man with whom
he had formed a rapport, rather than to express thoughts of self harm. As he had
seen him in his capacity as a Listener could not reveal the content of the
discussion that night. But after the man’s death he expressed his surprise that
the man may have taken his own life as he was not aware that he had had any
intentions of self harm.
18. After his cell sharing risk assessment was completed, the man was allocated to
shared double accommodation cell number 30 on the fourth level on C wing. He
was well behaved and had no disciplinary issues at Wandsworth. He had a
polite manner and he made friends with other African prisoners on the wing. He
seemed to settle in over the following week, being described as “a gentleman” by
a fellow prisoner. He saw Listener every day and when they spoke it was as
friends not as Listener to client. In these conversations, the man revealed that
he had a sense of anger and betrayal about the circumstances that had led to his
situation. He had said to a cell mate on 8 or 9 February that he had a good job
and a girlfriend in London and that he did not really wish to go back to Ghana.
But to others he appeared to be reconciled to returning home at the end of his
sentence. On 10 February, he requested a phone card so that he could call
someone in Ghana to make arrangements for his return.
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19. The man had three cell mates in C4/30 all of whom found him to be a quiet man.
One noted that he sometimes cried at night. One of his cellmates mentioned that
he had spoken of his girlfriend.
20. The man corresponded with his girlfriend and it is clear from the content that he
had a very strong wish to marry her. He attempted to phone her quite often but
experienced difficulties in getting a reply.
21. His girlfriend did not express a clear wish to marry the man and this appears to
have played on the man’s mind. The last letter that he sent to her included
expressions of how at times he felt despairing. He mentioned the prison
conditions he was experiencing that he associated with suicidal feelings
22. Although three visiting orders were issued to him during his time at Wandsworth,
the man did not send them out and therefore did not receive any visits. He spoke
on the telephone to his girlfriend about the possibility of a visit from her but no
arrangement was made.
23. During this time, the man gave no indication to anyone other than his girlfriend of
the feelings expressed in his letters.
24. At Wandsworth, prisoners choose in advance from a menu for their evening
meals, and on 12 February the man completed an order form for sandwiches for
the following ten days. His cell mate at that time, found him to be quiet and said
that he sat on the bed not saying much. The man did however mention his
girlfriend and said that he loved her.
25. On 13 February at 11.01 am, The man made a telephone call to Ghana. It is
understood that it included discussion of arrangements for his return to Ghana.
After the call the man mentioned to another prisoner, that there were financial
difficulties in this regard but that he would be alright. At 11.30 am the same
morning, the man called his girlfriend. He spoke of marriage to her and, while
she did not appear to flatly turn him down at any point, the impression given was
that they should not do anything soon and that they should talk about it when he
was released. Another call at 11.48 am had the same result. The man was seen
replacing the telephone receiver in an angry fashion after one of these calls. It is
not known which one but a reasonable conclusion is that it was at the end of one
of the calls to his girlfriend.
26. At around 12.15 pm, the man spoke to an officer. The officer explained that he
had little time at that moment as he was engaged in lunchtime duty but would be
happy to speak to him another time. The man seemed happy with this, was
smiling and said that he “…will be looking forward to speak with you.”
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27. At approximately 6.30 pm, another prisoner, who was responsible for bringing hot
water to each cell on the fours landing on the wing. He went to cell 30 and saw
the man whom he thought seemed fine.
28. At the 7.30 am roll check on 14 February nothing unusual was noticed in cell 30.
Hot water was taken to the cell at approximately 7.45 am. This requires the door
flap to be opened. Again nothing unusual was noticed.
29. At approximately 9.00 am the man’s cell mate, was taken from the cell so that he
could attend a number of appointments relating to his induction into Wandsworth.
This left the man alone in the locked cell.
30. At approximately 11.00 am, an officer opened the cell door for the wing social
and domestic session. He saw the man who was either sitting or lying on his
bed. They did not speak but the officer saw nothing unusual in the cell and
nothing to cause him to discontinue unlocking the rest of the prisoners on the
landing.
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Discovery of the death
31. At approximately 11.55 am on 14 February, the man’s cell mate returned to cell
30. He had completed the programme of appointments that he had for that
morning and was waiting for the cell to be opened. He looked through the spy
hole and saw the man’s legs protruding from the gap between the head of the
bunk bed and the window. He alerted an officer who looked through the spy hole
and shouted to another officer to blow his whistle. The officer became aware that
an incident requiring the emergency cut down equipment might be needed and
ran to get it from the wing office. The officer unlocked the door and observed the
apparently lifeless body of the man hanging by the neck from the top bunk.
When the officer opened the cell door and upon entry he took a prison issue
plastic cutlery knife that happened to be to hand and cut through the strip of bed
sheet hem from which the noose had been made. Assisted by two other officers
who had responded to the whistle, he lowered the man to the floor of the cell.
The officer cut the ligature from the man’s neck with the same plastic knife, and
he checked the man for a pulse. He also tried to ascertain if he was breathing
but these vital signs were not detected. Cardio pulmonary resuscitation was
begun by the SO and the officer who had unlocked the door.
32. The alarm was raised by the prison control room calling for a nurse to attend C
wing and for an ambulance at 12.03 pm. Attempts were also made to contact the
duty prison doctor but this was not possible. The prison control room confirmed
that there would be a doctor in the ambulance that had been despatched by the
emergency service as well as paramedic nurses.
33. Using the face mask from the cut down kit, the SO was giving mouth to mouth
resuscitation to the man while the officer who had opened the cell door was
maintaining chest compressions. Prison Nurse arrived at the cell at
approximately 12.10 pm and with the help of another Prison Nurse deployed the
oxygen equipment that she had brought with her. The man showed no signs of
life throughout the resuscitation attempts and there was some frustration on the
part of the staff attending to the man that the prison doctor had not yet arrived.
34. CPR continued and at approximately 12.15 pm the paramedic team including the
doctor arrived and took over the care of the man. Attempts continued to be
made to revive the man for a further 20 minutes before it became apparent that
they were not going to be successful and a collective decision was made to
cease attempts. Death was subsequently pronounced by the doctor at 12.36 pm.
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Examination of the issues
35. The man arrived at Wandsworth prison and went through the normal procedures
for new receptions. The chaplain saw him and was able to introduce him to
another prisoner, who was able to help the man settle in. The man was made
aware of the support available to prisoners who may feel suicidal, and took
advantage of the opportunity to speak to a Listener after lock up on his first night.
He did not do this again after that and it is possible that he did so on this
occasion because the duty Listener was the prisoner who had helped him to
settled in and with whom he had struck up a friendship. Certainly, the Listener
was as surprised as everyone else at the news of the man’s death.
36. The prisoner was a quiet man and gave no indication to prisoners or prison staff
of the inner turmoil that was reflected in correspondence with his girlfriend. All
who had known him were shocked by his death and found it difficult to believe
that he would take his own life.
37. The elements in his behaviour that might have triggered the initiation of ACCT
procedures were not obvious as he seems to have ensured that those around
him in prison did not realise how he felt. He came across as someone who was
not too happy about his return to Ghana at the end of his sentence, but was
reconciled to it and was making arrangements for his return. On Sunday 13
February he spoke with prisoners and staff but gave no clue to any other
feelings. He seemed relaxed and cheerful on that day.
38. It appears that the man was desperate to marry his girlfriend and expressed
despair over his perception that she would not agree to it. His language in letters
and phone calls is that of love and it seems that marriage to his girlfriend meant a
lot to him at that time. In his letter to her of 8 February he writes at length about
St Valentines Day and the date 14 February seems to have been significant to
him. He also writes that he wants forgiveness from her for an event that day and
that he could not “…stand that day where I am.”
39. What is also clear from the correspondence with his girlfriend is that the man felt
oppressed by the long periods that he was locked in his cell with nothing to do.
He describes it as “hell” and then writes of ending his life.
40. On inspecting the man’ cell, which had been preserved in its post incident state,
it was noted by the investigator that on top of a fairly large pile of papers and
other items on the table in the man‘s was a letter from his solicitor dated 21
January 2005. It advises the man that he has no realistic avenue of appeal
against conviction.
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41. On the morning of 14 February, his cell mate left the cell and the man was alone
for the rest of the morning. The Ombudsman’s office has received allegations
that a cell bell rang in C wing office unanswered by staff that morning. It was
also said that a spoof notice was put up by persons unknown on the wing notice
board about a memorial service for the man. My investigator could find no
evidence to support the first allegation, although it was noted that the system in
use did not have a mechanism for recording when a cell alarm was activated.
42. It was correct that a notice was put up by the Governor to publicise the memorial
service that was held in the prison chapel on 18 February. There was nothing
amusing about the notice that was seen by my investigator. We have uncovered
no evidence of a different notice.
43. The man’s cell door was opened at about 11.00 am but when the incident was
discovered it was locked. It should not have been possible for him to have
closed his door himself as the procedure for this type of unlock requires the
officer to leave the locking bolt in lock position on the open door. This is known
as ‘shooting the bolt’ and one officer believes that he would definitely have done
this. My investigator could not identify anyone who locked the door, but if it had
been open it is possible that a number of staff of various disciplines and duties
could have done so at the man’s request. This is normal procedure. If a prisoner
does not want to come out of his cell during an association period, he can
request his door be closed by a member of staff.
44. It is also practice at Wandsworth to lock any empty cell to prevent theft, and a
passing prison officer might do this as a matter of course. If it was not obvious
that the cell was occupied then this too could have happened.
45. On discovering the man hanging from the bunk bed, the staff response was
prompt and professional, providing care to the man very soon after the alarm was
raised. It was soon clear as the staff worked to revive the man that it was
probably too late to save him. Nevertheless, they continued to make the utmost
effort.
46. Although there is a system of daytime attendance for the duty doctor, he was not
available and therefore not able to assess the situation, manage or direct the
team’s first aid efforts. The duty doctor was contacted, but it is understood that
he was not in the prison as by then as he was having a meal break and
unavailable. His colleague who was in the establishment was not immediately
contacted, but when attempts were made to do so they failed because his mobile
phone was engaged. It is understood that the only method of contacting the duty
prison doctor is by mobile phone, and that there are no formal arrangements for
the doctor’s meal breaks.
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47. As the incident progressed some staff became quite upset that the doctor was
not there. It was expressed afterwards that staff felt unsupported in this difficult
situation. The officer who had found the man was particularly badly affected and
took sick leave as a direct result of his experience.
48. Following the incident, some staff were seen by senior managers and the staff
care team but no immediate post incident debrief was arranged. This was a lost
opportunity to go through events while all the participants were available and the
experience fresh in their minds. A debrief that took place some days later was
able to find critical points for discussion. The later session allows a more
considered view of events that have been established earlier, but can be less
effective in identifying all the issues. It is understood that there is currently an
on-going review of the critical incident debrief process, in order to establish best
practice.
49. There was a delay in contacting the next of kin. This was due to difficulties
concerning the man’s aliases and police advice that the matter would take a little
time to resolve. Once established it is understood that relations with the family
on the part of the prison were good. A senior manager was tasked with ensuring
that all possible assistance was offered.
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Conclusions
50. The man was found guilty an offence that meant that he would be deported to his
home country at the end of his sentence. It appears that he was not keen to
return to Ghana, but when the issue arose in discussion with others he gave the
impression that he was reconciled to doing so.
51. The man expressed a very strong desire to marry his girlfriend, the woman he
had met at the hospital, and seemed to spend a lot of time thinking about her.
She did not seem so keen to marry, neither was she aware of the man’s true
identity or situation. She had agreed to talk about his proposals of marriage
upon his release from prison not realising, as he did, that they would not have the
opportunity. The man would have been removed to Ghana.
52. The man was apparently emotional and increasingly despairing about his
predicament. But this was not noticed by his fellow prisoners or staff, to whom
he presented as a quiet man who had problems but who was dealing with them.
53. The man’s letters to his partner demonstrate that he was low in mood and
despairing of the situation he found himself in. He wrote, “It really is hell in here.
The doors are banged almost 24 hours a day. No communication to the world
whatsoever”. In a later letter he wrote to his girlfriend, he wrote “I am more
lonely. And I will be more lonely, I am in a small room where I live alone. And
all that is my friends are table and chair, my bed and your letters”. There was no
in cell electricity in the man’s cell, and he therefore had no access to a television
or mains radio to help keep his mind away from his apparently depressing
thoughts. It is clear that marriage to his girlfriend was very important to him and
it was apparent that this was not going to happen before he was deported. This
knowledge also seems to have affected the man’s state of mind and he
repeatedly refers to “killing himself” in his letters.
54. Valentine’s Day features in the last letter that the man wrote to his girlfriend on 8
February in which what seems to be the depth of his feelings is expressed. It
would appear the man had placed great significance on 14 February.
55. Despite a system of medical cover being in place for the day time period, the
duty doctor did not arrive at the scene until the medical care had passed to the
emergency doctor, who arrived as part of the paramedic team. While it must be
stressed that the final outcome would not have been altered, the staff attending
to the man, who continued with the CPR, would have had the additional clinical
support and advice from the duty medical officer. The lack of which was clearly a
frustration to them at the time.
56. In the aftermath of the incident the staff care team was alerted, but no immediate
or “hot” debrief was arranged. This was a pity because it is an opportunity for all
those involved to contribute to the post incident review and learning process.
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57. The lack of occupation of prisoners at Wandsworth is an issue of general
concern that may have impacted in this case. It is understood that in cell
electricity is being installed throughout the prison thus enabling prisoners to have
televisions and radios during the long hours of “bang up”.
58. The training figures for ACCT are low, as are the numbers trained in the related
areas of suicide prevention and awareness. This will not assist in ensuring that
staff awareness of potential suicidal prisoners is kept high. Neither will it
contribute to the correct operation of ACCT.
59. The prison roll has been at or near Operational Capacity in recent times and is
predicted to remain at this level for the foreseeable future (this is apart from
temporary reductions in numbers related to refurbishment programmes). It is
understood that the staff resources are used at the maximum to enable the
prison to operate safely and efficiently.
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Clinical Review
The man was in good health and had had no ongoing contact with the health care
services at Wandsworth.
The PCT was requested to provide a clinical review but has stated that they are not
responsible as the incident occurred before the transfer of commissioning responsibility
on 1 April 2005.
The man was seen on reception by a healthcare worker and it was noted that he had no
physical or mental health issues. The man did not use drugs or alcohol and was a non-
smoker.
The next documented entry in the medical record is when healthcare staff attended the
scene of the incident on 14 February 2005.
The use of the risk assessment for in-possession medication is seen as good practice
and should be disseminated throughout prison healthcare centres.
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Recommendations
That the duty doctor system be amended to ensure that if on site cover is to be provided
then a doctor attends any medical emergency. Additionally the doctors should be
issued with pagers or some other dedicated means of alert to ensure they can be
summoned in the case of an emergency.
That management guidelines be issued reminding those responsible during and after
operational emergencies of the importance of a hot debrief of all those involved.
Good practice
The use of the in-possession medication risk assessment is identified as an example of
good practice for the care and management of prisoners and their prescribed
medication.
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Glossary of terms
ACCT Self harm management system
CNA Certified Normal Accommodation for prisoners
CPR Cardio Pulmonary (heart and lung) resuscitation
F2050 Prisoner’s main record
Fish knife Ligature cutting tool
Governor Senior manager graded A-F
IMB Independent monitoring board
IMR Prisoner’s medical record
LIDS Computer database of prisoner’s details
Listener Prisoner trained by Samaritans to support prisoners at risk of self
harm
Operational
Capacity Maximum number of prisoners that can be accommodated
Oscar 1 Orderly Officer
POA Prison Officers’ Association
PO Principal Officer
SO Senior Officer
SAD Social and Domestic session for prisoners
Standards Audit Prison Service performance audit system
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