Individual at Wandsworth

Investigation into the circumstances surrounding the
death of a man
at HMP Wandsworth in January 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
February 2008
This is the report of an investigation into the circumstances of the death of a man
who was found hanging in his cell in B wing at HMP Wandsworth in January 2007.
The man was 40 years old.
I extend my sincere condolences to the man’s family and friends for their loss.
The investigation was carried out by two of my colleagues. Wandsworth Teaching
Primary Care Trust agreed to carry out a review of the man’s clinical care and
treatment while at Wandsworth.
I would like to thank the Governor of Wandsworth, and his staff for their help.
The man had a long history of mental health problems. His treatment included both
hospital care and care in the community. On one occasion, the man was detained in
a psychiatric unit for almost four years. One of the man’s consultant psychiatrists
reported that his compliance with medication when in the community was variable.
The man had been arrested in June 2006, when clearly mentally unwell. He was
remanded initially into HMP Belmarsh before being transferred to Wandsworth. By
the time of his transfer, the man’s mental health condition had stabilised.
Although the man spent a lot of time talking to prisoner Listeners in the final weeks of
his life, neither they nor anyone else who had contact with him anticipated that he
was at risk. After the man’s death a letter was found in his cell saying that he would
attempt to take his life.
I have made five recommendations. Three of the recommendations are about
arrangements relating to contact between prisoners and Listeners. The other two
recommendations are about adherence to national guidance when dealing with
deaths in custody.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2008
2
CONTENTS
Summary 4
The Investigation Process 6
HMP Wandsworth 7
Key Events 8
Consideration of the Issues 15
Recommendations 22
3
SUMMARY
The man was born in London in 1966. He had a number of jobs after leaving college
but in 1995 was diagnosed as mentally ill and admitted informally to a psychiatric in-
patient unit. The man had cut both wrists saying that he did so as a result of hearing
voices telling him to harm himself. From that time he received treatment both in the
community and as a mental health in-patient, once following a previous conviction.
One of the man’s psychiatrists who had treated him for many years reported that he
was warm, sympathetic and intelligent when well but could become aggressive and
violent when unwell. The psychiatrist also reported that the man’s compliance with
oral medication when in the community was variable.
On 24 June 2006, the man was arrested for carrying an offensive weapon in a public
place and for two linked offences. The man spent two days in police custody before
being taken to court where he was remanded into prison custody at HMP Belmarsh.
It is clear from the man’s clinical records and the clinical review that he was mentally
ill at this time. But not, it seems, to the extent that it was unusual for him to have
been initially placed into prison custody rather than into a psychiatric in-patient unit.
The man spent the first three months of his time at Belmarsh in the healthcare unit.
For a good part of this period the man was assessed as requiring the presence of
three Officers when unlocked. However, the man had agreed to restart his
medication and even by 15 July, Belmarsh’s consultant psychiatrist noted that he
was gradually settling. On 19 September, the man was judged well enough to move
to a standard prison wing. On 23 November, he was transferred to Wandsworth.
Upon his arrival at Wandsworth, the man was assessed by a doctor who noted that
he was mentally stable with no thoughts of self-harm. The man’s records at
Wandsworth contain only one entry referring to him acting strangely, although the
evidence of one of the Officers and one of the prisoners was that the man was an
unusual person.
On 20 December, the man was convicted for the offences with which he had been
charged. He was remanded back into Wandsworth to await sentencing. By this
time, the man had been on remand for six months but this is not an unusually long
period for a prisoner to have remained on remand.
During the final five weeks of his life, starting from just before Christmas 2006, the
man saw Listeners almost every day (Listeners are prisoners trained by the
Samaritans to give support to other prisoners). The Listener service is founded on
the principle of complete confidentiality. Despite this, the Listeners agreed to speak
to my investigators. They were not able to disclose what the man spoke about in
their contacts with him but all described him as calm by the end of their meetings
and none of them thought that he was at risk of self-harm.
Officers were unaware of the level of contact that the man was having with Listeners.
This is understandable for contacts during association time in the day as the man
could simply walk into a Listeners’ cell. However, at night time when the man and
the Listeners would have to be unlocked, not all these episodes were recorded in the
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wing observation book as should have been the case. And no entries had ever been
made in the man’s personal records to say that he had seen a Listener.
At just after 6.00am on a day in January 2007, the night Officer began his morning
role count. When he looked through the observation panel in the man’s door he saw
him at the cell window facing outwards. The Officer saw a cord running from the
man’s neck to the window but the Officer was not certain if he was hanging as his
feet were on the floor. The Officer ran to the landing below and called to another
Officer (a principal Officer) for help as well as calling the emergency nurse. The
Officers ran to the man’s cell, entered it and cut the ligature. The principle Officer
and nurse examined the man and found that he had no pulse, he was not breathing
and his body was cold to the touch. The staff concluded that the man was dead and
decided, entirely reasonably, that it was not appropriate to attempt resuscitation.
When staff searched the man’s cell they found a letter he had written to his solicitor,
dated 17 January, in which he said he would attempt suicide. Among other things in
the letter, the man said that he anticipated being put on intra-muscular tranquilising
medication and he did not consider that to be a life.
As with the prisoner Listeners, none of the Officers interviewed thought that the man
was at risk. Nor did the man’s solicitor who had visited him in prison many times.
5
THE INVESTIGATION PROCESS
The investigation was opened on 31 January 2007 when two of my colleagues
visited Wandsworth and met a number of prison staff, including the deputy governor,
the prison’s family liaison officer and a representative from the Prison Officers’
Association. My investigators also met a member of the Independent Monitoring
Board (IMB). My investigators informed the staff of the nature and scope of the
investigation. Notices were issued to staff and prisoners notifying them of the
investigation.
Eight members of staff and four prisoners were interviewed. All four prisoners are
Listeners who spent a considerable amount of time with the man. No additional
prisoners came forward to give evidence directly in response to the published
notices.
Wandsworth Primary Care Trust agreed to carry out a review of the man’s clinical
care and treatment while at Wandsworth.
One of my Family Liaison Officers (FLOs) spoke to the man’s sister. She said that
she had not seen or spoken to her brother for many years. She believed that he had
suffered mental health problems from a young age, but a diagnosis of mental illness
was only formally made within the last ten years. She said that her only concern
about her brother’s treatment was the seemingly contradictory information given by
health care professionals regarding his mental health around the time of his death.
The man’s sister spoke very positively about the help and support she received from
the FLO at Wandsworth, who, she said, had shown genuine interest and
understanding of what the family was going through after her brother’s death.
My FLO and one of my investigators visited the man’s ex-partner who had had a
child by the man. The man’s half-brother was also at the meeting. The man’s ex-
partner raised a number of concerns. She could not understand why the man had
remained on remand in prison custody for such a long time for what was a
comparatively minor offence. She said that he had received treatment at a
psychiatric clinic both as an outpatient and as an inpatient. One of the times as an
inpatient was after he was arrested following a previous disturbance. She therefore
wondered why the man was taken to prison this time rather than to a secure
psychiatric unit, such as the one where he had been before.
The man’s ex-partner said that he had written a suicide letter ten days before his
death, so she could not understand why staff did not notice that he was depressed.
Both she and the man’s half-brother were distressed about the way in which they
found out about the man’s death. The man’s half-brother said that he heard the
news from his father when visiting him about a fortnight after the man’s death. He
then passed the news to the man’s ex-partner. The man’s ex-partner and his half
brother were both named in the man’s suicide letter and so they both thought they
should have heard the news directly from the prison. The man’s ex-partner felt the
prison should be more sensitive to the fact that many families are fragmented and
should not assume that information is passed on within the extended family as a
matter of course.
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HMP WANDSWORTH
HMP Wandsworth was built in 1851. It is a local prison that holds just over 1,400
prisoners. Wandsworth is the largest prison in London. The main prison has five
wings leading out from a central hub. Each wing has four landings.
Although Wandsworth’s residential areas remain in the original buildings, extensive
refurbishment and modernisation of the wings has taken place. All cells have in-cell
sanitation and in-cell electricity is presently being installed throughout the prison.
The last inspection of Wandsworth by Ms Anne Owers, Her Majesty’s Chief
Inspector of Prisons, was a full inspection in July 2006 following up a previous
inspection in May 2004. In her introduction to the report Ms Owers wrote:
“Wandsworth … has had a difficult and troubled history, much of it recorded in
the inspection reports of myself and my predecessor …
“This inspection found an effective and united management team that was
taking steps to move the prison forward. They had inherited a prison that was
performing even less well than it had been at the time of the last inspection …
Since then, the prison had clearly improved: with greater confidence among
staff and managers, more time out of cell and more activities for prisoners,
and an improved focus on safer custody …
“However, this inspection also revealed the distance still to travel, and the
residual problems that remained …
“This is therefore an inspection of an improving prison, but one which has a
significant way to go before it is a good and well-performing prison on any of
our four tests of safety, respect, purposeful activity and resettlement …”
7
KEY EVENTS
The man’s time at Belmarsh
On 24 June 2006, the man was arrested for carrying an offensive weapon in a public
place. The weapon he was carrying was a wooden practice sword (a piece of
equipment used for practising martial arts). After spending two days in police
custody, the man appeared at Woolwich Magistrates’ Court where he was charged
with being in possession of an offensive weapon and with two further linked
offences. He was remanded into HMP Belmarsh.
On arrival at Belmarsh on 26 June, the man received a First Reception Health
Screen assessment. This is a standard part of the reception process when a person
first arrives in prison. In answer to questions about his mental health, the man said
that he had never received treatment from a psychiatrist outside prison and that he
did not have a psychiatric nurse or care worker in the community. He also said that
he had never received medication for mental health problems. In answer to
questions about self-harm, the man said that he had never harmed himself in the
past and that he did not feel like doing so at present. The health screening form
includes a section where the person completing it is required to record their
impression of the prisoner’s behaviour and mental state man. In this section the
healthcare worker wrote: ‘Would not engage in questions, poor eye contact, appears
agitated and, observed to be talking to himself and can be aggressive in his
response to questions’. The man was admitted to healthcare for a period of
observation.
On 28 June, the man was made subject to ‘controlled unlock status’ (that is, that he
should be unlocked only with the presence of three Officers). The reasons were
recorded as: ‘Mental state is very unpredictable. Has a history of assaults. Made
threats to staff [and threw his plastic] knife at [an Officer]’. The incidents reported
had occurred in the days leading up to 28 June. The man’s records at around this
time show that he would have ‘good’ days and ‘bad’ days. For instance, an entry on
28 June, the day he was made subject to controlled unlock status, status: Had cell
clean and shower [this morning]. Co-operated and was no problem to staff’.
On 15 July, the consultant psychiatrist at Belmarsh wrote to the psychiatric clinic that
had been involved in the man’s mental health treatment since 1996 to request that
the man be admitted there:
‘… [the man] arrived in HMP Belmarsh on [27 June] and was admitted to the
health care centre … [a doctor] assessed him … on [28 June] and found that
he was labile (unstable), irritable and volatile. In his mood he appeared
suspicious and angry, his thoughts were tangential and circumstantial
expressing persecutory beliefs …
‘… I first saw him on [30 June] and he remained volatile and expressed
persecutory beliefs … his speech was increased in rate and he was elated in
a way that I had not previously seen.
‘[The man] is gradually settling …’
8
Despite the consultant psychiatrist writing on 15 July that the man was gradually
settling, he was again made subject to controlled unlock status that very day. The
reason for this was recorded as: Mental state has become unstable. Has a history of
violence when unwell.’ The man remained subject to controlled unlock status until
31 August.
The man remained in the healthcare centre until 19 September. Upon his discharge
an ‘Inpatient Unit Exit Plan’ was completed stating the reason for his transfer to
standard location as: ‘Currently settled.’ In answer to a question on the form about
clinical risk factors it was noted: ‘Stops taking medication then becomes unwell.’
On 23 November, the man was transferred to Wandsworth. The reason for his
transfer seems to have been overcrowding at Belmarsh.
The man’s time at Wandsworth
On the man’s arrival at Wandsworth on 23 November a reception nurse referred him
to the prison doctor due to his history of mental health problems and need for
medication. The prison doctor saw the man and noted that he was: ‘… mentally
stable, co-operative and relaxed, no self-harm thoughts …’.
The first Officer told my investigators that he has worked at Wandsworth for almost
16 years. He said that when the man first arrived on the landing he was placed in a
single cell as he was considered a danger to other prisoners. The first Officer
noticed that there were a lot of entries in the man’s records from Belmarsh
suggesting that he was a difficult prisoner and that three Officers should be present
whenever he was unlocked. The first Officer said that he and the other Officers in B
wing try to treat all prisoners the same way. He explained to the man that coming to
Wandsworth was a new start for him. That no matter what was in his records from
Belmarsh the Officers in B wing would make their own assessment to see how he
got on. The first Officer told my investigators that the man was surprised, but also
contented to be told that.
The first Officer said that the man did not associate with other prisoners, instead he
tended to keep himself to himself. the first Officer said that the man mentioned to
him once that he was schizophrenic and also paranoid. The first Officer described
the man as an unusual person who would be a bit vague at times. The first Officer
attributed this to the man’s prescribed medication. The first Officer said, however,
that he never had any problems with the man, always finding him to be polite. The
first Officer found it hard to believe this was the same person who had caused so
much trouble in Belmarsh.
The first Officer was aware that the man had some contact with Listeners, including
a few times when he unlocked the man for this contact to take place. The first
Officer said that when a prisoner has been with Listeners he will ask them if
everything has been sorted out. If he has any concerns about the prisoner, he will
9
open an ACCT document1 for the prisoner to be monitored. The first Officer could
not recall ever noticing anything about the man indicating he might be worried so he
never considered opening an ACCT form.
On 1 December, the man was seen by a mental health nurse who noted that the
man was stable in mood and happy with his current medication.
On 4 December, the psychiatrist from the psychiatric clinic visited the man at
Wandsworth to assess his suitability to return to the clinic if convicted. The
psychiatrist subsequently wrote a report for the court recommending that the man be
admitted to the clinic. The psychiatrist could not specifically recall discussing his
report with the man’s probation Officer but he thought that he might well have made
such contact because he considered his psychiatric report to be very important for
the man’s future care and treatment. With reference to the referral letter of 15 July
from the consultant psychiatrist at Belmarsh, the psychiatrist from the clinic said that
the two of them would have met at case conferences to discuss the man. Availability
of beds at the clinic meant that the man could not be admitted immediately. He then
began to settle which diminished the urgency of his admission. The man’s referral to
the clinic then remained on hold pending his court case.
The man’s trial started on 18 December. It continued through 19 December and on
20 December he was convicted. He was remanded back into prison custody to
await sentencing. By then, he had been moved from C wing to B wing.
An entry by the second Officer in the wing observation book made at 6.00pm on 24
December shows that the man was unlocked that evening as he wanted to speak to
a Listener. The second Officer told my investigator that he did not know the man
and had no recollection of him. The second Officer said that he normally worked in
A wing but in December he had covered a few shifts in B wing due to staff shortages.
The second Officer said that when a prisoner has been with Listeners he always
asks them afterwards if they are okay. If he has any concerns about the prisoner he
will either open an ACCT form or speak to a more senior Officer. He said that the
fact that he had taken no such action in the man’s case meant that there must have
been nothing about his demeanour to cause him concern.
On 30 December, the third Officer made an entry in the man’s records: ‘Constantly
on [emergency cell bell], also claims he was not unlocked for meals which is
incorrect, has very strange behaviour patterns, staff should be aware’. The third
Officer told my investigators that from what he could remember of that time the man
kept raising the same point. This was that he had not been unlocked for his meals.
The third Officer would reply to the man that he had been, saying how many times
have I explained this to you. The man would giggle in response. The third Officer
thought initially that the man was deliberately trying to get a reaction. The third
Officer said though that when he spoke to another member of staff he was told that
the man had been a problem at his previous prison. The third Officer told my
investigators that after 30 December the man settled down. He understood what he
was told about the correct use of emergency cell bell (that it is for emergencies only)
1 ACCT (Assessment, Care in Custody and Teamwork) is the new procedure for monitoring those
prisoners judged to be at risk of self-harm or suicide. ACCT has replaced the F2052SH procedure.
10
and he became quite a pleasant prisoner on the landing. He was never a problem
again.
The third Officer said that he tries to build a good rapport with the prisoners on his
landing and he thought he had achieved that with the man. The third Officer is
Australian and the man would ask him questions about his country. The man did not
volunteer any information about his private life however, nor did he talk about his
court case. But he did mention a few things about Belmarsh and also said that he
quite liked Wandsworth. The third Officer said that the man was generally happy.
He never drew attention to himself and never seemed to have any difficulties with
other prisoners. The third Officer was unaware that the man had a high level of
Listener contact. He said that a lot of prisoners ask to speak to Listeners. The third
Officer said that he never saw anything in the man’s behaviour to indicate that he
was a person at risk of self-harm. The third Officer last saw the man on the day
before his death when he seemed his usual self.
On 8 January 2007, the man was assessed by a doctor and a psychiatric nurse from
the Prison Inreach team – he had been referred to the Inreach team because of his
mental health history. The man was noted as denying having any present thoughts
of self-harm or of suicidal ideation and they agreed that his risk of self-harm
appeared low. The assessors recorded that the man had no gross abnormalities in
his mental state.
A positive entry about the man’s behaviour was made on 11 January. It reads: ‘…
was a good help today when [another prisoner] was very emotional and stressed.
[The man] took him into his cell and spoke to him and managed to cheer him up and
get him to calm down.’
B wing’s observation book shows that at 9.55pm on 26 January, the fourth Officer
unlocked the man for him to talk to Listeners. The fourth Officer told my investigator
that he works permanent night shifts in Wandsworth’s Care and Separation Unit but
on 26 January he had been asked to work in B wing. The fourth Officer said that he
could not really recall the man. He said, though, that if he observes a prisoner
looking upset after being with Listeners he will routinely record that in the wing
observation book and in the prisoner’s history sheet. He will also make Oscar 12
aware of the situation and open an ACCT form if he considers that to be appropriate.
The fourth Officer said that given that he could barely recall the man and given that
he had written so little about him, it suggests that he had been okay that evening. As
far as the fourth Officer could recall, that night was the only occasion that he met the
man. He said that a record is kept if a prisoner has been unlocked to see Listeners.
The fourth Officer said that if he had unlocked the man at any other time to see
Listeners he would have made a record (there is no such record by this Officer).
The entry in B wing’s observation book on 26 January by the fourth Officer is one of
only two entries about the man being unlocked for him to talk to Listeners. The first
entry was made on 24 December 2006. But Listeners confirmed to my investigators
that they had seen the man on many occasions.
2 Oscar 1 is the radio call sign of the Officer in charge.
11
The fifth Officer said that the man was quiet and spent most of his time in his cell.
He was also a friendly man who did not cause any problems for the Officers. The
fifth Officer noticed the man spending time with Listeners. This would sometimes be
when prisoners were being locked in after association periods and if the man was
still talking to the Listener, the fifth Officer would leave the man’s door unlocked. The
fifth Officer said that nothing occurred to give him concern for the man’s safety. If he
had noticed anything amiss he would have asked the man if he was okay and if
appropriate taken further action such as making a record of the conversation or
speaking to a senior Officer. The fifth Officer said that none of the other Officers
ever mentioned to him having any concern about the man’s wellbeing.
Another Officer told my investigators that the man was a very reserved man who
never spoke about personal matters. However he was always very polite in
expressing his thanks whenever staff did anything for him. This Officer said that his
practice is always to check with Listeners after a prisoner has been with them to
check if everything is okay. In the man’s case the Listeners always said that there
were no problems. This Officer also said that all of the staff were very surprised
when the man took his life.
Each of Wandsworth’s wings has its own wing observation book. All significant
events should be recorded in the observation book. Most such events relate to
specific individual prisoners. In addition, a record of daily events is maintained at the
central hub off which all of prison wings lead out. Although B wing’s observation
book contains only two entries about the man being unlocked at evening/night time
to see Listeners, the record of daily events contains six such entries for the time the
man was in B wing.
My investigator spoke to the man’s solicitor. The solicitor estimated that he met the
man about four times while he was at Belmarsh and many more times at
Wandsworth. The first time they met was when the man was in healthcare and
subject to special unlock procedure. By their second meeting the man had been
transferred to normal location in Belmarsh and a psychiatrist had deemed him fit to
plead.
The solicitor said that he last saw the man about 10 days before his death. The man
was ‘in good form’. The solicitor said that he was stunned when he heard that the
man had taken his life. The solicitor’s colleagues and Council were also seeing the
man around this time and no one thought that he was at risk.
The discovery of the man’s death
The fifth Officer told my investigators that he started a night shift on the evening of
28 January. He received a handover from the evening staff during which nothing
was mentioned about any concerns with the man. The fifth Officer counted the
prisoners, including the man. The fifth Officer said that he had had no need to speak
to the man during the night and he did not ring his cell call bell. Just after 6.00am on
29 January, the fifth Officer began his morning role count. When he came to the
man’s cell on the 4’s landing he looked through the observation panel and saw the
man in an upright position by the cell window facing outwards. The fifth Officer
12
noticed a cord running from the window frame to the man’s neck. The man’s feet
were on the floor so it was not clear to the fifth Officer whether he was suspended or
was standing and looking out of the window. The fifth Officer called the man’s name
but he got no response. He kicked the door but again got no response. The fifth
Officer ran down the stairs from the 4’s landing to the 2’s landing where he called to
the Principal Officer (PO) for assistance. The fifth Officer ran back to the man’s cell
followed immediately by the PO. The PO unlocked the door and the fifth Officer
used his cut-down knife to cut the ligature. The fifth Officer said that as they lowered
the man to the floor it was obvious that he was dead as rigor mortis had set in. As a
result, they made no attempts at resuscitation.
In a written statement made on the day the PO wrote that he was on the 2’s landing
when the fifth Officer called for his assistance. The PO used his radio to send an
alert that there was a Code One3 incident on B4 landing and he followed the fifth
Officer to the man’s cell. In his statement, the PO explained that the man’s body
was cold and stiff. His arms were in front of his chest and the PO could not move
them away to allow him to attempt CPR (cardio pulmonary resuscitation). The nurse
then arrived and checked the man for a pulse but he had none. The PO wrote that in
consultation with the nurse and a senior Officer it was decided that resuscitation
should not be attempted.
The nurse made the following entry in the man’s medical record:
‘Called to B4 landing … [the man] was cold to touch and his face was
blue/purple in colour. He had no pulse … Unable to open his mouth. Placed
[defibrillator pads] on his chest – just a straight line [on read-out]. Gave
[oxygen] via mask. Ambulance … paramedics came, they checked the man
and said he was dead.’
A debrief was held with the staff who responded when the man was found hanging.
Staff were also offered the opportunity to see the care team.
After the man’s death
When the man’s records were checked it was found that no information had been
recorded about his next-of-kin. Wandsworth telephoned the firm of solicitors from
whom the man had received legal visits. They had no information about the man’s
next-of-kin but gave Wandsworth contact details of the psychiatric clinic where the
man had previously been treated. The clinic was able to supply the name, address
and telephone number of the man’s mother. Two of Wandsworth’s FLOs together
with one of the chaplains visited the man’s mother to break the news in person.
While there one of the FLOs telephoned the man’s sister. The man’s mother told the
prison FLO that her son had had a child with an ex-partner. The man’s mother said
that she did not have contact details for the ex-partner but she thought her son’s
father, from whom she is divorced, did. The man’s mother also mentioned her son
had a half-brother. The man’s mother told the prison FLO that she would contact her
ex-husband to tell him about their son’s death.
3 A Code One alerts staff about an emergency or life threatening incident.
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The prison FLO offered the man’s mother the opportunity to visit Wandsworth. The
prison FLO also advised her to approach the benefits agency about funding for her
son’s funeral and told her that Wandsworth would contribute as necessary.
On the day of the man’s death, police Officers visited Wandsworth, searched his cell
and spoke to staff. In keeping with standard practice following a death in prison
custody the cell was then sealed. Two days later the police gave authorisation for
the cell to be entered by prison staff. Staff collected the man’s belongings among
which they found a letter to his solicitor dated 17 January.
The man started the letter by declaring: ‘Didn’t do the crime – won’t do any more
time anywhere!’ The man then wrote about an incident that occurred while he was in
police custody adding that he was: ‘… severely ill at the time …’ The man went on:
‘It is almost certain that I’ll be back on major tranquilising intra-muscular injections.
That is no life. In protest at my fix-up I shall attempt to commit suicide. This is my
last and only suicide note …’
The man asked in the letter that his half-brother be informed of his death.
A diary was also found in the man’s cell but this only contains a number of routine
entries. The man made no entries about his thoughts on his court case, any
thoughts he might have had about his future or any plans to take his own life.
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CONSIDERATION OF THE ISSUES
The man’s psychiatric history, his arrest and detention in prison
The man was first diagnosed with a mental health illness in 1995 when he was
admitted informally to a mental health unit. In June 1996, the man was convicted on
counts of threats to kill and affray arising from a neighbour dispute. After again
being diagnosed as mentally ill, the man was admitted to the psychiatric clinic (a
mental health secure unit). The man remained in the clinic from August 1996 to
February 2000. After his discharge, the man continued to receive intermittent care
and treatment through the psychiatric clinic both as an in-patient and via community
care.
On 24 June 2006, the man was arrested following a disturbance that commenced
with him walking in the street carrying a wooden martial arts practice sword. He
spent two days in police custody before being remanded into custody in HMP
Belmarsh. He was diagnosed as suffering a relapse of his schizoaffective illness.
The man spent his first three months at Belmarsh under observation in healthcare.
There are quite a number of entries in the man’s records indicating that his mental
health state was not good. For a lot of the time the man was designated as a
prisoner to be unlocked only with the presence of three Officers. The man was
discharged from healthcare on 19 September when his mental health was assessed
as ‘settled’.
On 23 November, the man was transferred to Wandsworth. It seems that the reason
for the move was overcrowding at Belmarsh. On arrival at Wandsworth, the man
was seen by a doctor who found him to be mentally stable with no thoughts of self-
harm.
On 30 December, the third Officer made an entry in the man’s records that he was
acting strangely that day. Apart from that entry, it seems that the man largely
remained well while at Wandsworth. Having said that, the first Officer described the
man as unusual and at least one of the Listeners thought the same.
The man was assessed by a doctor and a nurse from the Prison Inreach team on 8
January 2007. The clinical review from Wandsworth PCT found that the Inreach
team’s assessment and management plan appears detailed, thorough and
appropriate.
Two questions asked by the man’s ex-partner was why he was sent to prison rather
than to a psychiatric hospital and also about the length of time he spent in custody.
It is clear that the man was mentally ill when he was arrested on 24 June 2006 and
taken into police custody. Even so, when the man went to court two days later he
was remanded from there into prison custody rather than a mental health unit.
Among others, my investigator spoke to the man’s solicitor and he spoke to the
man’s probation Officer who was asked to write a pre-sentence report on the man.
My investigator also spoke to the psychiatrist from the psychiatric clinic.
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The man’s solicitor said that it is not unusual for a person like the man to be in a
prison rather than in a psychiatric unit. Moreover, the man had said that he did not
want to be in psychiatric hospital. The probation Officer said that he had spoken with
the psychiatrist at the psychiatric clinic and so he was aware of the man’s clinical
history. The probation Officer said that with the lack of availability of psychiatric beds
it is common for people such as the man to be initially remanded into prison. He
said that he was not able to write his report before the man’s death, but had he
written it he would have recommended that the man be taken into a psychiatric unit.
The probation Officer said that psychiatrist at the psychiatric clinic was very clear
that this is what the man needed. The psychiatrist from the psychiatric clinic
confirmed all that the probation Officer said. He also said that the man’s health had
clearly improved during his time in Belmarsh and this diminished the urgency of any
admission to the psychiatric clinic.
The man’s solicitor also told my investigator that it is not unusual for a prisoner to be
on remand for six or more months.
Findings from the clinical review
The clinical reviewer’s conclusions include that the man received significant
psychiatric support at Belmarsh and that it seems his mental health was stabilising
by the time of his transfer to Wandsworth. The reviewer points out that although the
man’s clinical records at Wandsworth are brief, his prescription chart confirms that
he was continuing to take his medication regularly and that no concerns were noted
by the nursing staff. The reviewer goes on to say that it appears that the man’s care
at Wandsworth was reasonable.
Contact with Listeners
In common with the majority of prisons in England and Wales Wandsworth has a
Samaritan supported 'Listener' scheme. The Listener service is not about resolving
practical problems, instead it is to do with listening to prisoners without judging them
or telling them what to do. The support Listeners give is emotional and is intended to
empower the ‘caller’ to do what they need to do or to find the practical help they
need. The whole scheme is founded on the principle of complete confidentiality
between the Listeners and the ‘caller’. A Listener might speak to prison staff about a
particular situation, but only if the ‘caller’ gives permission.
To become a Listener, a prisoner must apply to both the prison and the Samaritans.
The prisoner attends a course in the prison that is run by the Samaritans and which
is of the same duration and the same content as the course that Samaritan
volunteers undertake. At the end of the course the Samaritans will only accept as
Listeners those whom they have assessed as being suited to the work.
If a prisoner needs to talk to a Listener, the contact might be made through a prison
Officer but sometimes Listeners are approached directly. They can meet in the
Listener's cell or in the caller's cell. Wandsworth has a Listeners’ suite so meetings
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can also take place there. This contact can be at any time, day or night. At night
time, meetings at Wandsworth will always be in the Listeners’ suite.
My investigators discovered that the man spent a great deal of time with Listeners
during the final five weeks of his life. My investigators spoke to four of Wandsworth’s
Listeners who had had contact with the man. A Samaritan volunteer sat in on the
interviews. The principle of complete confidentiality under which the Listener
scheme operates continues even after the death of a prisoner (the fear is that
without such a guarantee, some prisoners will be deterred from accessing the
service). Consequently, the Listeners could give only limited information to my
investigators about their contact with the man. They were able to say however that
the man spoke to Listeners almost every day during the final five weeks of his life.
Most of these contacts were during the day time and not recorded by the Listeners
as at that time only night time contacts were recorded. Since the man’s death,
Listeners have made a record of all contacts with prisoners.
The Listener who had the greatest contact said that the man came to his cell most
days in the final weeks of his life. The Listener described the man as mentally
unstable and a person whose manner caused other prisoners to feel uncomfortable
in his presence – some prisoners would chat to him, but many would try to avoid
him. The Listener said that there were times when the man could be very agitated,
but he usually calmed down as they spoke. The Listener was very surprised that the
man took his own life.
The other three Listeners had much less contact with the man. All said that on the
occasions they saw him he would talk until ready to leave and was always calm by
the time he had finished.
The Listeners mentioned two things to my investigators that would help them in their
role. They said that after spending time with a prisoner they try to see him again the
following morning to check that he is alright. However, if the prisoner is in a different
wing it can be difficult gaining access. The Listeners would therefore welcome freer
access across the prison. Two of the Listeners said that some Officers do not seem
to have respect for the work the Listeners do. My investigators were told that there
was a time when Listeners were invited to talk on induction courses to explain their
role to new staff. This no longer happens.
After speaking with the Listeners my investigators spoke with Wandsworth’s Head of
Safer Prisons. She told my investigators that her responsibilities include suicide
prevention and deaths in custody. The Head of Safer Prisons said that she chairs
the monthly suicide prevention meeting which both Listeners and the Samaritans
attend.
The Head of Safer Prisons was asked to comment on the recording of the man’s
contact with Listeners – the record of daily incidents held at the central hub contains
six dates during the final five weeks of the man’s life when he saw Listeners after
evening lock-up; the wing observation book contains only two such dates; no dates
had been entered in the man’s personal records. The Head of Safer Prisons said
that any time a prisoner has to be unlocked to see a Listener it should always be
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recorded and she would therefore expect the number of entries in the daily record to
match with the entries in the observation book.
The Head of Safer Prisons was asked to comment on what interaction she would
expect between an Officer and a prisoner who has been with Listeners at night time.
She said that at a minimum, she would expect the Officer to check that the prisoner
is alright. She thought that it would be a matter of good practice for the Officer to
make a brief record about that contact referring to the prisoner’s state of mind. She
said though that that is the ideal and it should be borne in mind that Officers are
often under a lot of pressure at night when there is only one Officer on duty in each
wing. She also pointed out that if the prisoner says that he is fine it is very difficult
for the Officer to read between the lines or go beyond what the prisoner is actually
prepared to disclose. The Head of Safer Prisons considers that the quality of care
for prisoners at Wandsworth has improved drastically in recent times, but that the
standard of record keeping has not improved at the same rate.
My investigators asked the Head of Safer Prisons to comment on the Listeners’
complaint that they sometimes find it difficult to make a follow-up visit on the morning
following time spent with a prisoner. She said that some of the Listeners are ‘Red
Bands’ which means that they are the most trusted prisoners and have security
clearance to access a lot of areas in the prison. However, other Listeners have a
lesser level of clearance and that places restrictions on their movements.
In conclusion, the Head of Safer Prisons thought that the vast majority of staff would
consider Listeners to be positive and useful. She said that without Listeners,
Officers would find their own jobs so much harder. She agreed that it would be a
good idea for Listeners to explain their role at induction courses for new staff.
Some of the Officers interviewed remembered the man having contact with
Listeners. However, none of them were worried that the man might be at risk. All of
the Officers said that they would have opened an ACCT form if they had been
concerned.
I agree with the Head of Safer Prisons that it would benefit prisoner care and welfare
if Officers were to check that prisoners are okay after seeing Listeners at night time.
Of course the confidential nature of the Listener scheme means that Officers must
be careful not to intrude on that relationship. Nor must they do or say anything that
might deter prisoners from accessing Listeners.
The Governor should remind staff to always record in the wing observation
book when a prisoner has been unlocked to see Listeners.
In the case that a prisoner has been unlocked to see a Listener, the Officer
involved should speak to the prisoner following the contact and note in the
prisoner’s record that they have seen a Listener.
I was disappointed to learn that two Listeners felt that some Officers have little
respect for the work they do. In my opinion, Listeners make a valuable and
significant contribution to the welfare of prisoners. The Head of Safer Prisons quite
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correctly pointed out that Officers would find their work much harder if there were no
Listeners.
The Governor should consider inviting Listeners to induction courses for new
staff to explain their role.
The discovery of the man’s death
The man’s death was discovered when the fifth Officer was carrying out his morning
roll check at just after 6.00am. The fifth Officer said that when he looked through the
observation hatch he saw the man in an upright position by the cell window facing
outwards. His feet were touching the floor. The fifth Officer noticed a cord running
from the window to the man’s neck, but it was not clear to him whether the man was
hanging or was standing and looking out of the window. The fifth Officer called the
man’s name and kicked the door but he got no response. The fifth Officer ran from
the 4’s landing down to the 2’s where he summoned assistance from the PO. The
two Officers went to the man’s cell, cut the ligature and lowered the man to the floor.
No attempts were made to try to resuscitate the man as rigor mortis was established
and it was obvious that he was dead.
There are several matters connected with the response when the man was found on
which I wish to comment. The first matter is the fifth Officer’s decision to summon
help rather than to enter the man’s cell alone. The fifth Officer said that he
considered going into the cell, but for security reasons judged that he needed the
presence of another Officer. This was a matter upon which the fifth Officer was
entitled to use his discretion and I accept that he exercised his discretion in a
reasonable way on this occasion.
Having decided that he needed support, the fifth Officer ran two floors below where
he called to the PO for help. At interview, the fifth Officer was quick to acknowledge
that he should have used his radio to summon assistance.
As already mentioned staff made no efforts to try to resuscitate the man as it was
obvious to them that he was dead. That decision contravened Wandsworth’s local
contingency plans that say if a prisoner is not breathing, resuscitation should always
be attempted. However, Wandsworth’s contingency plans do not reflect the national
guidance contained in PSO 2700. The PSO does not require staff to attempt
resuscitation where rigor mortis has clearly set in. The decision by staff not to
attempt resuscitation in the man’s case was therefore entirely appropriate even
though it contravened local instructions.
The Governor should revise Wandsworth’s contingency plan for dealing with
deaths in custody to bring it in line with PSO 2700. Specifically, that where
rigor mortis has clearly set in, it is unnecessary for staff to attempt
resuscitation.
Should staff have recognised that the man was at risk?
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The man’s mental health condition had stabilised by the time he came to
Wandsworth. Even so, those who came in contact with him described him as
unusual or odd. Twelve days before his death the man wrote a letter addressed to
his solicitor. The man wrote that he would almost certainly be put back on ‘major
tranquillising intra-muscular injections’. He said that that would be ‘no life’. The man
described the letter as a suicide note.
The man’s ex-partner told my staff that the man must have been depressed to have
written that letter and she could not understand why prison staff had not noticed. I
can understand this sentiment, however no one seems to have considered the man
at risk of self-harm. Although it is easier to identify risk with hindsight and the benefit
of a letter that signifies the man’s true feelings, no one knew of the letter until after
his death. It was not only the staff who were surprised at what happened. The
Listeners with whom the man had almost daily contact in the final weeks seem not to
have had any suspicion that he would harm himself. It does not automatically follow
that a prisoner who makes contact with Listeners for support might be at risk of self-
harm or suicide. Listeners are a means of emotional support at a range of levels. In
addition, the man’s solicitor visited him frequently in Wandsworth. The last time was
about 10 days before his death when he said that the man was ‘in good form’.
Contact with the man’s family
The man’s ex-partner is also the mother of the man’s child. She and the man’s half-
brother told my staff that they were very upset that they did not hear about the man’s
death until a fortnight after it had happened. Both thought that they should have
been told directly by the prison rather than via other family members.
The man had not given Wandsworth any details of his next-of-kin. Wandsworth
obtained contact details for the man’s mother through the psychiatric clinic having
initially made contact with the man’s legal team. Three of Wandsworth’s staff,
including the prison FLO then visited the man’s mother to inform her of her son’s
death. The prison FLO also spoke by telephone with the man’s sister. She told the
prison FLO that she would pass the news to the man’s father.
Two days later the police gave authority for the man’s cell to be entered. Among
other belongings, a letter was found that the man had written to his solicitor. In the
letter he gave contact details for his ex-partner and his half-brother. Wandsworth did
not contact either of these two family members as it was assumed that they would
hear through other family members.
The instructions contained in Prison Service Order (PSO) 2710 say that following a
death the prison must notify the next-of-kin and any other person the prisoner has
reasonably requested should be informed.
Guidance supplementary to PSO 2710 about liaison with bereaved families includes:
‘3.4 The family may be large, split geographically, at odds amongst
themselves. Many modern families are split by divorce or separation and
there may be several branches all with equal rights to information. The
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Family Liaison Officer may be able to get the family to nominate a single point
of contact who undertakes to keep other family members up to date. This
may not always be possible, or may not work in practice, so the Family
Liaison Officer should be prepared to deal with different sections of one family
if necessary …’
The man had not given any information directly to Wandsworth either about his next-
of-kin nor anyone else he would want informed in the case of his death. However, in
the letter to his solicitor the man made it clear that he wanted his half-brother to be
told of his death. By the time the letter was found two days had passed by since the
man’s death. I do not think it unreasonable for Wandsworth to have assumed by
then that the man’s mother would have informed the man’s father and that he would
have told his younger son (the man’s half-brother). The conclusion that Wandsworth
did not do anything inappropriate is of course no consolation to the family for whom I
have every sympathy.
PSO 2710 also gives guidance on funeral arrangements. It advises that prisons
should offer to pay reasonable expenses and £3,000 is the figure that is considered
reasonable. PSO 2710 goes on to say that this offer should be made irrespective of
any entitlement the family may have from the Social Fund. When the prison FLO
visited the man’s mother she advised her to first seek funding from the Benefits
Agency. The prison FLO told her that Wandsworth would then pay any further
contributions needed. This was not in line with the guidance set out in PSO 2710.
The Governor should remind his family liaison Officers to follow the guidance
contained in PSO 2710 about the offer of payment of funeral expenses.
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RECOMMENDATIONS
I make the following recommendations (the Prison Service’s responses to the
recommendations following issue of the draft report are set out below each
recommendation):
1. The Governor should remind staff to always record in the wing observation book
when a prisoner has been unlocked to see Listeners.
Prison Service response: Recommendation accepted. A Governor’s Order had
been issued to this effect.
2. The Governor should issue an instruction that in the case that a prisoner has
been unlocked to see a Listener, the Officer involved should speak to the prisoner
following the contact and note in the prisoner’s record that they have seen a
Listener.
Prison Service response: Recommendation accepted locally. However, recording
the contact should be decided on a case by case basis. Many prisoners do not use
Listeners to the same extent as Mr The man and it may not be necessary to record
their contact with Listeners.
3. The Governor should consider inviting Listeners to induction courses for new staff
to explain their role.
Prison Service response: Recommendation accepted. The Head of Safer Prisons
is discussing the possibility of this with the training department. Incorporating a brief
presentation in the ACCT awareness training of the role of Listeners will be
introduced. However as induction training is usually conducted in a building outside
the prison, the suggestion is to either use Samaritans Volunteers to speak about the
role of Listeners or move the training venue. The target for completion is December
2007.
4. The Governor should revise Wandsworth’s contingency plan for dealing with
deaths in custody to bring it in line with PSO 2700. Specifically, that where rigor
mortis has clearly set in, it is unnecessary for staff to attempt resuscitation.
Prison Service response: Recommendation accepted. The deaths in custody
contingency plan has now been revised to bring this in line with PSO 2700.
5. The Governor should remind his family liaison Officers to follow the guidance
contained in PSO 2710 about the offer of payment of funeral expenses.
Prison Service response: Recommendation accepted. The Head of Safer Custody
has now undergone Family Liaison Officer and Family Liaison Co-ordinator training
and will co-ordinate the response to bereaved families. This will ensure that the PSO
2710 guidelines on funeral expenses will be adhered to in a consistent manner.
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