Individual at Acklington

Investigation into the circumstances surrounding the
death of a man
at HMP Acklington in January 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
January 2008
This version of my report has been anonymised for publication on my website. The
man died in January 2007, after hanging himself in his cell on H wing at HMP
Acklington. He was 23 years old.
My colleagues and I offer our sincere condolences to the man’s family and friends.
Two colleagues from my office carried out the investigation. I wish to thank the
Governor of Acklington for making the necessary facilities and information available
to my investigators, and for the assistance of the prison’s Liaison Officer.
In the course of the investigation, I asked for a clinical review to be carried out into
the care and treatment received by the man whilst in custody. I am grateful to the
clinical reviewer for his assistance.
I conclude that the man kept his intentions very close to himself and gave no
indication of what he was planning to do. The evidence is of a man who had settled
reasonably well to the prison regime and was making plans for his future release.
However, he had made an application for transfer a month before his death. He was
also aware that he was to be deported at the end of his sentence and had begun an
appeal process against the decision. The appeal hearing was to have taken place
two weeks after the man’s death.
I have been concerned to learn that the night manager did not go into the cell or
carry out his own checks of the man’s vital signs, but relied on those of junior staff
who were not qualified first aiders. My report makes eight recommendations.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2007
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CONTENTS
Summary
The Investigation Process
HMP Acklington
Key Findings
Issues
Conclusion
Recommendations
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SUMMARY
The man was serving a four year prison sentence imposed at the Crown Court in
January 2006. Although he was only 23, prison was not a new experience for him
and he had previously served four custodial sentences. However, what was new
was the intention to deport him back to his home country at the end of this latest
sentence. He was appealing against the decision.
In August 2006, the man transferred to HMP Acklington from HMP Manchester. The
transfer did not go smoothly. At first he refused to leave his cell, and for a short
period of time he prevented prison staff from entering by erecting a barricade against
the cell door. However, he removed the barricade and the transfer to Acklington
then went normally.
Due to the nature of his offence, the man was allocated to the vulnerable prisoner
wing. He appears in the main to have settled in reasonably well, although he did
have a fight with one other prisoner and had made an application for a transfer.
Additionally, an allegation of racial abuse was made against him, and he too made a
similar claim against a prisoner. Neither allegation could be substantiated by the
prison, but they were recorded as racial incidents.
On the day of his death, a night patrol officer carrying out his normal roll check duty
at 5.35am looked into the man’s cell and saw part of his face against the cell
observation panel. Believing him to be hiding, the staff member went to seek
assistance from his colleagues. They responded very quickly. When they entered
the cell, found the man hanging by a ligature secured to the door hinge. The officers
had great difficulty in cutting the ligature away from his neck and, as they did so, his
body fell heavily to the floor.
Sadly, it would appear that it was much too late to attempt resuscitation and, after
staff received confirmation from paramedics that the man had died, the cell was
locked pending the arrival of police. After the police were satisfied that the death
was not suspicious, the man was taken later that morning to the mortuary.
I conclude that the man took his own life. I make eight recommendations.
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THE INVESTIGATION PROCESS
1. Following notification from the Prison Service that the man had died in
Acklington, the investigation was allocated to one of my investigators. He
contacted the Governor on 22 January, and arranged to travel to the prison and
open the investigation on 25 January. An initial meeting was attended by the
Governor, the Independent Monitoring Board Chairman, a representative of the
Prison Officers’ Association, the prison’s Clinical Team Leader and the prison’s
Liaison Officer.
2. The investigator was briefed about what had occurred. Following the meeting,
he was shown the cell where the man had been found. The investigator
identified from the briefing those staff he wished to interview, and arranged to
return to the prison at a later date to commence the investigation in detail.
3. The clinical reviewer received a brief from the clinical team leader regarding the
man’s medical history and was given a copy of his medical records. The clinical
reviewer was asked to identify any history of mental health problems in the past
and to comment on the overall appropriateness of the treatment the man
received whilst in custody. On 8 February, the clinical reviewer submitted his
report to my investigator and made two recommendations for the prison.
4. On 20 February, the investigator and one of my family liaison officers visited the
man’s mother at her home address. The mother made my staff very welcome
and asked them to look at a number of issues and concerns that she had in
relation to her son’s custody. Unfortunately, some of these questions were
outside my terms of reference. However, my report has dealt with the
questions that I am able to answer.
5. I am aware that the man’s mother believes that a third party was involved in her
son’s death, but I am satisfied that both the police and my own investigation
has found no evidence to suggest a third party was involved. Additionally, as
part of the normal service that my office offers, and at her request, the mother
was given a redacted copy of the man’s prison records.
6. The investigation reopened on 2 April. Seven prison staff were interviewed and
their interviews recorded on tape. Unfortunately, the recording quality of one
interview was not as good as I would wish. However, I am satisfied that the
person interviewed was not involved with the man at the time of his death, and
was providing background information only about his arrival at Acklington.
Additionally, the investigators spoke to the prison chaplain and one prisoner
(neither discussion was formally recorded as the participants were providing
background information). The investigators identified two prisoners who were
in cells either side of the man’s cell on the night he died, but were unable to
speak to either. One had been discharged and the other man declined to be
interviewed. The investigators completed their interviews on 4 April and, before
leaving the prison, fed back their initial findings to the Governor, including the
two recommendations made by the clinical reviewer.
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HMP ACKLINGTON
7. Acklington prison is a category C establishment situated near the village of
Acklington, close to Morpeth in Northumberland. It was built on the site of a
former RAF base and accommodates convicted adult male prisoners with a
mixture of prisoners including men serving life sentences. About half the
population are vulnerable and/or sex offender prisoners. The prison can
accommodate a maximum of 871 prisoners. It provides employment in farms
and gardens, education and a variety of workshops. On 21 January 2006, the
prison unlock roll was 849.
8. H wing is divided into four landings each with 30 cells and, in total, can
accommodate up to 120 prisoners. The wing accommodates vulnerable
prisoners who, because of the nature of their offences or for other reasons,
cannot be placed into what is known as “normal location”. The ground and
second landings are reserved for prisoners on induction or waiting to be
transferred into one of the other vulnerable prisoner wings. Wing facilities
include showers, telephones, laundry, as well as a pool and football table.
9. Between Monday and Friday, prisoners are unlocked in the morning at 7.55am.
They are locked up for the night at 7.15pm. At weekends, the prison is
unlocked at 8.30am and on Saturday is locked up at 7.15pm. On Sunday the
prison is locked up for the night at 5.20pm.
10. The most recent inspection carried out by the HM Chief Inspector of Prisons
was in April 2003 when an unannounced follow up inspection was undertaken.
The inspection found that Acklington was largely a safe prison. However, the
report commented on suicide prevention and anti-bullying training, highlighting
the need for more extensive training especially for permanent night staff.
Healthcare
11. The prison does not have 24 hour medical cover. Outside the normal operating
hours, the prison relies on the services of an on call doctor, or if necessary on
the emergency services.
Night Manager
12. At night time, as well as officers and OSGs there is a senior officer (SO) on
duty. The SO is responsible for the prison and, in the event of an incident, staff
refer to the SO for advice and instructions. If necessary, the SO in turn will
refer to the on call Duty Governor for advice
Operational Support Grades (OSG’s)
13. Operational support grades are uniformed members of staff. They are issued
with security keys and carry out a number of tasks, but not the full range of
duties given to a prison officer.
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Anti Ligature Knives
14. Staff in contact with prisoners are issued with specially designed knives, known
as fish knives, to use in an emergency to remove a ligature. The knives have a
concealed blade which is placed against a ligature and which can be pushed
forward to cut it without harming the prisoner.
Night State 10.00pm – 6.00am
15. Night state is when the prison is fully locked up for the night and staffing levels
are at the minimum. There is often just one night patrol officer per wing or, on
occasions, between two wings. Their role is to monitor the security of the wing
and prisoners.
16. In night state no one can gain entry to the prison or leave it without the night
manager’s permission. To allow anyone to enter or leave the prison before
6.00am when the security systems disengage, the night manager would have to
override the in-built security systems which engage from 10.00pm. It is only in
exceptional circumstance or when the Duty Governor requires entry that night
state would be broken.
17. During night state it is not normal to unlock a cell unless the night manager has
sufficient staff resources in place to deal with the situation. Night patrol officers
do not carry security keys and are therefore unable to move freely around the
prison. However, they do carry a cell door key in a sealed pouch which is
secured to their uniform belt. In the event of a life threatening situation, or if it is
felt necessary to enter a cell, the night patrol officer has first to break the pouch
seal to obtain the key. In the first instance, the officer must summon assistance
and should only enter a cell on their own if safe to do so.
18. Unlike the night patrol officers, the night manager does carry security keys and
is able to move freely about the prison. The manager will usually visit each of
the wings during the night and check on the welfare of the staff and ensure they
are carrying out their duties correctly
Patrol State
19. Patrol state is the name given to other times when prisoners are locked into
their cells, for example during staff meal times. In patrol state, it is only the
prisoners’ cells that are locked, whilst other parts of the prison may be
functioning normally. There may be at least one officer patrolling the wing and
quite often two. The patrol officer deals with any cell call bells, and checks
those prisoners on Assessment, Care in Custody and Teamwork (ACCT)
documents (documents for those prisoners =judged at special risk of suicide or
self harm). Additionally, patrol officers monitor the security of the wing. They
carry the normal prison security keys and, if necessary, can access most parts
of the prison including individual cells.
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Roll checks
20. Roll checks are carried out to confirm the individual wing totals correspond to
the prison total. Whenever a roll check is done, the officer has to physically see
the prisoner is in the cell but they are not required to confirm the prisoner is
alive. The reason for this is that some roll checks are carried out very early in
the morning, and it would be inappropriate to wake the prisoner to check if he or
she is alive. However, if the prisoner is subject to ACCT monitoring, the officer
must confirm that the prisoner is alive. During normal observations, if the
officer has any doubt about the condition of the prisoner, or is unable to see the
occupant, they must seek assistance immediately and if necessary, enter the
cell. Roll checks are carried out at midnight, 6.00am, 7.30am, lunchtime,
4.00pm and 9.00pm.
PSO 2700 Assessment, Care in Custody and Teamwork (ACCT)
21. ACCT requires staff to identify any concerns, take action, and document those
actions for prisoners identified as at risk of suicide or self-harm. The ACCT
document should be available to all the staff where the prisoner is located.
Within 24 hours of the document being opened, the at-risk prisoner will be seen
by an assessor and have a case review meeting. The meeting draws up a care
and management plan, known as a CAREMAP, and a member of staff is
nominated as the case manager. Wing managers take on the role of case
manager, oversee the management of the ACCT document and attend case
reviews.
Race Equality Officer
22. The Race Equality Officer is responsible for co-ordinating and supporting the
work of the prison’s Race Equality Action Team and Diversity Management
Team. It is a full time position managed by a principal officer.
Code Blue
23. Code blue is a local procedure used to alert the communications room staff that
someone is experiencing breathing difficulty. The radio operator in turn alerts
healthcare staff and they attend carrying the emergency equipment.
Previous Deaths at Acklington
24. Since my office took over the responsibility for investigating all deaths in prison
custody on 1 April 2004, there have been three apparently self inflicted deaths
(including the death of the man who is the subject of this report) at Acklington
and eight due to natural causes.
Police Investigation
25. With all deaths in custody, the police are notified by the prison as soon as the
death has been discovered. In the first instance the police treat the area as a
potential crime scene. As part of their investigation, they note the names of
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everyone involved, and those who have been in contact with the person who
has died. Additionally, they note the identity of all those entering and leaving
the cordoned area. It is only when the police are satisfied that the death is not
suspicious that my investigators are allowed to begin their own investigations.
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KEY FINDINGS
26. The clinical review has identified that in September 2005 the man suffered from
eczema and, although not connected, was thought to be suffering from
paranoid psychosis. He was referred for a mental health assessment. The
assessment concluded that his paranoid ideas and auditory hallucinations were
probably related to the use of cannabis and did not believe that he needed
ongoing supervision. It went on to say that his problems settled once
imprisoned, and the clinical review suggests the assessment diagnosis was
correct.
27. In January 2006, the man was sentenced at the Crown Court to fours years’
imprisonment. Although the prison records do not make it clear, it would
appear he had been to HMP Forest Bank and HMP Manchester before
transferring to Acklington.
28. At about 8.30am on 8 August 2006, whilst at Manchester, the man barricaded
himself into his cell and placed a razor blade into his mouth. He was protesting
about being transferred to Acklington and refused to go to the prison reception
to prepare for the journey. After a short while, he gave up his protest and
transferred to Acklington without further incident.
29. When the man arrived at Acklington he went through the normal reception
procedures and was interviewed by the reception officer. In one of the records,
the officer noted that the man had complained about the transfer, saying he
would be unable to have visits. She made a note to show that he was allocated
to the prison induction wing, H1 (a vulnerable prisoner wing). She noted that he
had been polite and respectful and had been offered the support of the
chaplain.
30. The earlier history of auditory hallucinations was identified by healthcare staff at
Acklington, but no follow was required up in view of the diagnosis. The man’s
use of cannabis and the eczema were also noted.
31. Six days later (24 August 2006), the reception officer made a further entry in the
man’s record, noting that he had settled in to the prison and was happy to be at
Acklington. The officer told my investigator that she was satisfied that her entry
was a true reflection on how he was at the time. She explained that any
prisoner can request a transfer to a different establishment after they have been
at Acklington for three months, unless there are compassionate reasons for an
earlier transfer. The officer said that the man would have been aware of the
transfer procedure as it is explained to every prisoner during induction. She
confirmed that the man did not make a transfer request on compassionate
grounds during the three month period.
32. On 28 October, the man’s mother wrote to the Governor asking for him to be
transferred nearer home, as she was unable to visit at Acklington. Although the
letter is dated 28 October, the prison has recorded the letter as received on 4
December.
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33. Eleven days later (15 December 2006), the principal officer (PO) wrote to tell
the man’s mother that the man had not at that stage applied for a transfer.
Unfortunately, the letter does not appear to have ever been posted and due to
an internal mistake the prison wrongly closed the file.
34. On 26 December, the man submitted a request to transfer to another prison. I
understand that it normally takes about three months from an application being
made to a transfer taking place. However, any transfer is subject to the
receiving prison having the available space so it can take much longer. At the
time of the man’s death, the application process had not been completed and
no arrangements for transfer had been made.
35. My investigators found that two racial incident reports were raised in relation to
the man. The first was opened on 15 November 2006 after a prisoner was
found to have a cut to his face and bruising, and alleged that the man had
assaulted him. Another prisoner, who was apparently in the area at the time,
reported to staff that he heard the man make a racist comment and this was the
reason for the form being raised.
36. The prison’s Race Equality Officer (REO), who is a principal officer, told the
investigator that the man and the other prisoner were reported to the Governor
for fighting and dealt with under the prison disciplinary system. It was during a
disciplinary hearing that the man told a senior manager (SO) at the prison, that
the other prisoner had called him a monkey. The SO opened a racial incident
report on 18 December as the man believed the comment to be racist.
37. The REO said that, due to both prisoners making counter claims about what
was said, the racist incident investigations could not be proved. However, both
were recorded as racist incidents.
38. The man was given an additional 28 days in prison for fighting, but the
punishment was suspended. (This meant that the 28 days would not be
activated at that time, but could be activated if the man was found guilty of
another breach of prison rules.) However, he was moved to H wing as a
precautionary measure to get him away from an area where he had problems.
39. On 8 January 2007, the Asylum and Immigration Tribunal office wrote to the
man in relation to his appeal against deportation. The letter told him that his
appeal would be heard on 2 February at the Magistrates’ Court. At the same
time, the Governor was notified of the appeal date and asked to arrange for the
man to be taken to the court.
40. Contained within the documents handed to my investigators was a copy of a
letter written by the man and dated 18 January 2007. The letter, which
apparently had not been posted, was addressed to one of his friends. There is
nothing contained in the letter to suggest anything about what the man was
about to do. In fact, he talked about being released from prison.
41. One of wing officers based on H wing had been on duty in the wing during the
evening of 20 January. At interview, he said that he did not know the man well,
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but felt that he would have asked the officer for anything that he might have
wanted. The wing officer added that he was aware of the man contesting his
deportation.
42. My investigator spoke to the wing officer to establish if he had locked the man
up for the evening on 20 January, to determine his mood, and whether the
officer had any concerns about his safety. He said that he locked the man into
his cell at about 7.20pm, after first of all checking that he was in it. Once he
had completed locking up the landing and verifying the correct number of
prisoners, he confirmed to the wing manager that his landing roll was correct.
He went on to say that he had no concerns about the man’s safety. Having
completed his work for that day, the officer left the prison at about 7.30pm.
43. The Operational Support Grade (OSG) works on a regular basis as a night
patrol. He told my investigators that he had been employed at the prison for
about four years and had received specific training related to his work when he
first joined the Prison Service. He confirmed that he had received no training in
first aid, and that his training mainly concerned security.
44. At interview, the OSG said he started his duty at about 8.10pm on 20 January.
When he arrived at the prison, he collected the equipment that he would need
to carry out his work. This included a prison radio, anti ligature knife and a cell
door key, which is held in a sealed leather pouch and carried by the OSG at all
times. He then made his way to the wing, where he arrived at approximately
8.45pm.
45. In addition to the OSG, there were two prison officers based in the wing for the
night. The OSG said the officers were not required to patrol the wing or assist
him with his work. I understand the officers’ duty at night is to respond to
incidents when required. They also carry out some searching duties outside
the cells, but after searching they are free to relax. The OSG told the
investigators that the officers normally sit watching television.
46. The OSG told the investigators that, when he arrived on the wing, he received a
briefing from the wing manager. He was told about prisoners being monitored
under the ACCT procedure. He told the investigators that the man was not on
the list of ACCT prisoners.
47. At about 9.05pm, after receiving the briefing, the OSG began a full roll count of
the prisoners on the wing. He told the investigators that it took him about 15 to
20 minutes to complete, after which he confirmed the wing roll was correct.
48. My investigators asked the OSG if he remembered seeing the man that evening
when he carried out the roll check. He said yes, and was satisfied that the man
was alive when he looked into the cell. At about 10.30pm, he carried out a
further roll check and, as previously, he confirmed the wing roll was correct.
49. At around midnight, the OSG spoke to another prisoner in the wing who was
complaining about loud noise. The OSG went to a cell on the landing below
where the man lived and spoke to a prisoner who was deaf and had turned his
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television volume up. The prisoner turned down the volume, but there was still
a lot of noise coming from another cell. The OSG investigated where the noise
was coming from and found that it was from the man’s cell.
50. When the OSG looked into the cell he saw the man with his back to the cell
door, dancing and singing. At interview, the OSG described him as happy and
in a good mood. He tapped on the observation glass and asked him to turn the
music down, which he did. My investigators asked if it was unusual for the man
to be singing and dancing at night and whether the OSG had had to speak to
him previously about excessive noise. The OSG said he did not know the man
and had not spoken to him previously.
51. The investigators asked the OSG if he entered the cell to speak to the man and
he said he did not. The OSG did not call the night manager and no one entered
the cell before the time when the man was found hanging. The investigators
asked the OSG if he could recall what the man was wearing at the time. He
said that he was only wearing a pair of track suit bottoms, and confirmed that
no one entered the cell.
52. The senior officer on duty that night told the investigators that he had been an
SO for 16 years. Prior to this he had been a prison officer for 12 years. He
said that SOs are not permanently employed to work on nights; they work
approximately two sets of nights per year, each lasting one week.
53. The investigators asked the duty SO if he had received any specific training to
work on nights. He said there was no specific training other than being given
what he referred to as a manual. The SO clarified that the manual was actually
the prison’s contingency plans which would guide him through any particular
incident. There was no specific training for night managers, and they each
learned what to do from each other by “handing things down”. The SO told the
investigators that he had not received training in first aid. My investigators
asked if he had ever received training in dealing with a death in custody. He
said not, but added that he had read the death in custody contingency plan
about two nights before the man’s death.
54. The duty SO told the investigators that, as part of his normal night manager
duties, he is based in the prison’s staff facility area which is central to the rest of
the prison. He told the investigators that he goes around the prison three times
during the night and speaks to the OSG wing patrol staff. He ensures they are
okay and there are no problems for him to deal with. He said that the visits are
irregular and staff would not know when he was due. The SO said that, whilst
he sees every OSG, he does not necessarily see the officers as they “can be
dotted about”. He added that the officers must remain in contact with him by
radio. He said that on the night of the man’s death there were two officers on H
wing, one covering A, B, and C wing, and the remaining two officers stayed with
him. The SO said that he last saw the two officers on H wing at about 10.00pm
on 20 January.
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21 January
55. At around 5.35am, the OSG began the morning roll check, starting on landing
one followed by landing two. He told my investigators that, when he arrived at
the man’s cell (2-18), he looked into the cell using his torch and saw that the
bed was empty. He said the sheets were folded back and there was a roll of
bed clothing neatly folded on the foot of the bed. At first he thought that the
man was in the toilet and tapped on the observation glass to obtain a response.
56. The OSG was unable to obtain a response and began to call out the man’s
surname. At the same time, he looked in the right hand side of the cell. He
thought he could see the tip of the man’s nose and lips and also a silhouette.
He tried calling to the man again, but did not obtain any reply. Although he had
a cell door key in his sealed pouch, the OSG did not open the door as he
thought the man was hiding. He also had a prison radio, but did not use it.
Instead, he returned to the wing office to alert the two officers in the television
room.
57. My investigators asked the OSG if he suspected that the man was hanging. He
said not, believing that the bars or bed are normally used. He added that he did
not think the man was hanging due to the position he was in. However, at
interview, he said that when he went to speak to the officers he told them that
he thought the man was hanging, but could not give a clear explanation as to
what had changed his mind other than the man was at normal height when he
looked into the cell.
58. The OSG said the two officers went straight to the cell, opened the door and cut
the man down. He said the officers told him to continue with his roll check, but
to first of all contact the night manager and tell him they had a code blue on H
wing.
59. At interview, the OSG said he telephoned the prison communications room and
the call was answered immediately. He told the officer answering the telephone
call that there was a code blue on H wing and gave the name and cell location.
He heard the officer telling the night manager and the rest of the prison about
the code blue over the prison radio.
60. After alerting the communications room, the OSG continued with the wing roll
check and, after confirming the roll, he completed his paperwork. In addition,
he carried out a further precautionary check of the three prisoners in the wing
who were being monitored under ACCT.
61. The prison officer has been at the prison for over eight years and normally
works on K wing during the day. He told my investigators that, at the time of
the man’s death, he was working on nights, something he does about every six
months. Although he was due to start work at 8.45pm, he arrived early at
approximately 7.30pm and went directly to K wing to allow a member of staff to
go home.
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62. At about 10.45pm, after completing his work, the prison officer and the duty
officer went to K wing staff rest room. He said they carried out a roll check in
another wing at about midnight, after which they both returned to K wing where
they remained until the OSG approached them at about 5.35am to tell them that
the man was hanging.
63. The prison officer said that he and the duty officer ran to the cell, which he
estimated to be about 80 to 100 feet away. The prison officer was the first to
arrive at the cell, and, before unlocking the door, he looked in to see if the OSG
could be mistaken. He said he looked into the cell and saw what looked like
someone standing behind the door on the right, looking into the cell. He tried to
gain a response by calling the man’s name and tapping on the observation
glass, but was unsuccessful.
64. The prison officer unlocked the cell door. He told my investigators it was
difficult to open as the body was wedged against the corner of the cell door and
wall. He managed to open the door sufficiently for him and the other officer to
squeeze through the gap and enter the cell.
65. When the prison officer went into the cell he saw a ligature, believed to be a
piece of torn bed linen, around the man’s neck. The ligature was leading up to
the top corner of the door where the hinge is. The officer was carrying an anti
ligature knife, which he removed from its holder and tried to place between the
ligature and the man’s neck. He was initially unsuccessful as the ligature was
too tight. The enclosed space inside the cell prevented the duty officer from
holding the man up to relieve the pressure on his neck. Eventually, the duty
officer managed to place the knife under the ligature and cut it free. At that
point, the man fell heavily to the floor as the officer could not support the
weight.
66. I understand from the duty governor that the ligature had been secured to the
top door hinge by a piece of wire. This had apparently been placed around the
hinge before the ligature was attached to it.
67. Due to the way the body fell, the officers had difficulty laying him flat on the
floor. However, they succeeded and the prison officer checked for any signs of
life. He tried to find a pulse and listened for any sound of breathing, but due to
the man’s tongue being so swollen he doubted that he was breathing and did
not detect anything. The prison doctor said the man had defecated. He said
the man’s tongue was protruding and recalled that his skin was dull and felt like
rubber. The officer also thought that the body might have been warm, adding
that he did not remember it being cold to touch
68. My investigators asked the prison officer if he was first aid trained. He said he
had not received any training since leaving the Prison Service College,
although added that local training at the prison was available. He said that a
few years previously he had asked to attend a number of training courses but
attendance was restricted. However, it is not clear whether one of the training
events was in first aid.
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69. The investigators asked the prison officer if he attempted cardio pulmonary
resuscitation (CPR) on the man. The officer said that, as well as not being first
aid trained, he was not trained in CPR. He said there was no space in the
man’s mouth to perform CPR, due to the swelling of the tongue. He added that,
in other circumstances, he would have felt compelled to try CPR but did not
know the ratio for chest compressions and breaths.
70. Shortly afterwards, additional staff began to arrive and the prison officer left the
cell. He told my investigators that, before leaving, he looked around the cell for
any sign of a suicide note but did not find one. He found two pieces of paper,
one a certificate and the other a canteen order form.
71. My investigators asked the prison officer if he had noticed anything else. He
remembered that the television was switched off, the bed was not made, and
the man’s clothes were folded at the end of the bed. He added that the man
was wearing boxer shorts and described the sheet as being strewn across the
bed. The officer said he remembered the cell was very warm.
72. The investigators asked the prison officer if he knew what rigor mortis was. He
said he had a “rough understanding” and explained that the man’s body was
not stiff, and again described it as rubbery and moveable.
73. The duty SO was in the prison restaurant area and heard the code blue radio
message over his prison radio. He said that he and the two officers who had
been with him went to H wing, which he estimated took him about six minutes.
When he arrived he met the prison officer who told him that he and the duty
officer had cut the man down as he had been found hanging and, in their
opinion, had died. The SO asked the officer if he had tried to resuscitate the
man, and the prison officer told him that he did not feel this was appropriate.
74. The prison officer told the investigators that, when he left the cell, the duty SO
was outside and did not enter the cell but instead left to deal with the
contingency plans. The prison officer and the duty officer went back into the cell
to move the man’s body as it was obstructing the door. Having moved the man
to the centre of the cell, the officers left and closed the door behind them. Soon
after they left the cell, the paramedics arrived and began to check for signs of
life. After connecting electrocardiograph equipment to his body, the
paramedics told the officers that the man was dead.
75. As the prison officer was no longer required at the cell, he left the area and
went to an office where he met a police officer, the Governor and Duty
Governor. He said that the second prison officer took him into a separate room
to ask him how he was feeling and make sure that he was okay. He said the
Governor was very supportive, which he appreciated. In addition, the local care
team and managers had been very supportive throughout.
76. The OSG told the investigators that he escorted the paramedics to the cell. He
saw the man lying on the floor with his head towards the cell door. After taking
the paramedics to the cell he returned to the wing office to continue with his
16
wing patrol duties. He later accompanied two police officers to the cell, but did
not remain with them as the area was restricted.
77. The investigators asked the duty SO if he entered the cell and he said that he
had not done so. He told an officer to remain at the cell and keep a log of what
happened, adding that he did not know of any reason why he would go inside.
He said the officer had described what he had seen and told him that the man
appeared dead and had been so for some time.
78. My investigators told the duty SO that the two officers who had been at the cell
were not first aid trained, which he was unaware of. The investigators
suggested that, as the night manager, he ought to have checked for himself
what the condition was inside the cell and whether he could detect any signs of
life. The SO told the investigators that it would have been a waste of time
because he too had no first aid training. He went on to say that once an officer
has checked, he is mindful of the time factor for requesting emergency medical
assistance and has to accept what the officer has told him.
79. The duty SO said he contacted the prison communications room to ensure the
contingency plans were in place and, as the prison does not have 24 hour
medical cover, he wanted to ensure the emergency services were called. At
about 5.55am, the duty SO had to go to the security department to obtain two
keys which were locked in the office safe in order for the main gates to be
opened to allow the ambulance in. The keys are used to override the prison
security systems and allow the gates to be opened during night state. The SO
deployed his staff to escort the ambulance crew and police officers who had
also been asked to attend the prison.
80. After overriding the security systems, and while the paramedics and police were
in the prison, the duty SO continued with the normal unlocking of the remainder
of the prison. As a consequence, staff unconnected with the man’s death had
normal access to the prison which would otherwise have been inaccessible.
81. My investigators spoke to Physical Education Instructor (PEI). He told them
that the man had been selected to join an NVQ Level 1 course in sport and
recreation. He said the course ran for three mornings each week and
participants were required to complete home work. The PEI said that the man
had progressed well on the course, and could have gone on to level 2 and
beyond had his offence not precluded him. The PEI described the man as
bright and articulate, but someone who would display high and low moods. He
last saw him on 17 January and stressed that he did not show any signs of
being suicidal. The PEI told the investigators that he remembered writing a
report and telling the man that “he could be the star of the show if he put his
mind to it”.
17
After the man’s death
82. At about 7.00am on 21 January, the prison doctor arrived and confirmed that
the man had died. The Governor and a few of his senior management team
spoke to staff involved and offered them support. As well as this, the local care
team was made available to any member of staff requiring additional support.
83. The Governor wrote to all prisoners telling them that the man had died and that
the death would be investigated. He briefed his managers and reminded them
about the need to support prisoners.
84. The prison’s contact with the man’s family is described later in this report.
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ISSUES
Night managers
85. The role of a night manager is to take overall control of the prison and deal with
any incident they are faced with. Unlike during the day when a senior prison
manager is in overall charge of the prison, night managers have to make their
own decisions, occasionally in isolation, until the on call Duty Governor can be
contacted.
86. Acklington is no different to any other prison in that, although the grade may
vary, the night manager is in charge of the prison. The Duty Governor is off
duty, but on call and contactable by telephone or pager. Additionally, governor
grades receive specific training in the management of incidents and their own
local contingency plans. This should equip them to deal with most incidents
they are likely to face.
87. The duty SO told the investigators that he had not been given any specific
training in managing at night. At interview, he said to read the manual that is
given to night managers would take approximately ten years. Whilst I accept
that the comment was exaggerated, it does raise issues about training for night
managers.
88. Because the SOs do not work as night manager more than twice a year, it is
very likely they will not remember everything required of them from six months
previously. It may not be safe to assume, therefore, that they will pass on the
correct information to each other. In any event, those taking over responsibility
for the prison must have sufficient training to enable them confidently to carry
out their duties. The training needs of night managers is an issue locally but
may affect the wider Prison Service too.
The Prison Service should consider whether there is a specific need for
training night managers in incident management.
The Governor should consider whether there is a specific need for
training night managers and whether the night instructions are user
friendly.
The Duty Senior Officer
89. When the duty SO arrived at the cell, he was told by the prison officer that the
man had been found hanging and had died. He asked the prison officer if he
had tried to resuscitate the man and was told that he had not.
90. When my investigators asked the duty SO if he had entered the cell and
checked the man’s condition for himself, he told my investigators he had not
and did not know of any reason why he should have done so. He went on to
say that the prison officer had checked and he had to accept what he had been
told and so instead left to deal with the local contingency plans.
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91. I accept that contingency plans have to be dealt with quickly and that the duty
SO was apparently the only person with access to the safe containing the
override keys. However, not checking for himself what he had been told left the
duty SO vulnerable to criticism.
92. Additionally, the duty SO did not check to see if he could detect any signs of life
and told the investigators it would have been a waste of time as he had had no
first aid training. This also causes me some concern, as all prison officers are
trained in first aid when they first join the Prison Service. It may well have been
some time since the SO’s training took place, but not to enter the cell and check
for basic signs such as breathing or pulse was questionable practice. Although
I make no formal recommendation, this may be something the Governor will
wish to examine further at a local level.
First Aid and Cardio Pulmonary Resuscitation Training
93. HMP Acklington is situated in an isolated part of the country and does not have
emergency medical services on its doorstep, nor healthcare staff employed at
night. The absence of medical staff at night, the distance to the nearest
hospital and the likelihood that paramedic assistance in an emergency will not
be available rapidly, leaves everyone in the prison vulnerable unless proper first
aid is administered as soon as possible. It is therefore very important that staff
working on nights are competent to administer first aid and CPR sufficient to
support a patient until trained specialists can attend. (However, I accept that in
the man’s case, it was probably too late to attempt resuscitation.)
94. In his clinical review, the doctor says that from the man’s appearance he was
clearly dead. The report confirms that no signs of life were detected.
The Governor should review the training for all staff employed on nights
and ensure sufficient first aid and CPR trained staff are on duty during the
night and at any other time when healthcare is closed.
The OSG
95. Following any death in custody, the ACCT guidance states that the prison
should review all open ACCT documents to check those prisoners who are
being monitored. As a member of staff working permanently on nights, I am not
certain that the OSG would have been trained to know the procedure.
However, using his own initiative, he decided that he should ensure that the
three prisoners in his care were safe. At what was an extremely difficult time,
he kept his head, taking positive steps to protect three vulnerable prisoners.
This is professionalism that should be formally recognised.
The OSG should be commended for his decisive action in ensuring the
safety of three vulnerable prisoners being monitored under ACCT.
96. At interview, the OSG told the investigators he had carried a prison radio, but
had not used it to raise the alarm as he had not thought to do so. Instead, he
went to the television room to alert the two officers. Clearly, there is a need in
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such circumstances to obtain assistance by the quickest and most appropriate
method and it is for this reason that the Prison Service provides radio
communication, alarm bells, telephones and whistles to attract attention. I
accept that there may have been little anyone could do for the man, but in
another case it could mean the difference between life or death. It should be an
automatic response by prison staff to use the emergency equipment provided.
The Governor should remind all staff how to obtain prompt emergency
assistance.
The ligature
97. It would appear that the ligature had been tied to a piece of wire which had first
of all been secured to the top hinge of the cell door. It is not known where the
wire came from or how the man obtained it. Neither is it known when the wire
was secured to the hinge. It could have been done whilst the door was open,
or later when closed by bending it into the shape of a hook, passing it through
the gap in the door and then pulling it back around the hinge. Whatever the
method used, it was certainly a deliberate act. The clinical review supports the
view that the man’s actions were premeditated.
Deportation
98. The man had appealed against the decision to deport him at the end of his
sentence and was aware that the appeal date had been arranged for 2
February 2007. Although known to him and the prison, the information had not
been passed to healthcare (or, if it was, the details were not recorded in his
medical record). The clinical review notes that the deportation may have been
a risk factor, although it is not certain what the outcome of the appeal hearing
was likely to be. However, the clinical reviewer judges that the risk would have
been more significant if the decision to deport had been confirmed. In contrast,
the mother told my investigators that the prospect of being deported did not
concern her son.
99. The clinical reviewer says in his report: “In view of his behaviour and general
demeanour, even if healthcare had been informed, it is by no means certain
that a mental health risk assessment would have identified the intent to self
harm or suicide. [The man] skilfully concealed his intentions from everyone”.
Because it cannot be certain whether healthcare is routinely informed about
deportation decisions, the clinical review makes the following
recommendations.
The Governor should ensure that healthcare are informed when prisoners
are to be considered for deportation.
Healthcare should ensure that such prisoners are carefully assessed to
eliminate, as far as possible, the risk of suicide.
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Family contact
100. The man’s mother asked if I could explain why she was not informed of her
son’s death until 3.50pm on 21 January. I understand that due to the distance
from the prison to her home address, the police officers who went to the prison
following her son’s death were asked at the same time to assist in contacting
her. An officer agreed to contact Greater Manchester Police on the prison’s
behalf, but unfortunately I do not know when this happened.
101. After being told of her son’s death, the mother telephoned the prison and spoke
to the Duty Governor. He told her about the circumstances and arranged to
telephone back the following day at 10.00am. The mother told my investigators
that she did not receive the planned call. One of the investigators spoke to the
Duty Governor about the arrangement. He said that he did make the call at
10.00am, but unfortunately the telephone kept redirecting to an answerphone
facility. He said the man’s mother telephoned him late that day and gave a
different telephone number to the one provided previously.
102. Whenever anyone dies in prison custody, the family of the prisoner should be
invited to visit the prison and offered the opportunity to see the area where the
person was found. To ensure arrangements happen as smoothly as possible,
the prison has a family liaison officer whose role is to organise and facilitate the
visit. I am pleased to learn that the prison offered the man’s mother the
opportunity to visit Acklington.
103. The mother met the Duty Governor before going to the cell where the man died.
The mother told my investigators that, before her visit, she had asked for the
cell to remain exactly as it was when the man was found, and she was assured
that this would happen.
104. When she went to the cell, she saw that her son’s bed was neatly made, with
no signs that anyone had been on it, and his shoes were alongside and not at
the foot of the bed as was his usual routine. In addition, on the pillow were a
set of wooden rosary beads, which she believed had been placed there by
someone else as the man was not a Catholic. My investigators have examined
the prison records and, although I cannot account for the beads on the pillow, it
would appear that the man had been allowed to have them in his possession
since he was in HMP Manchester.
105. As with any serious incident it is easy to give out information which, although
well intended, may not necessarily be fact. The mother said she asked that the
cell be left exactly as it was when the man was found hanging and was
apparently assured it would be. In fact, it is clear that the cell had been tidied
up. I am satisfied that it was cleaned out of respect for her visit and that no one
intended to mislead or cause additional stress at what was an extremely difficult
time. And obviously there has to be a balance between decency and health
and safety which will need to be handled very sensitively. But wherever
possible, the wishes of the family should be accommodated. If they cannot be
followed, an explanation should be given.
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106. Following a death at Acklington an information leaflet is usually given to the
bereaved family. It refers to the inquest and post mortem and explains that the
family are allowed to have an independent person present at the post mortem.
The mother said she was not told this by the prison or the coroner’s office, and
only learnt of it after the post mortem was carried out when the leaflet arrived
from the prison. She said the funeral was delayed as she then waited for a
second post mortem to be conducted.
107. The mother said that the prison did not return her son’s clothing to her in time
for his funeral, and this resulted in her having to purchase new clothes for him.
An investigator spoke to the Duty Governor about this and he said the clothing
was sent by courier and it was the company’s responsibility to deliver the
package on time.
108. In addition, the mother said that after her son’s death she was given a number
of names and telephone numbers at the prison to call if she wanted anything.
She explained to the investigators that, prior to his death, she had telephoned
the prison and, in order to speak to anyone about the man, she had to go via
the switchboard. It was only after the death that the prison gave out names and
telephone numbers of staff who could be contacted.
109. I understand that on the back of every visiting order sent from the prison is the
telephone number of the ‘Critical Incident Line’, which is available 24 hours a
day. Any visitor who has a concern about any prisoner can telephone the
number and leave a message. The messages are checked daily and any
necessary action taken.
110. I welcome the dedicated telephone number, but am unclear how people like the
man’s mother who do not visit the prison would know of its existence. Although
I make no formal recommendation, the Governor may wish to consider the
point.
111. More generally, I believe there is a need for Acklington to consider how the
prison communicates with bereaved relatives in light of the mother’s concerns
listed above.
The Governor should review how best to meet the needs of bereaved
relatives in light of the concerns raised by the man’s mother.
Bullying
112. The mother told my investigators that during a telephone call with the man he
told her he was being bullied within the prison. Additionally she said that he
was being called a “black bastard” and “paedo” by officers and they were
encouraging prisoners to do the same.
113. One of my investigators met the prison’s Race Equality Officer. He told her that
he had been at Acklington for four years and a Principal Officer for one year.
He said that he was responsible for answering queries from prisoners and
dealing with the monitoring procedures. In addition, he supported the
23
implementation of the Race Equality Action Plan, answering complaints and
applications from prisoners and staff of a racist nature.
114. The Race Equality Officer said that there were approximately 50 racist
complaints made during 2006. (At the time when my investigator spoke to him
in 2007, the number of complaints was about 25 for the year.) He added that
this was an increase on the previous year. He explained that he personally
does not investigate every complaint, but oversees them before they are
passed to the Race Equality Action Team leader and Deputy Governor who
check the quality of the investigation reports.
115. At interview, the REO said that approximately 20 per cent of the prison’s staff
had been trained in race equality. He added that the figure was mainly non-
uniformed staff, which means the majority of those trained are not front line
prison officer grades.
116. As noted earlier, the REO told the investigators that there had been two racial
incident reports raised in relation to the man. Due to both prisoners making
counter claims, the investigations could not be proved.
117. The REO went on to say that prison staff at Acklington were reluctant to report
prisoners who make racist comments. In his opinion, they do not feel confident
to report such behaviour. He added that he had brought it to the attention of
the prison Race Equality Action Team, and that it was being addressed by
additional training. The Governor will wish to ensure that this is indeed the
case.
Recommendations arising from previous deaths in custody
118. There are similarities between the recommendations in this report and those I
have made in previous investigations at Acklington, especially those relating to
training. In previous investigations at Acklington, I have made the following
recommendations and regrettably they have arisen again here:
• There should be mandatory training for prison officers in resuscitation
techniques to ensure that staff who discover prisoners asphyxiated by ligature
are able to offer immediate assistance.
• Consideration should be given to providing first aid training for all staff who
have contact with prisoners.
• The Governor should review arrangements to ensure that staff are trained and
equipped to recognise an emergency and call for immediate assistance using
the standard prison emergency procedures.
I urge the Governor and wider Prison Service once more to give due
consideration to these matters.
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Staff Support
119. It would appear from what my investigators were told that staff felt supported by
the prison’s management and the appropriate care mechanisms were in place.
25
CONCLUSION
120. I am satisfied that no one else was involved in the man’s sad death. I am also
satisfied that no one could reasonably have suspected what he was planning to
do. He appears to have hidden his true intentions very well. He had indeed
written about his future on leaving prison.
121. It is uncertain what effect the deportation issue may have had on his mind. (As
noted, his mother has said this was not a concern.)
122. The man had not wanted to be transferred to Acklington and was not receiving
visits from his mother. He made an application for transfer a month before his
death. However, the other evidence suggests that he had settled reasonably
well at the prison.
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RECOMMENDATIONS
1. The Prison Service should consider whether there is a specific need for training
night managers in incident management.
The Prison Service have accepted the recommendation.
2. The Governor should consider whether there is a specific need for training night
managers and whether the night instructions are user friendly.
The Governor has accepted the recommendation.
3. The Governor should review the training for all staff employed on nights and
ensure sufficient first aid and CPR trained staff are on duty during the night and
at any other time when healthcare is closed.
The Governor has partially accepted the recommendation.
4. The OSG should be commended for his decisive action in ensuring the safety of
three vulnerable prisoners being monitored under ACCT.
The Governor has accepted the recommendation.
5. The Governor should remind all staff how to obtain prompt emergency
assistance.
The Governor has accepted the recommendation.
6. The Governor should ensure that healthcare is informed if prisoners are to be
considered for deportation.
The Governor has accepted the recommendation.
7. Healthcare should ensure that such prisoners are carefully assessed to
eliminate, as far as possible, the risk of suicide.
The Governor has accepted the recommendation.
8. The Governor should review how best to meet the needs of bereaved relatives in
light of the concerns raised by the man’s mother.
The Governor has accepted the recommendation.
27