Individual at Sudbury

Investigation into the circumstances
surrounding the death of a man at HMP Sudbury
in September 2007
Report by the Prisons and Probation Ombudsman for
England and Wales
April 2008
This is the report of an investigation into the death of a man who was a
prisoner at HMP Sudbury. The man was found in his car in a country lane in
Derbyshire, by a member of the public on 3 September 2007, having
apparently taken his own life by asphyxiation. The man was 49 years of age.
I would like to express my condolences to the man’s family for their loss. I
hope that my report helps their understanding of the circumstances leading to
his death and addresses any concerns they may have.
Although the man died after failing to return to Sudbury from weekend leave, I
decided to investigate his death on a discretionary basis. I took this action
because of the national publicity surrounding the man’s death and because he
had been in custody until very shortly before his death.
The investigation into the man’s death was carried out by one of my
investigators. I would like to thank the Governor of Sudbury and his staff for
their co-operation and assistance.
A story about the man had appeared in a national newspaper on the weekend
before he died. It may well be that this story and its consequences preyed on
his mind and was a contributory factor in his death. However, from my
investigation it is evident that no one at Sudbury could reasonably have
foreseen the actions that the man was to take.
Stephen Shaw
Prisons and Probation Ombudsman April 2008
CONTENTS
Summary 3
The investigation process 5
HMP Sudbury 6
Key Findings 7
Issues 15
Recommendations 17
SUMMARY
The man, a life sentenced prisoner, arrived at HMP Sudbury on 19 April 2005,
having spent the previous nine years progressing through the prison system.
On arrival at Sudbury, the man undertook the resettlement work required of a
prisoner serving life. He was seen by staff at the prison as being a ‘model
prisoner’ and for the past year had been working at the Prison Service Stores
near Sudbury. The man, like a number of prisoners at Sudbury, was
permitted the use of his own car.
On Friday 24 August 2007, the duty governor at Sudbury was informed by the
Prison Service Press Office that a national newspaper was to publish an
article about the man the following Sunday. The details and nature of the
article were unknown. The man was considered to be at an increased risk of
absconding and also vulnerable to the actions of other prisoners when the
story became public. As a consequence, it was decided to transfer him
temporarily to closed conditions at HMP Dovegate. However, the man’s
category D status remained unchanged.
During the reception process at Dovegate, the man complained of chest
pains. He was located in the healthcare unit and a number of tests were
completed, all of which proved negative. A Registered Nurse at the prison
said that the man had expressed no self harm ideation at the time nor did he
display any psychiatric or psychological symptoms.
On Sunday 26 August 2007, the newspaper published its story about the
man. It reported that, on finishing work at the Prison Service stores, he had
visited a local library and had eaten in a local pizza restaurant with friends.
On 27 August, security information obtained by Sudbury suggested that the
man would be assaulted if he returned to the prison. However, on 28 August,
staff took the decision that he could return to Sudbury if he wished to.
Although apprehensive, the man confirmed with staff his wish to return to the
prison. He said he wanted to face the situation head on, and with the support
of his family who lived near by. The man returned to Sudbury from Dovegate
that afternoon.
On his return to Sudbury a fellow prisoner spoke with the man at length in his
cell. The man told his fellow prisoner how he wanted to “end it all” and that he
would kill himself in his car. During their conversation, the man told the
prisoner that he was not to tell anyone what he had said. The prisoner said
that, over the following days, a number of prisoners made remarks about the
man, but the man remained strong, ignoring the comments that had been
made.
On Thursday 30 August, the man was informed that it would no longer be
appropriate for him to keep his job at the Prison Service stores or have
continued use of his car. However, he was allowed to seek alternative
employment in the community. Because of this change in his circumstances,
the man was given permission to return his car to his brother’s house during
his weekend home leave. The man’s time at Sudbury over the following days
appears to have been unremarkable, with nothing of note recorded on his
prison record.
On Sunday 2 September, the man left the prison at 8.05am, as authorised
under the conditions of his day release. At 12.10pm, the man bought a
number of items from a local hardware store, including piping and tape. At
1.30pm, the man’s brother returned to his home to find that the man had left a
number of items there, including his phone, personal papers and a computer
memory stick.
Later that afternoon an Operational Support Grade (OSG), who was working
on the gate at Sudbury, received a phone call from the man’s father,
questioning his son’s state of mind. The OSG obtained the contact details of
the man’s brother and spoke with him at 5.10pm. She advised the man’s
brother that there was still time for the man to return to the prison, and he
should ring again after 7.00pm for further news.
The man failed to return to Sudbury at his curfew time of 7.00pm and as a
consequence staff implemented the prison’s abscond procedures. At 8.30pm,
the man’s brother contacted the prison once again. He told the OSG that he
had found a letter on the computer memory stick that his brother had left at
his home. Derbyshire Police were informed of the situation immediately.
At 5.00pm on Monday 3 September, a member of the public came across the
man’s car in a deserted country lane with the engine still running. The man
was found dead in the car. Derbyshire Police attended and subsequently
informed both the man’s family and Sudbury of his death.
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was conducted by one of my
investigators. Notices were issued to staff and prisoners at HMP Sudbury
informing them of the investigation, and inviting them to contact the
investigator should they wish.
2. My investigator visited Sudbury and reviewed the man’s prison records.
These included his core prison record, medical records and a number of
statements made by staff. A number of staff at the prison were
interviewed.
3. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, this report will be sent to the Coroner to
assist in his enquiries into the man’s death.
4. One of my Family Liaison Officers contacted the man’s family. This was
to give them the opportunity to meet with the investigator, to discuss the
purpose of the investigation and to raise any concerns they wished to be
addressed. The man’s family raised a number of matters which I address
later in this report.
In their response to the draft report the man’s family asked that it be noted
that, although there had been previous articles about him in the media,
none had impacted upon him as significantly as the one published before
his death. Given that the man subsequently lost his job and use of his car
the family feel that the article affected him greatly.
The man’s family also suggested that it was possible that a further trigger
could have been the pressure the man felt as a result of the ongoing
impact his offence was having on other family members.
HMP SUDBURY
5. Built as a US Air Force hospital, HMP Sudbury was converted into a prison
in 1948. Sudbury is a category D open resettlement prison, housing men
who are nearing the end of their sentences. The regime is centred on re-
establishing prisoners’ links with the wider community. The prison has
accommodation for 571 prisoners in single and double cell
accommodation. Approximately 55 of the men at Sudbury are life
sentenced prisoners.
6. About 200 of the prisoners at Sudbury are released into the community for
the purposes of voluntary work/paid employment, education and training.
Due to Sudbury’s rural location and lack of public transport, some
prisoners working outside the prison are permitted to use their own cars.
However, only those prisoners who have been through a security and
assessment procedure are given permission to do so, and the use of cars
is governed by a number of rules and regulations.
7. All prisoners permitted to leave the prison are subject to risk assessments
which are reviewed on a regular basis. During weekends it is not unusual
for 300 prisoners to be released on temporary licence for employment and
resettlement day release and including escorted/unescorted town visits at
any one time. Sudbury lacks a secure perimeter fence and, like other
open establishments, relies in part upon trust that prisoners will not
abscond.
KEY FINDINGS
8. On 17 July 1995, the man was remanded into custody at HMP Norwich. It
was recorded on his prison record that he had been charged with murder
and had attempted suicide twice, once by asphyxiation whilst at large and
once by biting his wrists in police custody. Staff at Norwich opened an
F2052SH, recording that the man appeared very low, bewildered and
confused. (The F2052SH was the document formerly used to assess and
observe prisoners at risk of self harm. This has now been replaced by the
Assessment, Care in Custody and Teamwork (ACCT) process.)
9. On 2 August 1995, the man was admitted to the Norvic Clinic, a secure
psychiatric unit, under the Mental Health Act 1983. Whilst at the clinic, the
man made some improvement, although his mood declined and in
November 1995 he expressed ideas of suicide. In June 1996, after his
trial and conviction, the man returned to HMP Norwich.
10. The man was sentenced on 3 July 1996 at Norwich Crown Court.
Because of his vulnerability, staff at the prison opened another F2052SH.
It was recorded that he had a history of depression and had maintained
that, if convicted of murder, he would end his life. The F2052SH was
closed during a case review on 11 August, staff recording that the man
was feeling more positive and his mood had improved.
11. Between 1996 and 2005 the man made steady progress through the
prison system, serving his sentence at a number of establishments. The
last F2052SH to be opened was whilst he was at HMP Wakefield in 1997.
The man told staff at Wakefield that he could not cope with what he had
done. Following a Parole Board review recommending category D status,
the man transferred from HMP Highpoint to Sudbury on 19 April 2005.
12. At Sudbury, the man undertook the resettlement work required of a life
sentenced category D prisoner. As part of the resettlement process, and
after a six month qualifying period, he was allowed on escorted town visits.
These were followed by unescorted town visits and unpaid work in the
community. More recently the man had been undertaking full time paid
work at some prisoner property stores near the prison. The man had also
begun making regular visits to a local hostel, lodging several nights over a
weekend.
13. In both 2005 and 2006, articles about the man appeared in the press. A
story appeared in a Nottingham paper in March 2006. It reported that the
family of his victims were angry about him being released on unsupervised
day release visits only ten years after his conviction.
14. The man’s prison Probation Officer, told my investigator that in the months
before his death he had been preparing for his release. She said that the
man was quite concerned by the views of the victims’ family and the
articles in the local press. During a risk assessment in July 2007 it was
recorded that:
“The man had reported that he had sensed a change of attitudes with
other prisoners towards himself and believes this may be because of
press releases. The man has expressed his concerns for his safety
and expects assaults from the victims’ family members or associates of
the family upon release.”
15. The man’s probation officer told my investigator that in recent years there
had been nothing to suggest that the man had been at risk of self harm.
(However, she also said that, on learning of his abscond, she believed that
the man would kill himself. She said that he knew any future employment,
relationships and life generally would be difficult upon his release, and he
was becoming more aware of this as his contact with the community
increased.) The man’s personal officer, told my investigator that in the
months leading to the story that appeared in a national newspaper on
August 26 2007 there was no change in the man’s behaviour. When
prisoners had previously given him “problems”, he “never rose to the bait.”
16. The last risk assessment, approving the man’s release on temporary
licence, was completed on 20 July 2007. The man’s resettlement activity
or work risk assessment was approved on 27 October 2005.
17. On 21 August 2007, the man left Sudbury at 6.29am, returning to the
prison at 7.04pm.
18. On Friday 24 August, the duty governor was informed by the Prison
Service press office that a story about the man was due to appear in a
national newspaper that weekend. The man was working in the Prison
Service stores at the time and was asked to return to the prison
immediately. The duty governor at the time told my investigator that,
although the full details of the story due to appear in the newspaper were
not yet fully known, the man had admitted attending the local library and
eating in a local restaurant.
19. The core hours for prisoners working at the Prison Service stores are from
8.00am to 4.30pm between Monday and Thursday, with a 3.30pm finish
on Friday. Prisoners who work at the stores are required to be present
between these hours and are not permitted to leave before the 4.30pm
finish. Should a prisoner undertake any overtime, contact is made with
staff at the prison advising them of the extra hours to be worked.
However, I understand that no overtime has been available to prisoner
employees for a number of years.
20. The man’s activity schedule, dated 4 July 2007, which formed part of his
licence conditions, states that he was permitted to leave Sudbury after
6.00am and was to return by 8.30pm. The man was allocated an amount
of time, not greater than 45 minutes, to travel either to or from work. My
investigator was told by a governor at Sudbury that the man’s timings were
introduced when he first started working at the Prison Service stores, at
which time he was required to travel by public transport. She said that the
facility to take a meal break was built in to the return time, as the man
would not be back in time to collect a meal from the prison kitchen. The
governor said that the man was only permitted to use his car earlier in
2007 and his licence should have been amended to reflect the reduced
travel time.
21. Although staff at the prison are aware if a prisoner returns later than their
licence permits, there are no procedures that enable staff to establish
whether or not a prisoner has taken longer to travel from work than the
time allocated for doing so. My investigator was told by a governor that
staff had no reason to suspect that the man had breached the terms of his
licence conditions and that the timings were reviewed once the newspaper
story was published. Another of the man’s licence conditions was that he
was not to enter any betting shops, or other social venues, which were not
necessary or related to the purpose of his release.
In their response to the draft report Sudbury said that if a prisoner
breaches a period of temporary licence by returning later than his licence
permits he may be subject to the Governor’s adjudication. They said that
this procedure would include investigation of the reasons for the late
return. They said that staff had no reason to suspect that the man had
breached the terms of his licence until the newspaper article was
published. Sudbury said that the timings were reviewed once the
newspaper article was published.
22. As a consequence of the allegations that were to be made in the national
press, the man was placed on report (a process which marks the start of a
prison disciplinary hearing known as an adjudication) for failing to comply
with the conditions of his licence. The man was issued with the F1127A,
Notice of Report at 3.55pm on 24 August. The notice alleged that, on 21
August, he had left the Prison Service stores at 4.30pm and in breach of
his licence had failed to return to the prison immediately upon completion
of his work.
23. The duty governor took the decision that the man should also be
temporarily transferred to closed conditions at HMP Dovegate. The man
was formally advised of this action, as were the other relevant authorities.
The duty governor at the time told my investigator that this action was
taken because of the man’s increased risk of absconding and the possible
danger he faced from other prisoners. However, it was decided that the
man would not be reclassified and would remain a category D prisoner. A
senior officer noted in the man’s wing history sheet that he was being
returned to closed conditions:
“… until a decision is made on his possible abscond risk and any
adverse response from other prisoners about the newspaper article.”
24. On the afternoon of Friday 24 August, the head of operations at Dovegate
spoke to the man during his reception at the prison. She wrote in a
memorandum dated 6 September that, “The man expressed some
concern for his safety if he was placed onto normal location, due to the
nature of his crime.” For this reason the man was located in the
healthcare unit.
25. The man was also seen by a nurse at the prison. In an e-mail dated 6
September she said that a number of tests were taken in healthcare as the
man had complained of chest pains. She said that, although the tests
proved negative, the decision was taken to keep the man in the healthcare
unit. The nurse said that the man told her he had no suicidal thoughts.
There were no psychiatric or psychological problems to suggest to the
nurse that the man was at risk of self harm.
26. Whilst in Dovegate, the man spoke with his brother on the telephone. The
man’s brother told police that the man had seemed very distressed and
upset. He said that it was the last time that he spoke with the man.
27. On Saturday 25 August, the man’s adjudication took place at Dovegate.
The F256 Record of Adjudication Hearing recorded that he had failed to
return from his resettlement workplace promptly. However, the adjudicator
dismissed the adjudication on a technicality, believing that the F1127
Notice of Report form had not been issued to the man within the specified
timescale. (This was an error on the adjudicator’s part and the paperwork
had in fact been issued in time.)
28. On Sunday 26 August, a national newspaper published an ‘exclusive
report’ entitled, “Killer who massacred his family pops out of prison for
pizzas.” The paper reported that during the previous week the man had
left work at 4.30pm, then attended the local library, where he used the
internet, before meeting with friends in a pizza restaurant for a meal. The
paper reported that the man returned to Sudbury for his 7.00pm curfew.
29. On 27 August, the man’s personal officer went to the man’s place of work
and spoke with the foreman in charge of prisoners. The man’s personal
officer advised the foreman that it was unlikely the man would be returning
to work at the depot. The man’s personal officer told my investigator that
whilst he was at the Prison Service stores he noticed the newspaper
article “lying around”, and there was a strange atmosphere with people
obviously having discussed what had happened.
30. A Security Information Report was submitted by an officer on 27 August. It
was recorded that a number of other prisoners had commented, to another
prisoner, that if the man were to return to Sudbury he would be assaulted
because of the nature of his offence. However, the information contained
in the report was unsubstantiated and no names of those who had
allegedly made the threats were given.
31. On Tuesday 28 August, the resettlement manager received a call from the
lifer officer at Dovegate, asking what was to happen to the man. Following
a discussion with the deputy governor at Sudbury it was agreed that the
man could return to Sudbury providing that he wanted to. However, it was
agreed that, should the man not wish to return, an alternative category D
prison would be sought. The lifer officer at Dovegate spoke with the man
that morning. She put several options to him, including returning to
Sudbury or transferring to an alternative establishment. In a memorandum
dated 4 September the lifer officer wrote:
“the man stated he was apprehensive about going back to HMP
Sudbury. However, [the man] felt he had to face the situation head on
if he had any chance of release, to which he stated he was due a
hearing in 2008.”
She added:
“… he felt he must return to HMP Sudbury to enable [the man] to return
to his usual routine. He stated his family were fairly local and HMP
Sudbury meant he was able to see them more often.”
The lifer officer reported to the resettlement manager that the man was
happy to return to Sudbury and, although apprehensive, he would
overcome this in time with the full support of his family. The man was
informed that he would be able to return to his old cell, which had a
camera located outside, and was where he said he would feel safer.
32. The resettlement manager told police that he spoke with the man on his
return to Sudbury. He said that the man appeared physically well, but
described him as a little bit nervous. The man was anxious about how he
would be received by other prisoners but had no concerns with regard to
his safety and did not appear distressed.
In response to the draft report the man’s family said they remained
concerned that he was not assessed on his return to Sudbury. The man
was given several options with regard to returning to Sudbury, and was
offered the opportunity, during a meeting with the lifer officer at Dovegate,
to be transferred to an alternative establishment should he wish. The man
said that he wanted to return to Sudbury in order to be close to his family.
The man was also seen by the resettlement manager on his return to the
prison.
33. That afternoon, another prisoner spoke with the man. In a statement of 10
September, the other prisoner said that he spent quite a lot of time with the
man talking through what had happened and trying to help him put things
into perspective. The prisoner said that he hardly saw the man for the
remainder of the week.
In their response to the draft report the man’s family said they remained
concerned that his change in behaviour was not picked up by prison staff.
(The day after the man had gone missing the prisoner had told staff in the
lifer unit that the man had been the subject of name calling and bullying,
and that he had stayed in his room and had not eaten.)
In open conditions prisoners have more freedom and personal
responsibility, spending much of the time unsupervised. As a
consequence of this, staff have limited opportunities for observing
prisoners close at hand.
34. Another prisoner at Sudbury told police that he talked with the man for
about an hour and a half that Tuesday afternoon. The man told the
prisoner how “he felt crap and hated himself for what he had done”. The
prisoner said that the man talked about an attempt at suicide he had made
in the past. The man told the prisoner how he wanted to end it all and that
he was going to kill himself in his car. The prisoner said that the man
asked him not to mention their conversation to anyone. The prisoner
agreed that he would not. The prisoner said that their discussion then
moved onto other topics. When he left, the man told the prisoner that he
had been “cheered up”.
35. In his statement to police, the prisoner said that over the coming days
other prisoners had been making “snide” comments and saying “nasty”
things about the man. However, the prisoner said the man remained
strong, ignoring the comments. He told police that the man would not go
running to staff, but would just “deal with it”. He said that by Wednesday
29 August the man seemed better and was looking forward to his town
visit. (The prisoner told police that, when he heard later that the man had
not returned from his town visit on 2 September, he spoke with a senior
officer, telling him of the conversation he had had with the man on the
previous Tuesday afternoon.)
36. The man’s personal officer told police that a few prisoners had tried to
“wind the man up” in the dining hall. He said that the man had handled the
situation well, wanting to face his problems head on and deal with them.
37. Probation records say that on 28 August, due to the publicity caused by
the newspaper article, the man’s planned release and stay at approved
premises in Derbyshire was cancelled. However, it was decided that the
man would be permitted day release on the following Sunday, 2
September. A senior officer completed the relevant paperwork which
allowed the man to leave the prison between the hours of 8.00am and
7.00pm.
38. A principal officer, senior officer and personal officer met with the man on
the morning of Thursday 30 August. In a memorandum of 4 October the
principal officer wrote that:
“… it had been brought to my attention as principal officer of
resettlement that the man had requested to continue with his outwork
placement at the Prison Service storage facility.”
39. A principal officer spoke with the man’s personal officer and another senior
officer who both thought it inappropriate that the man should continue to
work at the Prison Service stores. It was agreed that the man would be
taken off the stores work placement and would no longer have use of his
car. He would, however, be allowed to seek alternative employment. In
his statement the principal officer said:
“It was clear from the newspaper reports that the man had abused this
facility [use of car], so therefore he would not be allowed his car for his
next work placement.”
40. The man was informed of the decisions that had been made. The
principal officer said in his statement that the man “…asked whether he
could take his car home on Sunday as he had a resettlement day release,
this was agreed.” The man’s personal officer told my investigator that the
man was not pleased with the decisions that had been taken, but accepted
the reasons. The principal officer told my investigator that the man knew
his behaviour was inappropriate and was not surprised that the privilege of
using his car had been withdrawn.
41. On Friday 31 August, the man spoke with his sister. The man told her that
his weekend hostel visit had been cancelled, but that a day release had
been brought forward to Sunday 2 September. The man added that he
had lost his job and would no longer have use of his car. The man’s sister
asked him if someone had been “having a go at him”, but he said that he
would rather not talk about it. The man’s sister told police that although
her brother was “down” he was also slightly positive, never indicating that
he wanted to take his own life.
42. On Sunday 2 September, the man left the prison at 8.05am. At about
12.10pm he bought tape and hose piping from a local hardware store.
43. At about 1.30pm, the man’s brother returned home, having not heard from
his brother during the day. The man’s brother told police that a number of
items had been left at his home by the man. These included a mobile
phone, bank cards, insurance papers and a computer memory stick.
44. The OSG, who was on gate duty at Sudbury on the afternoon of 2
September, said that at approximately 4.50pm she received a call from the
man’s father who expressed concern about his son’s whereabouts and his
possible state of mind.
45. The OSG spoke to the man’s brother at about 5.10pm, having obtained his
contact details from the man’s father. The man’s brother indicated that the
man had visited his home, leaving a number of personal items, but was
not there at that time. The OSG explained that the man was on licence
until 7.00pm and might still return to the establishment.
46. The man’s brother contacted the prison again at 7.20pm to see if the man
had returned. The OSG said that he had not. At approximately 7.25pm,
the OSG informed the duty manager that the man had failed to return from
his day release. The duty manager in turn informed the duty governor at
7.40pm, at which time the prisoner abscond routine was activated.
47. At about 8.00pm, the man’s brother checked the memory stick which had
been left at his home. He found on it a letter of intent that had been
written by the man at 11.00am. Part of the letter said:
“This recent event has made me realise that this will never go away, I
am never going to get another chance to start again to have a normal
life.”
48. At 8.30pm, the man’s brother telephoned the OSG once again, informing
her of what he had found. The OSG contacted Derbyshire Police at
8.35pm.
49. On 3 September at approximately 5.00pm, the man’s car was found by a
member of the public in a country lane. A hosepipe was seen to run from
the rear of the car and through an open window. The car’s engine was still
running. The man was found inside the vehicle and pronounced dead at
the scene by paramedics. At 6.40pm, Derbyshire Police contacted the
prison to report that a man, thought to be the missing prisoner had been
found.
50. Having been informed of his death by Derbyshire Police, the man’s brother
and sister visited Sudbury on 4 September and collected his property.
During their visit, the man’s family met with the Governor and were
introduced to the family liaison officer.
51. The man’s psychologist and probation officer attended his funeral.
ISSUES
52. I am satisfied that staff at Sudbury could not have foreseen the actions
taken by the man on 2/3 September. It is evident that, from the time the
Prison Service were informed of the newspaper article, staff at both
Sudbury and Dovegate took full consideration of the man’s circumstances
when making decisions about him. In the week after the newspaper story
broke, the man met with staff on a number of occasions and was also
offered the opportunity to transfer away from Sudbury to another category
D establishment.
53. Although I am satisfied that staff at both Sudbury and Dovegate gave due
consideration to the man’s circumstances I do have one observation to
make. When Sudbury became aware of the newspaper story, the
reasoning behind the man’s transfer to closed conditions was clearly
recorded and relevant paperwork was completed. However, the reasoning
and consideration behind the man’s transfer back to Sudbury, also a
significant event, was not clearly or properly recorded in his prison record.
54. Officers involved in the decision making process agreed with my
investigator that an adequate note of the various meetings held with, and
about, the man should have been made in his prison record. Due to a
misunderstanding between staff, a full record was not made. I therefore
recommend that:
The Governor should remind all staff at Sudbury of the need to make
a clear record of all significant events and decisions relating to
prisoners.
55. I appreciate that open establishments such as Sudbury have many
prisoners who are temporarily released on a daily basis. I am aware of the
operational difficulties involved in ensuring all return directly to the prison,
and within specified agreed times, whilst at the same time striving to
provide opportunities for prisoners in preparation for their release. My
investigation has established that the man’s temporary release times for
working in the community were set when he was required to travel by
public transport. It is unfortunate that when his circumstances changed,
and he began driving to work, these timings were not reviewed until a story
was about to be published in the media.
56. However, as a consequence of these events, I am aware that a Notice to
Prisoners was issued on 30 August, and reissued on 5 September. The
notice advised all prisoners that the practice of having a meal outside the
establishment must cease, and that they must return from all work
placements by 6.30pm in order that they can eat in the prison. The notice
also said that up to date travel plans must be completed by all prisoners. I
make the following two recommendations:
The Governor should complete a full review of resettlement and
licence procedures ensuring that they meet the requirements of
relevant Prison Service Orders and practice.
The Governor should review the systems used to identify those
prisoners who breach the terms and conditions of their licences.
57. During contact with my family liaison officer, the man’s family questioned
why he had been allowed to return to Sudbury following an incident with
another prisoner, and after the publication of the story about him. My
investigation has established that the man had previously been the subject
of newspaper articles and of talk by other prisoners. However, given the
choice of returning to Sudbury or to another prison, the man took the
decision to return to Sudbury in order to continue with his normal routine
and ongoing resettlement. The man told staff that, although he was
apprehensive about his return, he would overcome any difficulties with the
support of his family, wanting to face any issues “head on” himself. Sadly,
and unbeknown to both staff at the prison and to his family, the man then
confided to another prisoner his intention to take his own life.
58. The man’s family was also concerned that he had been unable to talk with
his probation officer around the time of the newspaper article. My
investigator established that the man’s probation officer was on holiday
when the story broke. However, the man was seen throughout this period
by officers and other prison staff whom he knew well and with whom he
had worked closely during his time at Sudbury. There is no evidence to
suggest that the man requested any additional support either from his
probation officer or other members of staff at this time.
59. The man’s family also questioned whether he should have been assessed
prior to his temporary day release on 2 September, given what had
happened and his history of depression. My investigator has established
that the man was assessed by a nurse at Dovegate shortly before the
newspaper article was published. At this time the man showed no
psychiatric or psychological indications that he was at risk of self harm.
Staff at Sudbury are all trained in the ACCT process (to assess, observe
and support prisoners at risk of self harm). Although the man’s state of
mind was not formally assessed on his return to Sudbury, at no point did
he express to staff either verbally or physically any intention of self harm,
only confiding his intention to a fellow prisoner.
60. The newspaper story may well have been a major contributing factor in the
man’s decision to take his own life. He also seems to have felt that the
grave offences that led to his imprisonment would continue to affect his life
after release, and that it would be difficult for him to live unchallenged in
the community.
61. The means the man used to kill himself were identical to those he had
employed immediately before his arrest.
RECOMMENDATIONS
The Governor should remind all staff at Sudbury of the need to make a
clear record of all significant events and decisions relating to prisoners.
Partially Accepted - In response to the draft report HMP Sudbury said that in
the majority of cases records of significant events are recorded, it is accepted
however that on occasion more detailed information is required that both
shows the rationale behind some decision making processes and the resulting
outcome. This to be raised with the Senior Management Team collectively
and disseminated to all staff via a Notice to Staff.
The Governor should complete a full review of resettlement and licence
procedures ensuring that they meet the requirements of relevant Prison
Service Orders and practice.
Accepted – The Head of Resettlement is to be tasked with undertaking a
formal review of the current procedures in place at Sudbury, the objective is to
ensure we are fully compliant with the requirements of all relevant Prison
Service Orders.
The Governor should review the systems used to identify those
prisoners who breach the terms and conditions of their licences.
Partially Accepted – Systems are in place that identify any breaches of
licence conditions and in the case of outworkers random unannounced visits
are made on offenders to check compliance with their licence conditions
whilst at work. Consideration is now given to the time it takes an offender to
travel back from his place of work and this is now also reviewed if his
circumstances change, i.e. improved transport. HMP Sudbury say that this
recommendation will be included in the formal review of the resettlement and
licence procedures.