Individual at Dovegate

Investigation into the circumstances surrounding the
death of a man at HMP Dovegate in June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
February 2009
The man was found hanging in his cell at HMP Dovegate in June 2008. He had
used a torn bed sheet as a ligature attached to an unauthorised makeshift block he
had glued to his cell wall. Staff discovered him when they began unlocking cells in
the morning. The officers on the landing, and another prisoner, responded quickly
but they could do nothing to save his life. My colleagues and I would like to extend
our condolences to the man’s family and all those affected by his loss.
The investigation was carried out on my behalf by an assistant ombudsman and two
of my investigators. A review of the man’s clinical care was carried out by a team,
on behalf of the local Primary Care Trust (PCT). I am grateful to the clinical review
lead for her assistance.
The man was in a Therapeutic Community at Dovegate where there is an ethos of
group support and of talking through problems. His death was unexpected and the
community, including both staff and prisoners, were shocked and upset. I thank the
Director of HMP Dovegate for the co-operation of his staff and that of the residents of
the man’s wing.
I make five recommendations; two relate to policies, one to training, one to
unauthorised items in cells, and one to sharing information. I also draw the
Director’s attention to the clinical review panel’s recommendation regarding
communication between the Therapeutic Community and Healthcare. There are
also issues regarding emergency response and the return of unused medication.
These latter two issues were highlighted in a report I issued into an earlier death in
custody at Dovegate (published after the man’s death) and I am aware that work is
being taken forward to address them. I do not, therefore, make further formal
recommendations but draw the matters to the Director’s attention.
On the day of the man’s death the Director discovered that two officers had not
carried out proper roll checks. I should record here that the Director has already
taken the appropriate action.
Stephen Shaw CBE
Prisons and Probation Ombudsman February 2009
2
CONTENTS
Summary 4
The Investigation Process 6
HMP Dovegate 7
Therapeutic Communities 8
Key Findings 10
Issues Considered 24
Recommendations 31
3
SUMMARY
The man had been in prison since May 2006. In June and July 2006, before being
sentenced he had attempted suicide. The reasons for his attempts appear to be a
culmination of anxiety over his sentence and relationship difficulties with his wife.
Several assessments show that he told staff he was disappointed in himself for
getting involved in drugs and crime when he was trying to sort his life out.
The man transferred to the Therapeutic Community (TC) at HMP Dovegate on 31
December 2007. He was trying to deal with issues surrounding childhood abuse
when in local authority care and was doing this by means of legal action and
personal counselling. He believed that a TC could help him continue the work he
had begun in personal counselling.
The man had minimal contact with the healthcare unit and the consultations he had
related to an injury to his hand and chest problems. No concerns were apparently
raised regarding his mental health and so there were no consultations relating to
mental health for self-harm or depression. The clinical review panel felt it was likely
that the disclosure of his childhood abuse would have caused him psychological
distress. My investigators are now aware from the suicide notes left by the man that
he believed the TC had helped him deal with these issues.
He took time to settle into the TC, but this seems to be because he was worried
about his progression through the prison to be a category D prisoner. The man left a
letter for one of his sisters and one for the staff of the TC unit (TCD) he lived on. In
the letter to staff he told them that he had been wrong about the TC initially. It had
helped him to “box” the issues he had about his childhood and he was no longer
ashamed by them.
On 4 June 2008, the man received a letter from his wife ending their relationship. He
was upset, but staff and residents thought he was acting more positively than he
would usually deal with things. On Saturday 7 June, he appeared to have a typical
day on the wing. He spoke to staff and other residents but spent most of his time in
his cell. One prisoner told my investigators that the man seemed “brighter” and
enjoyed some “banter”.
During the night, between 10.30pm and 11.00pm, a prisoner in the cell next to the
man heard a bang but thought nothing more of it. The night officer did not check the
man’s cell during the early morning roll check as he should have done. The relieving
officer did not check either. After the wing day staff came on duty, officers began
unlocking the cells. At approximately 8.20am, one of the officers opened the cell and
found the man hanging from a makeshift wooden block glued to his wall. The
officers responded quickly and cut him down, but they were aware that he had been
dead for some time and there was nothing they could do. Healthcare staff were
called, as was an ambulance. Healthcare staff attempted resuscitation despite the
fact that he was clearly beyond revival. When the paramedics arrived, they
pronounced the man’s death.
Staff and prisoners at Dovegate described him as a quiet person. Everyone said
that he was difficult to interpret because he always seemed to have the same
4
expression on his face. Nobody appeared to have any idea that he felt low or was
struggling to deal with any problems. In fact, they felt the opposite and believed he
was being more positive about dealing with things. In the letter he left to his sister,
the man talked about “pretending” and “putting on a brave face”. Sadly, this seemed
to have worked and the people he came into contact with thought he just had a quiet
personality. All of those to whom my investigators spoke said that his death was a
complete shock.
5
INVESTIGATION PROCESS
1. My office asked for all the relevant prison documents including the man’s core
prison records, medical file and recordings of monitored telephone
conversations. My investigators also visited the prison with the clinical
reviewer.
2. Notices to staff and prisoners were sent to the prison to be displayed. They
invited anybody with information to talk to my investigators. Apart from the staff
and prisoners whom my investigators identified to interview, two other prisoners
asked to speak with them. Neither prisoner knew the man, but they wanted to
talk about self-harm in general and mental health services on the Therapeutic
Communities. There were several prisoners, including the man’s closest friend
on the wing, whom my investigators asked to speak to. These prisoners
declined to be involved in the investigation.
3. Dovegate commissioned its own internal investigation into the events
surrounding the man’s death. We have seen the findings of the internal
investigator, which are consistent with my own. Additionally, the internal
investigator reported on some security issues which are neither related to the
man’s death nor within the remit of this investigation. I therefore make no
comment on these other matters.
4. Two staff were suspended when it transpired that full roll checks had not been
carried out by outgoing night staff and oncoming day staff. The officers were
still suspended when my investigators carried out their interviews. From the
written statement provided by one of the officers and the findings of the prison’s
internal investigation, my investigators were able to get the information they
needed and have therefore not sought to further interview the two officers.
5. A review into the man’s clinical care in prison was commissioned and carried
out by a panel on behalf of the local PCT. The review was received by my
office on 24 October 2008.
6. HM Coroner for Staffordshire was informed of my investigation. The Coroner
has kindly shared the post mortem with my investigators. He will receive a
copy of this report.
7. The man’s wife was identified as his next of kin. One of my Family Liaison
Officers has been in contact with her and three other family members to offer
them the opportunity to be involved in this investigation. The issues raised by
the family are as follows:
 The man’s wife would like to know why he was not checked on during the
night. She feels that he was depressed and wonders why nobody picked up
on this.
 The man’s brother and sister would like to know how he was able to make
and hide the items used for a ligature point as well as having the tablets he
took so that he felt no pain. They also asked why their brother was not
checked on during the night.
6
HMP DOVEGATE
8. Opened in 2001, Dovegate is a category B prison for adult male prisoners
sentenced to over four years. It is managed by Serco under contract to the
National Offender Management Service (NOMS). It currently holds up to 860
prisoners. This is made up of 660 in the main prison and 200 in the Therapeutic
Community.
9. Healthcare services in Dovegate are provided by Serco Health. There is a
relatively new healthcare management team. The healthcare manager had
been appointed at the end of 2007 and the deputy at the beginning of 2008.
The new managers are currently reviewing the existing policies and procedures
of the healthcare department.
10. Her Majesty’s Chief Inspector of Prisons has recently carried out an inspection
of Dovegate but her report is not yet published. The last published inspection
(unannounced) of the Therapeutic Community was August 2006. The Chief
Inspector found that the TC, “remained a largely safe and well controlled place
with impressive levels of peer support and self-management that distinguish
successful TCs. Reception and induction were effective, bullying was under
control, levels of self-harm were low, there was little evidence of drug misuse
…” The Chief Inspector also found that prisoners in therapy received, “very
good support from staff, while those outside therapy had a less positive view.”
11. An area of concern was the number of prisoners who had opted out of therapy
but had not been returned to the sending prison or been allocated elsewhere.
This put a strain on the TC and the discipline issues on the wings
disproportionately involved them.
12. The Independent Monitoring Board (IMB) also has concerns about the
unsettling effect caused by the number of prisoners no longer in therapy. My
investigators spoke to the IMB member with TC responsibility. She reiterated
the concerns about moving prisoners on. She did, however, say that the new
Director (in post since February 2006) had made a large number of
improvements to the prison as a whole. The IMB member acknowledged that
the Chief Inspector’s report for the main prison (2006) was not positive in all
areas, but that since 2006 the Director had improved areas such as safety and
purposeful activity.
7
THERAPEUTIC COMMUNITIES
13. There are currently five democratic TCs across the prison estate (these differ
from drug treatment TCs). Dovegate is the largest, comprising four units of 40
places each, a High Intensity Programme Unit (HIP) with 20 places, and an
Assessment and Resettlement Unit (ARU) with 20 places.
14. The treatment model for TCs is described in the Information for Offender
Managers and Offender Supervisors as follows:
“Therapeutic Communities provide group therapy and structured
community living where members are encouraged to have shared
responsibility for day to day decision making and problem solving. TC
intervention centres on addressing the risk factors and offending behaviour
needs that inevitably emerge in this environment.”
The key features include:
 “Daily group or community meetings
 Use of community activities to promote skill development and
generalisation, e.g. work assignments, delegated responsibilities,
organising events, involvement in prisoner/staff committees
 Staff supporting the community in democratic decision making and
providing pro social role models
 Staff and prisoners challenging and giving feedback about behaviour that
is anti-social or linked to offending behaviour patterns
 Opportunities to participate in additional therapies such as Art Therapy
and Psychodrama.”
15. Residents1 who apply for, and are accepted, are expected to remain on the TC
for at least 18 months. There are set criteria for applications onto a TC. At
Dovegate these include: 1) no positive mandatory drug test in the preceding six
months; 2) not on a self harm monitoring form for the preceding four months.
16. All new candidates for the TC initially stay on the ARU for a period of
assessment (usually 28 days). After this, if accepted, they are allocated to one
of the four units.
17. If residents choose to leave the TC they need to fill out a ‘48’ form. Their
decision to leave is discussed in small therapy groups, community groups and
by the staff. The resident has 48 hours to think about everything that is
discussed and choose whether to remain or to leave.
18. Staff elect to work on the TC and have to go through an application and training
process to determine their suitability.
19. The TC differs from a main prison wing in that it is a community run in a
democratic manner. The atmosphere tends to be more relaxed than on a main
1 In Therapeutic Communities, prisoners are referred to as ‘residents’.
8
wing. There is a higher ratio of staff to residents and, as a result, there is more
interaction between everyone on the unit. The therapy process can be very
intense. Residents are often reliving very traumatic experiences in their
discussion groups.
Small therapy groups
20. Staff on the units also act as group facilitators. The community is divided into
small groups of a maximum of ten. They are used for discussing any problems
or anything a resident might wish to talk about in line with the therapeutic
process. This could be anything from sentence issues to childhood problems,
and residents share their experiences. The community as a whole also meet
for group discussions, which are usually about issues affecting life in the
community rather than individual problems.
Family relationships course
21. The Family Relationships Course consists of four modules. It aims to develop
parenting skills and understanding of family relationships. It also covers
understanding human behaviour in relationships and developing personal
confidence and self-awareness. The course usually runs over 12 weeks and
takes place on three days a week – Wednesdays, Thursdays and Fridays.
22. Participants are allowed one acceptable absence. In exceptional
circumstances, and if the sessions can be caught up, the tutors have discretion
to allow more than one absence.
9
KEY FINDINGS
23. The man was remanded into custody at HMP Forest Bank on 16 May 2006.
My investigator did not have the full records from Forest Bank, but they did
include an ACCT2 form dating initially from 16 June 2006.
24. The form showed that prison staff had opened an ACCT on the man after his
cellmate had approached them and handed over a razor blade with which he
said the man had tried to kill himself. The man did not want to talk to staff
about it, but at a review later that day he told staff that his wife wanted a
divorce. He said that he did not have any current thoughts of suicide or self
harm but staff set up a support plan and continued to monitor him for the next
six days.
25. The ACCT was closed on 22 June. The man said he had had contact with his
wife and the situation had improved. He told staff again that he had no
thoughts of harming himself. However, later that day another prisoner told
staff that the man had said he was going to harm himself because he was no
longer on an ACCT. A review took place and he again told staff that he was
fine. Unfortunately, some of the sheets are missing from the second form, but
it appears that he was monitored overnight and the book closed on 23 June.
26. He attempted to hang himself on 4 July, although there is no copy of the ACCT
document in the files my investigator received. The medical record has an
entry by the mental health in-reach team on 5 July, after a meeting with the
man. The entry shows that he was upset about his wife wanting a divorce and
was paranoid that she was seeing another man. (In a log of key events in his
life, written as a therapy exercise, he said he was also upset about his
imprisonment and he had heard that the victim of his crime had died (of natural
causes).) He told the mental health in-reach team that his “head was done in”
and that he “felt ashamed” and regretted what he had done (a reference to the
suicide attempt). He said that he was “fortunate to be alive and had not
thought about family. No thoughts to do so again – feels has learned a lesson.”
He told staff that he believed his suicide attempt had been unsuccessful for a
reason. (In various other documents through his period in custody he said the
same and appeared to be looking forward and attempting to sort his life out.)
27. The man was transferred to the healthcare unit for two days on an open ACCT.
He then moved back to the residential wing, still on an open ACCT. He was
prescribed anti-depressants (Citalopram), but did not feel they were of benefit
and so stopped taking them. The records do not show when the ACCT
document was closed, but from a separate assessment form it would appear to
have been on 13 July 2006.
28. After appearing in court on 8 August 2006, he was taken to HMP Manchester
rather than returning to Forest Bank. (Due to population pressures within the
prison estate, it is a regrettably common occurrence for prisoners to leave one
2 Assessment, Care in Custody and Teamwork (ACCT). A monitoring form and process for
supporting prisoners at risk of harming themselves.
10
establishment to attend court in the morning and return to another in the
evening.) His prison records did not immediately follow him, and on 22 August
a Community Psychiatric Nurse (CPN) logged in the temporary medical file that
his full notes were still unavailable. The CPN assessed the man and found no
current evidence of mental illness or thoughts of self harm. The CPN waited for
some further information from Forest Bank which was received two days later
on 24 August 2006. This confirmed his previous suicide attempts. The CPN
referred the matter to healthcare managers and was going to speak to relevant
staff at Forest Bank.
29. The mental health in-reach team at Forest Bank faxed a discharge summary
sheet to Manchester. The summary showed that the community counsellor
had been contacted by Forest Bank and he continued to see the man in prison.
The man was reported to have felt “brighter in mood and more optimistic re the
future”. He had gained employment as a wing cleaner and did not feel the
need to take anti-depressants at that time (at Forest Bank).
30. The mental health in-reach team at Manchester did not take him onto their
caseload because, when they assessed him, he was showing no signs or
symptoms of mental illness. In fact, since being at Manchester he had become
a Listener3 on his wing.
31. The next entry in his medical record relates to a hand injury for which he
regularly took painkillers. There are several medical contacts and treatments
relating to this and chest problems throughout the rest of his time in prison.
32. The man returned to court and was convicted in October 2006. On 7
November, he received an Indeterminate Public Protection sentence4 with a
tariff of two years and nine months.
33. The records show that the man was eager to go to a TC to help him come to
terms with his childhood abuse and address his offending behaviour. The TC
at Dovegate received a self-referral from him in May 2007. On the form,
applicants are requested to fill out a question regarding self harm and suicide.
He answered the question as follows:
“… I hung myself in July 06 at Forest Bank. It was for a number of
reasons. At that time I really didn’t want to be around any longer. I
had messed up once again after doing so well for so long. I thought I
had lost everything good in my life. And I felt a lot of guilt as the victim
of my offence died and at the time I thought it could have been down to
me and my co-accused. It all got too much in my head, but luckily I
was found unconscious in time. I would like to stress I do not feel
3 A Listener is a prisoner trained by the Samaritans to provide a similar service within the prison.
4 An indeterminate public protection sentence is one where a minimum tariff is imposed, but the
prisoner must satisfy the Parole Board that he is fit for release and does not pose any threat to the
community. A prisoner’s risk factors are identified by psychological assessments and they are
required to complete prison courses that might help to reduce their risk and improve their chances of
being considered for release on licence.
11
suicidal anymore. It actually done a lot of good as I have come to
terms with a lot and it woke me up.”
He concluded the referral by saying, “I want to be a ‘normal’ person and be
there for my children, with a normal job so I can provide for them. I want to do
normal family things and not be around any more rubbish.”
34. In a review of his sentence planning in October 2007 (at Manchester), the man
told the assessing officer that he was “coping okay” and “far better than he had
been when he first came into custody”. He told the officer that he had not
coped well due his current offence, and felt that everything he had tried to do to
sort his life out had been for nothing because he had re-offended. His self
harm and suicide attempts were also discussed. He told the officer that, “at
present there are no issues of self harm or suicide”.
35. The Director of Therapy at Dovegate told my investigators that the man was
initially turned down for the TC due to security reasons involving drugs. The
man wrote to Dovegate that he was confused and unsettled by their decision.
He also made a complaint to Manchester in which he mentioned preparing
himself for going to therapy. After some liaison with Manchester and the
assurance that the security information was circumstantial, Dovegate agreed to
review their decision. On 19 December 2007, Dovegate wrote to the man to let
him know he had been accepted for assessment for the TC.
36. On 31 December, the man transferred to Dovegate. When he arrived he had a
reception health screen. He told the nurse of problems with collapsed lungs.
The nurse (a registered mental health nurse) noted no signs of mental health
problems. He was a little unsure about how the TC ran, but accepted that that
was normal. The nurse noted that he had no thoughts of self harm or suicide.
37. As per procedure, the man initially lived on the ARU for further assessment and
suitability checks for the TC. The wing history sheets from the unit show that
he settled and attended all the relevant groups. They also note that he was
generally quieter than other members of the community but that his confidence
was growing. In his Personal Goal Schedule (used to highlight particular
problems residents will try to address) the man chose the following as his
goals:
Short term: “to get selected for the TC.”
Medium term: “to get a better understanding of what happened to me and
why.”
Long term: “to be at home and be a dad to my kids with the past behind
me where it belongs.”
When writing how he would achieve these goals, he cited talking, trust and
being “… open and honest with the community to be able to get something
from it”.
38. Nearly a month later, on 25 January 2008, the man was selected for a place on
the TC. He moved to TC ‘D’ into cell number 3. This cell is a safer cell, which
12
should mean that there are no ligature points. There are three such cells on
the unit. Due to space on the unit, the cells are not solely for anybody at risk of
self harm and can be used for any prisoner on the unit. The man was given
cell 3 only because it was available, not for any concerns of self harm.
39. It took him a while to settle once on the TC and, at one point early on, he
wanted to transfer to another prison. A lot of his anxiety was about his
progression through the prison system. He was worried about the situation for
those with indeterminate sentences and believed that, as a category C prisoner
going to do therapy in a category B prison, he would not follow the natural
progression to a category D prison. Staff on the wing explained that this was
not the case and that he could, if applicable, move from Dovegate to a category
D prison.
40. The Prison Custody Officer (PCO), one of the community small group
facilitators, told my investigators that the man came across as having problems
with trust. He initially found it difficult to open up within the group. It was
thought that this was because there were people on the unit who were from the
same area outside prison as him, and because he believed that some were not
taking therapy seriously. He did not, at the beginning, want to divulge the
childhood abuse issues. The PCO told my investigators that the staff worked to
motivate the man. He was one of the first TC residents to be referred for a job
in the main prison canteen, and by this point was happy to remain at Dovegate.
41. Before getting the job in the canteen, the man attended the pottery class as
part of his education timetable. The course was due to come to an end
because the tutor was leaving. This was when he applied for the job in the
canteen. He also enrolled on the Family Relationships Course and started it on
14 May 2008.
42. As with other courses, he underwent an assessment to determine his
motivation and suitability for the programme. He told the tutors about his
childhood, his family and his offending behaviour. The assessment shows that
he found social interaction difficult even with family members (the exceptions
being his older sister and his wife). He wanted to do the course so that he
would not “find it so hard to sit and talk to people or find a way to make it
easier. To help find a resolution to difficulties with mum.”
43. A tutor on the course described the man as ‘quiet’ when she assessed him and
took this to be his natural demeanour. She said at interview that he worked
well in small groups, and would give input when necessary, but preferred
working with the quieter people rather than those who were boisterous.
44. One of the exercises on the course involved making a ‘life snake’ (like a
ladder). It is a tool to record memories at different rungs (stages) through a
participant’s life. The man reflected on the abuse he had suffered when in
care. He told the tutor that he did not want to be specific about events and did
not want to talk about it, and she said that he did not have to. He
acknowledged that looking at family units would be difficult, but the tutor said
that he persevered and did all the work which was required of him.
13
45. During his time at Dovegate, the man had contact with the healthcare unit in
relation to his hand injury and chest problems, for which he received
medication as necessary. At various consultations he was prescribed anti-
inflammatories (Diclofenac) and painkillers. The last consultation was on 30
May following a computed tomography (CT) scan on his wrist. He was
prescribed Diclofenac and Acupan (painkiller).
46. On 2 June, the man telephoned home at 8.11am. He had tried twice earlier
that day but had been unable to get a response. He discussed a planned visit
(his wife, children and brother) for 21 June. He telephoned one of his brothers
at 12.19pm, and they also spoke about the visit which his brother said he
needed to change to 22 June. At 5.00pm, he telephoned his wife again. He
told her about the visit change and repeatedly asked her if something was
wrong. He telephoned his wife again at 6.28pm. He told her that he had
started a job in the prison canteen. This was the last conversation he had with
his wife.
47. The following day (3 June 2008), the man telephoned his brother (at 2.06pm
and 7.35pm) and one of his sisters (at 6.06pm). During these calls he shared
his concern that his relationship with his wife might be over. He had been
unable to speak to his wife or children since the previous evening. In the
telephone calls to his brother, he asked if he would still bring the children to the
visit on his own if there were problems with his wife.
48. The man did not attend the Family Relationships Course the next day
(Wednesday 4 June). The tutor checked to see why and was told that he was
sick. Later that day the man received a letter. Although the prison do not
record who letters are from, by comparing the telephone list it would appear
that this was the letter from his wife asking him not to contact her any more. At
5.07pm that evening, the man telephoned his sister and told her that his wife
“has gone” and he explained about the letter. He also told his sister that he
had been unable to get through on the telephone to his wife and children since
2 June. This was the last telephone conversation he had with anyone.
49. In interview a friend on the wing said, that he was aware that the man had
received a letter from his wife earlier in the week saying that she did not want
him to contact her any more. The friend spoke to him about it and suggested
that it might be alright in a week or two, but the man had said it would not. The
pair did not talk about it much more, although the friend said that the man was
down in mood and did not want to take part in the Family Relationships Course
they were both participating in.
50. The friend said that, prior to the man receiving the letter, he had regularly been
on the phone during the day to his wife and children. But in the days before his
death he did not use the phone as much. The records confirm that he did not
make any telephone calls after 4 June. The friend remembers that, on the
Saturday the man died, he had been more like his old self on the wing. The
pair had shared some banter and the friend said he was glad to see the man in
better spirits. He was very shocked the next morning when he heard that he
14
had died because he felt that his mood had picked up (and that in the TC
people could be more open about their feelings and problems).
51. At interview, the tutor said that on Thursday 5 June, the man arrived at the
Family Relationships Course classroom, but asked if he could be excused.
She had already allowed him the absence on Wednesday. He told her that his
“head wasn’t in it” and that he was finding the course difficult. He then told her
that he had received a letter from his wife ending their relationship, and wanted
some time off. There was some discussion about absences and remaining on
the course. The man told the tutor that he probably would not attend the
following day (Friday) either, and accepted that he would probably lose his
place on the course. The tutor said that he was “subdued” but that that was
how she had always found him to be. Another tutor took him back to the wing.
(the second tutor’s email to the internal investigator gives the date as 4 June
although this is then marked out in pen to 5 June but back again to 4 June.)
52. The second tutor told the therapy manager that the man would not be attending
the course that day and that he had received a ‘Dear John’ letter (a phrase
denoting the ending of an intimate relationship). The therapy manager went to
speak to him. The man told her that he was having some problems with his
wife. Although it is usual practice for a resident who does not attend a class or
work through choice to remain in his cell for the day, he asked if he could go to
his work. He told the therapy manager that he did not want to be behind his
door and wallow in the problem; he wanted to be active and keep his mind
focussed. Although aware that this would cause some friction with other
parties, the therapy manager agreed that it would be best for the man and let
him go to work at the canteen. Neither member of staff recorded this
information in his wing history sheet.
53. My investigators asked the therapy manager about her view of the man’s mood
at the time. She said that he did not seem emotional. Although she could tell
he was sad, she felt that he was quite positive. She believed that, by asking to
do something different rather than worry about the problem, he was acting
positively. At interview, the therapy manager said that she thought it was a
change because normally he would avoid problems. She believed he was
being positive and proactive.
54. On Friday 6 June, a second PCO took the man across to the canteen. They
had to wait for a long while at one of the gates while a roll check took place. At
interview, the PCO said that the man talked about his wife and children and the
problems he was having. The PCO told the man that his wife perhaps just
needed some space and that she might still let him have contact with the
children. The PCO said that the man smiled at that thought. He did not think
that he was very sad, but that he was trying to think positively about the
situation. The PCO said that, later that afternoon, the man was doing what he
usually did: listening to music in his cell.
55. Later that day, a researcher (who the prison had contracted) was on TCD
asking residents a variety of questions about life on a TC. The therapy
manager sat in on one of the sessions where the man was present, and recalls
15
him being forward thinking in his responses and that there was no indication at
all of the events to come.
56. My investigators asked the therapy manager what the normal procedure would
be if somebody received something like the letter the man had from his wife.
The therapy manager said that staff would speak to the person and also
encourage him to use their small group as a support network as well as staff.
She confirmed that it would not automatically mean that somebody was put on
an ACCT, that the person would be assessed in terms of how they seemed to
be coping and their behaviour: for example, withdrawing etc. She said that, in
the man’s case, there were no signals and everyone felt that he was trying to
deal with his problems in a different way than he normally would i.e. forward
thinking and being positive.
57. A third PCO who has worked on the TC for three and a half years, remembers
speaking to the man quite a lot during the week before he died. She was
unaware of the letter but knew that he was having relationship troubles. He
had told her that his wife had “done a runner” and that he had not had contact
with her. He also told the PCO that another woman he had had a child with
was back “on the scene,” and this was causing problems in his relationship with
his wife. The PCO had offered to help or to contact his wife for him, but he
declined the offer. He told her that he was going to ask his brother to go
around and see his wife.
58. Nevertheless, the man did ask the third PCO to see if she could sort something
out to enable him to return to the Family Relationships Course the following
Monday. The PCO said she would try. When my investigators asked her for
her view of the man’s’ mood that week, she reiterated what others had said in
that he “stayed the same”. There did not seem to be any noticeable difference
in his behaviour.
59. On Saturday 7 June, the first PCO made a retrospective entry in the man’s
wing history sheet. He realised that nobody had recorded that he had been
working in the canteen shop that week. The PCO added this to the history
sheet, as well as noting that he had told him about “personal problems with his
wife”. At interview, the first PCO said he could not remember exactly what the
man had said but that he was unaware of the letter he had received from his
wife.
60. The second PCO was also on duty that Saturday. He signed that he had
carried out the fabric checks (check of the cell) which took place during the day.
He did not report seeing a wooden block/hook in the man’s’ cell. The PCO
said at interview that he must have missed it when he made the checks. He
remembers seeing the man throughout the day. He did not notice anything out
of character, and he queued up as usual for his meal at around 4.30pm. He
then stayed in his cell for most of the time until ‘lock up’ which was at
approximately 5.45pm (which is earlier on weekends than during the week).
61. Another resident on TCD, told my investigators that the man had told him he
had received two letters, the last being a couple of days before his death (my
16
investigators have only been given one letter). He said that the man still
participated on the TCD, and that the night before he was found dead he had
seemed no different to usual.
62. Between 5.40pm – 5.50pm, the third PCO locked the man’s door. She
remembers seeing him sitting on his bed and she said, “I’ll see you in the
morning.” She told my investigators that he said, “Yes [PCO’s name] I’ll see
you in the morning,” and smiled and gave her the thumbs up sign. She then
finished her shift about 6.00pm.
63. The second PCO was still on duty and not due to finish until 8.45pm. Between
7.00pm and 7.30pm he carried out the roll check. He remembers seeing the
man laying on his bed, having a cigarette. His television was on. He waved
and gave the PCO the thumbs up sign. He is certain that there was nothing
obstructing the observation panel in the cell door at the time and, if there had
been, says he would have made sure it was taken down.
64. The officer on night duty on 7 June came on to the wing at about 8.45pm. He
would have been required to carry out another roll check (for TCC and TCD)
and report the numbers before any of the day staff could leave the prison. The
handover from the second PCO was reportedly straightforward and he had no
issues to highlight.
65. During the night, the night duty PCO would have had to patrol TCC and TCD
and ‘peg’. (This involves ‘checking in’ at random points across the wings
through the night. It is not designed so that each cell is checked. There is no
requirement to check on residents during the night unless they are on an ACCT
or there are particular concerns.) A second resident on TCD, was on an ACCT
so the night duty PCO would have been checking on him. To get to the second
residents cell from the office he would have had to pass the man’s cell, albeit
possibly walking on the opposite side of the corridor.
66. The resident in the cell next door to the man told my investigators that all the
prisoners were locked up around 5.45pm on Saturday 7 June, as is customary
on a weekend evening. He said that the TC residents watch television, listen to
music or read books in the evening. He said that residents do not generally
speak to each other out of the windows when they are locked up, and that he
did not speak to the man that evening.
67. The resident next door said that around 10.30pm – 11.00pm he heard a
banging noise from the man’s cell, but thought nothing of it at the time. He felt
that with hindsight there might have been signs in his mood or state of mind,
but because residents are engaged in therapy they can sometimes be down
and upset.
68. At 11.15pm and 4.30am, the Night Orderly Officer (NOO)5 visited the TC as
part of the routine night checks. She remembers one resident on TCD being
5 The NOO is responsible for the prison at night and is in charge of any incidents or problems. During
their rounds they check prisoners on ACCTs and ask officers if there are any other concerns on the
17
on an ACCT, but said at interview that no other concerns were raised when she
visited the officer on the wing.
69. The Command Suite incident log shows that the night duty PCO called his roll
count (39 residents) in at 6.35am on 8 June. This would have been entered on
the log retrospectively. The night patrol log was also completed with 39,
although there is nowhere to fill in the time of the check. However, the night
duty PCO told the internal investigator that he started the count at 5.15am. He
told the internal investigator that the man’s cell was obscured and he had
decided not to wake him.
70. At approximately 7.00am, a fourth PCO came on duty. He took over from the
night duty who then left the prison. In his statement to the internal investigator
the fourth PCO said that he did not carry out a separate roll check at 7.00am
(as per the local policy) because in all the time he had worked at Dovegate,
oncoming staff generally accepted the word of their outgoing colleagues. The
second PCO arrived about 50 minutes later, shortly followed by two other
PCOs.
71. At just after 8.15am, the three PCOs began unlocking the cells on TCD. A few
minutes later, the third PCO opened the man’s door. She could not see him in
his bed or in the shower room and so opened the door a bit wider. She then
realised that he was sitting on the floor at the bottom of his bed, fully dressed.
The third PCO thought that the man had fainted and said, “[the man’s name]
what are you playing at?” She then noticed something like a sheet hanging
from a hook and realised it was around his neck. The third PCO screamed for
her colleague to bring the fishknife (used for cutting ligatures). She then tried
to lift the man to get the weight off his neck.
72. All three officers pressed their personal alarm bells, although only two
registered in the communications room (at 8.20am). The communications
room log shows that radio call signs Oscar 1 (NOO) and Hotel 4 (Healthcare)
were alerted to the call for assistance. The second resident, who had already
been unlocked, heard the third PCO scream and went to help. A fifth PCO had
also arrived at the cell and the second resident tried to help by getting the
ligature off. The second PCO entered the cell shortly afterwards and used his
fishknife to cut the ligature. The second resident returned to his cell. The
officers lay the man on the floor with his head in the third PCO’s lap. The fifth
PCO checked for a pulse even though the officers realised that he had been
dead for some time. The third PCO held him in her lap until the medical staff
arrived.
73. At approximately 8.15am, two Registered General Nurse’s (RGN) were
preparing to hand out medication on the main wings. One RGN remembers
that, just as the cells were being unlocked on the wing, an alarm came over the
radio (at 8.20am). She said that the message from the communications room
was not clear, and the nurses did not know the location or if they were needed
wing; they also make sure that the officers have filled out the forms relevant to night duties. The NOO
does not check individual cells.
18
immediately. When she was sure that it was a medical emergency and knew
the location, she picked up an emergency ‘grab bag’ (medical equipment) and
oxygen (although not a defibrillator) and started running to TCD. When she
arrived at the security gates, her colleague, also running, had just arrived.
74. At this point, neither nurse knew exactly what they were responding to. In
interview, one of the RGN’s said that it took them a couple of minutes to get to
the unit and that they walked at a fast pace from the gates (after running to the
gates). She said that there are usually three nurses on duty on a Sunday, one
for the TC and two for the main prison. On the day that the man died they were
short staffed. There were only two nurses on duty, both in the main prison at
the time he was found.
75. The incident log kept by the Unit Manager, shows that at 8.24am she had
called for healthcare assistance again. However, this is not recorded in the
communications log. When the nurses arrived at the man’s cell (at 8.24am),
officers had already cut him down and laid him on the floor. One RGN said
that, from her medical experience, she could see that he was dead but she is
not authorised to pronounce death. Both nurses assessed him to see if he had
a pulse or blood pressure reading but could not find any. His pupils were fixed
and dilated. The nurses were of the opinion that rigor mortis had set in.
However, both nurses believed that, because they could not pronounce death,
they had to commence cardio pulmonary resuscitation (CPR). Neither nurse
was aware of the prison’s ‘death in custody’ contingency plans and PSO 2700,
Annex 136, which state that CPR does not have to be attempted if rigor mortis
has clearly set in. The log kept by the Duty Director records that CPR was not
attempted by the officers, but does not record that CPR was attempted by the
nursing staff. At interview, it was discovered that that neither nurse had up to
date training in CPR.
76. Several incident logs were kept but none captures all the information and the
timings differ. The communications log does not record the emergency
services response. The timings which follow are taken from the incident logs
recorded by the Unit Manager, Duty Director and the officers stationed outside
of the man’s cell. Oscar 1 completed a log in the contingency plans but the
timings are all different to the other logs and do not correspond to other
evidence available.
77. An ambulance had been called at 8.32am by Oscar 1 following a request by the
first RGN on scene. The Duty Director’s log records the paramedic first
response arriving on TCD at 8.43am. The officers at the cell record the time as
8.48am. The officers’ log shows the subsequent ambulance arriving at TCD at
8.57am and the man being pronounced dead at 9.00am, whereas the Duty
Director’s log does not record the ambulance arriving and says that he was
pronounced dead at 8.45am by paramedics. The contingency plans record
8.49am as the time of death. The CCTV shows the first response paramedic
arriving onto the TC yard at 8.44am and the ambulance at 8.52am. (When my
investigators viewed the CCTV they were made aware that the clock ran four
6 Prison Service Order (PSO) 2700, Suicide Prevention and Self-Harm Management.
19
minutes faster than real time and the times above are four minutes less than
the time shown.)
78. The Reverend (the Anglican chaplain) had also been called to the prison. He
arrived while the paramedics were still in the cell. He determined that the man
was Roman Catholic and so he prayed the prayer of the dead. He then spent
some time with staff before holding the Sunday service. He returned after the
service to provide support for any of the residents on the TC who wished it.
79. A ‘hot debrief’ took place at 1.30pm on Sunday 8 June. With the exception of
the third PCO, who had to seek medical treatment after hurting her hand trying
to lift the man, all relevant staff attended. Support was made available to staff
and prisoners, and the man’s death was discussed in the small therapy groups
by the community.
80. The news of the man’s death was broken to his wife by police from the
Manchester area. Additionally, the Duty Director and the Reverend travelled to
Manchester to visit the man’s wife that afternoon. The Reverend told my
investigators that the prison had offered continued support to the man’s next of
kin. The family did not wish to visit the prison. His possessions have been
returned including a budgie which he kept. They have asked the family how
they wish to keep in contact, if at all, and have left it to them to decide what
support they would like from the prison.
20
Events after the man’s death
81. One of the residents my investigators interviewed said that the healthcare staff
who responded to the call for medical assistance were walking over from the
main prison. He said that they were laughing and joking and that other
residents had been shouting at them through their windows. My investigators
have tried to look on CCTV at the route the nurses took, but there were no
cameras focussed in that direction. I can confirm that the initial call for
assistance went over the radio at 8.20am and the second at 8.24am. The
CCTV does show the nurses entering the unit at 8.24am.
82. One of the RGN’s made an entry in the man’s medical record regarding the call
to his cell. Neither nurse gave, or was aware of the necessity to provide a
written statement to the Director detailing their involvement. However, a copy
of the sheet she wrote on was collected with all the officers’ statements.
83. The second resident, who tried to assist the PCOs on scene, told my
investigators that he was very shocked when he returned to his cell. He said
that he had acted on instinct, but that he was upset and shocked at finding the
man dead. He also said that it was difficult to know how the man was feeling
because he showed nothing. The second resident had been put on an ACCT
the day before the man died. His view is that staff give a high standard of care.
He said that he approached them to say how he had been feeling the day
before the man died and they put him on an ACCT straightaway. He believes
there was little staff could do unless someone came forward and told them how
they were feeling. He said that the man told him not to self harm, so he was
the more surprised by his actions.
84. The man had hanged himself using a bed sheet attached to a block of wood
that had been glued to the wall and painted over. It is not known how he got
the block of wood, but he most likely obtained the glue and paint from the
pottery classes he attended.
85. My investigators asked some of the officers on the wing what they would do if
they saw an item such as this in a cell. The officers said that they would
remove any unauthorised items. The officers were also asked about
obstructions on a resident’s observation panel. Each officer said that they
would get them removed. The third PCO said that, if necessary at night, she
would ask the NOO to come to the wing and open the cell door.
86. Wing staff were also asked if they were aware of the man’s previous suicide
attempt. No staff interviewed had any knowledge of this prior to his taking his
life. It appears that wing staff receive minimal history records when a resident
takes his place on a wing.
87. Various items were taken from the man’s cell after his death. There were two
letters that he had written (one to one of his sisters and the other to the staff of
TCD). The letters go some way to explain his state of mind shortly before his
death. In the letter to staff, he thanked them for how they had been with him
and how they had helped him work through the issues of his childhood abuse
21
so that he was no longer ashamed of himself. He wrote that the staff might find
it “silly” that he was taking his life because his wife had left him, but he
explained that it was more than that. He did not want to live without his
children and, because he had had a vasectomy, he did not consider a new life
with a new partner to be a possibility. He explained that he could not handle
the thought of “existing” in prison and then being on his own when he was
released. He left instructions for who he wanted contacted (his brother and
sister) and messages to be passed to his friends on the wing. He also asked
that his budgie be given to his stepdaughters.
88. The man wrote that he had taken some illicit drugs on the Wednesday before
his death because he had planned to take his life then. He explained that he
had felt horrible (possibly meaning the effect of the drugs,) and was going to
speak to staff, but when his door opened he was taken for a drug test. He felt
that if he told staff then it would look like he was trying to cover up for taking
drugs. He wrote that the night he took his life he had taken “plenty of tablets”
(these appear to refer to prescription tablets rather than an illegal substance).
He reiterated that he had dealt with his childhood issues, but felt guilt that the
victim of his crime had since died and that he could no longer handle being in
prison. He wrote that all he wanted was a family and to be a proper father. He
felt that he had lost all that and would not even get a Father’s Day card. The
man did not want anyone to blame his wife because she had “stuck by” him for
years.
89. In his letter to his sister, he repeated how he felt about his family and his future.
He added that he was “sick of pretending everything is ok and putting on a
brave face when inside I’m in bits.” He wrote that he had planned to take his
life for a while, and that he had obtained the “thing to put on me wall months
ago and grafted to get it up. I’ve grafted tablets to put me out of it.”
90. Other items found in the man’s cell included the following medication:
 One paracetamol tablet. There is no log of this in his medical record at
Dovegate, and the last prescription was at Manchester. It is possible he
obtained it from another resident or it was not recorded by healthcare staff.
 Three aspirin tablets. There is no log of these tablets in his medical
record. As before, it is possible that he obtained them from another
resident or it was simply not recorded.
 One bottle of Omeprazole (used to reduce stomach acid) containing 11
capsules, issued on 6 March 2008.
 One box of Diclofenac (anti-inflammatory) tablets containing 84 tablets. A
14 day supply was prescribed on 30 May for the wrist injury and issued on
2 June 2008. The dosage is not logged but a previous prescription (March
2008) showed that one tablet was to be taken twice a day.
22
 One bag of Nefopam (Acupan) (a painkiller) containing 16 tablets. A
seven day supply was prescribed for the man’s wrist injury and issued on
3 June 2008.
91. The toxicology report showed that the man had codeine in his urine screen,
but this would be consistent with a therapeutic dose and was unlikely to have
been associated with his death. It is not known where he obtained the
codeine because he had not been prescribed any codeine based medication
whilst at Dovegate. In contrast to what he wrote in his suicide note, the
toxicology report does not suggest that the man had taken a lot of medication
before he died.
23
ISSUES CONSIDERED
Emergency response
92. In Dovegate’s local policy - Director’s Rule PROG016 - ACCT “The
management and prevention of Suicide and Self Harm” - chapter 3 advises on
“required actions following incidents of self-injury”. The following is instructed if
a prisoner is found hanging:
 support the body to reduce constriction,
 cut the prisoner down – using the fish cutter provided,
 cut and then release the ligature,
 place the prisoner on his back on a flat, solid surface,
 check for signs of life, if none present, clear airway and attempt
resuscitation using a face mask with a non return valve unless rigor
mortis of the limbs has clearly set in. (The national Prison Service Order
(PSO) 2700 in relation to self-harm and suicide gives the same
instructions in relation to hanging.)
93. Dovegate’s contingency plans for “Death in Custody” however, instruct those
first on scene to “… always attempt resuscitation using your airway mask, do
not assume death.” The plans also give instructions to use a colour code to
alert staff to the problem, for example “code blue for hanging”.
94. The emergency call for assistance on 8 June did not provide healthcare staff
with enough information. The two nurses on duty were in different areas of the
prison from each other and the TC. Neither nurse was aware of what they
were responding to, or initially where they needed to go. One nurse took an
emergency bag, but did not take a defibrillator.
95. It appears that the man died some time between 10.00pm and midnight the
night before, and therefore the emergency response and equipment would not
have made any difference to the outcome. However, this will not always be the
case.
96. In another recent death at Dovegate, I made a recommendation that the
emergency response system should be reviewed and clarified. This
recommendation was made after the man’s death. I am pleased to note that in
response to that recommendation a review is taking place.
97. The officers who found the man did not attempt CPR. They believed that he
had been dead for a long while and that rigor mortis had set in. In accordance
with PSO 2700, staff are not expected to carry out CPR in this circumstance.
However, the nursing staff were unaware and, even though they believed him
to be dead, thought they had to attempt CPR. .
98. My investigator has compared the local and national policies for responding to
somebody found hanging. There are discrepancies between Dovegate’s
‘Death in Custody’ contingency plans, their ‘Management and Prevention of
Suicide and Self Harm policy’ and PSO 2700 in relation to the same. It would
24
seem that these discrepancies led to the nurses attempting CPR on someone
who was clearly dead. This was not respectful to the memory of the man and
must have been traumatic for the nurses themselves.
99. In the Key Findings section of my report, I have indicated that several logs were
kept by various members of staff after the man was found dead. I appreciate
that there may be small differences in times recorded on a clock or according to
an individual’s watch. However, at two points the officer at the cell’s log
differed from other logs by up to 15 minutes.
100. Not all relevant information was recorded in the appropriate logs either. For
instance, the arrival of the paramedic and ambulance is not in the
communications log. Additionally, the communications log has “approximate”
timings. These examples can cause confusion and doubt, particularly if CCTV
of particular areas is not available.
101. Although one of the RGN’s made an entry in the man’s medical file regarding
the medical response, neither nurse provided a written statement as per the
requirements of the contingency plans. Additionally, as I have said, the nurses
were not aware that they did not need to attempt resuscitation if rigor mortis
had clearly set in.
I recommend that the Director revises the local policies at Dovegate
relating to ‘Deaths in Custody’ and the ‘Management and Prevention of
Suicide and Self Harm’ to ensure that they are consistent with each
other and national policy. The Director should also ensure that the
agreed policies are made clear to all staff. This should include
emergency response codes, and a first on scene protocol.
102. The nursing staff who responded to the man had not received an annual
update for resuscitation and emergency life saving techniques. The training
records of the wing staff were not checked for this investigation. However, any
first aid trained staff, whether medical or operational, should have the regular
refresher training.
I recommend that the Director and Head of Healthcare ensure that all
relevant staff receive refresher training in life support as soon as
possible. This should be monitored annually.
Medicine Management
103. A quantity of medication was found in the man’s cell after his death. With the
exception of paracetamol and asprin, the medication was prescribed to him.
None of that which was prescribed is codeine based and it is not known where
he obtained the codeine based medication which was in his system.
104. In relation to the type of medication he had in his cell, all were within the ‘in
possession’ guidelines. This said, he should not have had this quantity in his
cell. In my investigation into the previous death at Dovegate to which I
referred, in-possession medication was also an issue. I recommended that a
25
review of in-possession medication should take place. I am pleased to report
that this policy is being reviewed and the return of unused medication will be
incorporated into the review.
Ligature points
105. The man was in a safer cell although, as previously mentioned, this was not
because staff felt he was at risk of self harm. Nevertheless, this cell should
have reduced ligature points.
106. My investigator received minutes of three Prisoner Information and Activities
Committee (PIAC)7 meetings, these being from September and October 2007.
A concern across the prison was lack of space to hang clothes. The prison
were looking at ways of dealing with the matter, but it was made quite explicit at
the meeting on 20 September 2007 that wall hooks were only to be stuck down
with an adhesive sticker. The reason that hooks and hangers (other than those
authorised) had previously been removed was because the Director thought
that they could be used as a ligature point.
107. It is tragic that this risk had been raised - and some makeshift hooks had
already been removed across the prison several months prior to the man’s
death - yet he was able to use this very method. He told his sister he had
planned it and had obtained the block “months ago”. He appears to have used
glue and paint available in the pottery class to attach the block to the wall. I am
aware that the pottery class had ended some time before he took his life.
108. It is difficult to comment whether he had these items expressly for the intention
of making a ligature point or where he obtained the wooden block from. If he
had been collecting items as he said, including the block and medication not
prescribed to him, it might suggest there were reasons other than the ‘Dear
John’ letter that led to him taking his life.
109. Fabric checks of the cells are carried out daily. None of the officers said they
noticed the block during the fabric checks. Again, it is not possible to confirm
when exactly the man stuck the block to the wall. The police suggest that it
must have been before the night of his death because it took a degree of force
to remove it.
110. The Director and prison managers are already aware of the risks of such
makeshift hooks. Albeit that some unauthorised hooks or shelves are put up
for legitimate storage solutions, they remain unauthorised.
I recommend that the Director reinforces the message that unauthorised
items must be removed without delay, and ensures that officers do not
become complacent but more vigilant when carrying out cell fabric
checks.
7 These meetings discuss residential matters, usually one subject per wing. The IMB report that the
mood and atmosphere of the prison is well measured at these meetings. Staff/Prisoner relationships
had also improved as a result. They are held on the TC as RIAC – the ‘R’ being for ‘residents’.
26
Roll checks
111. Roll checks are carried out four times a day at Dovegate. It is also routine
practice nationally for night staff to carry out their own roll check when they
start duty and before going off duty. Oncoming day staff are expected to do
their own count. From the reports of staff, it appears that this is the way it
should also be done at Dovegate. However, this is not explicit in Director’s
Rule SEC061 (Roll Checks), nor are the instructions clear in Director’s Rule
SEC002 (Night Procedures).
Director’s Rule SEC061 – ‘Roll Checks’
112. Paragraph 1.1 in the policy states: “HMP Dovegate will perform at least four
complete counts per day, during which every prisoner will be accounted for.”
At paragraph 2.1 times are given when routine checks should be carried out.
They are as follows:
Roll check times Monday-Friday Weekends
Before morning 0600hrs 0700hrs
unlock
At lunch time 1245hrs 1300hrs
At teatime 1800hrs 1800hrs
After lock up at night 2045hrs 2045hrs
The policy does not incorporate Night Officers’ roll checks.
Director’s Rule SEC002 – ‘Night Procedures’
113. At paragraph 4.2.4, instructions are given for the Night Officer to do the
following once s/he has arrived on duty:
“The Night Officer must ensure that they check that all the prisoners
are accounted for by actually seeing the prisoner in his cell, or
confirming that a person is present by gaining a verbal response from
the prisoner if required. This procedure is normally carried out at the
same time as the cell doors are checked.”
The procedures do not give any instructions for carrying out the same check
at the end of a shift.
114. The second PCO carried out a roll check between 7.00pm and 7.30pm on 7
June before the end of his shift. The night duty PCO signed that he started
duty at 8.45pm and for the roll at the beginning of his shift and the end of his
shift. The end of shift roll is not timed but, in his interview with the internal
investigator, the night duty PCO said he did this at 5.15am.
115. The rules are explicit in respect that a roll check should mean seeing every
prisoner clearly and gaining a response where necessary. The night duty PCO
confirmed to the internal investigator that he had not looked into the man’s cell.
27
He had seen the obstruction over the observation panel and had decided not to
wake the man. The night duty PCO realises that he should have done this.
116. The fourth PCO, who relieved the night duty PCO from his night shift at
7.00am, took his word that the roll check was complete and did not make his
own roll count. He told the internal investigator that in the four years he had
been at Dovegate staff generally took the word of their colleagues. He had
only seen one officer carry out a separate roll check after a handover. He went
on to say that staff would not wake residents at 7.00am and would wait until
8.15am unlock to get a response from them.
117. I do not believe that the failure by the night duty PCO and the fourth PCO to
carry out proper roll checks resulted in or affected the man’s death. However, it
is very poor practice. The prison’s internal investigation has already
recommended the night patrol log should make clear the duties and
expectations of night staff. I support this recommendation.
118. Additionally, the policies outlining duties and protocols should give the same
consistent message. Currently they do not adequately cover the duties and
there are discrepancies between the ‘Roll Check’ policy and the ‘Night
Procedures’ policy.
I recommend that the Director reviews the policies on ‘Roll Checks’ and
‘Night Procedures’ to ensure they are consistent with each other and
national guidelines and adequately explain the duties and expectations
of staff.
119. The night duty and fourth PCO were both suspended from duty pending the
prison’s internal investigation. Both officers were disciplined. The fourth PCO
has undergone retraining in his officer duties and the night duty PCO has
resigned. Therefore, I make no recommendations in addition to the actions
already taken by the Director.
Communication and Recordkeeping
120. The clinical review panel made a recommendation regarding the sharing of
information between the TC and the healthcare team, specifically in relation to
psychological assessments which may improve risk assessment within the unit.
The panel also recommended that better communication takes place between
staff to ensure additional monitoring of a prisoner known for impulsive actions
when s/he receives bad news.
121. My investigators found that wing staff were not aware of the man’s previous
suicide attempt at Forest Bank. They also found that, with the exception of the
first PCO’s entry in the wing history sheet relating to the man’s problems with
his wife, no entry was made with regard to him receiving a letter from his wife
ending their relationship. As a result, at least two members of staff did not
know that he had received such a letter.
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122. Whilst the ethos of the TC is about therapeutic discussion and peer support,
important information such as a letter with bad news should be recorded in a
resident’s wing history sheet. All staff should be aware of an issue such as this
so that support can be made available within the small groups or the
community, even if an ACCT is not opened. The man’s family has questioned
why he was not monitored more closely after receiving the letter, given his
history in Forest Bank. I have tried to answer their questions within the Key
Findings section and below.
123. Unless a prisoner is on an ACCT there is no mandatory requirement to check
on him/her through the night. The officers on TCD did not know about the
man’s suicide attempt at Forest Bank. In practice, it is not possible for staff to
know the histories of all the prisoners they look after, especially events that
have taken place two years earlier and in a different prison. I appreciate that
this will probably not offer much comfort to his family. However, I am satisfied
that the staff on TCD (as well as other residents) had no indication of the man’s
real feelings or intentions after receiving the letter ending his marriage. I am
also satisfied that, had the staff believed he was at risk, they would have
ensured he was monitored and given additional support.
I recommend that the Director of Therapy ensures that the TC officers
receive full wing history sheets from sending prisons. The Director of
Therapy should also remind staff to log any significant events in a
resident’s wing history sheet so that all staff are aware of relevant
information.
124. Because there was no indication and, therefore, no identified need to share
information between the TC and healthcare, I do not make a formal
recommendation as per the clinical review. However, this might not always be
the situation and the clinical review panel make a valid point. The Director and
Head of Healthcare will wish to satisfy themselves that communication between
the TC and all aspects of healthcare takes place, and is open and not inhibited
by the TC criteria or medical in confidence (where possible).
Suicide and Self Harm Management
125. The man had a history of self-harm. With hindsight it could be argued that he
should have been considered for ACCT when he received the letter from his
wife. However, even when a prisoner is on an open ACCT, observation levels
vary. Unless someone is on constant observations, there is still a possibility of
self harm or suicide. Even with hindsight, I do not believe that it could be
argued that the man should have been on constant observations.
126. All of the officers who came into contact with the man and worked closely with
him during therapy, firmly believed that he was trying to work through the
separation from his wife in a more positive manner than he usually dealt with
problems. This belief was also held by the prisoners who spoke to my
investigators. There appears to have been no indication that he was going to
take his life.
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127. As I have mentioned, although the ethos of the TC is for community
discussions and support to deal with problems, it does not preclude the use of
extra monitoring on ACCT. The second resident was placed on ACCT when he
alerted staff to his feelings. I am confident that, had staff sensed that he was
not coping or if he had sought help, he would also have been placed on an
ACCT.
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RECOMMENDATIONS
1. I recommend that the Director revises the local policies at Dovegate
relating to ‘Deaths in Custody’ and the ‘Management and Prevention of
Suicide and Self Harm’ to ensure that they are consistent with each
other and national policy. The Director should also ensure that the
agreed policies are made clear to all staff. This should include
emergency response codes, and a first on scene protocol.
Dovegate has accepted this recommendation.
2. I recommend that the Director and Head of Healthcare ensure that all
relevant staff receive refresher training in life support as soon as
possible. This should be monitored annually.
Dovegate has accepted this recommendation.
3. I recommend that the Director reinforces the message that unauthorised
items must be removed without delay, and ensures that officers do not
become complacent but more vigilant when carrying out cell fabric
checks.
Dovegate has accepted this recommendation.
4. I recommend that the Director reviews the policies on ‘Roll Checks’ and
‘Night Procedures’ to ensure they are consistent with each other and
national guidelines and adequately explain the duties and expectations
of staff.
Dovegate has accepted this recommendation.
5. I recommend that the Director of Therapy ensures that the TC officers
receive full wing history sheets from sending prisons. The Director of
Therapy should also remind staff to log any significant events in a
resident’s wing history sheet so that all staff are aware of relevant
information.
In addition to these recommendations, I draw the Director’s attention to paragraphs
101 and 109 to ensure these reviews cover the issues in this and my previous death
in custody report. I also draw his attention to paragraph 129 in relation to
communication between the TC and Healthcare.
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