Individual at Leeds

Investigation into the circumstances surrounding the
death of a man at HMP Leeds
in July 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
July 2007
This is the report of an investigation into the death of a man who was found
hanging in his cell at HMP Leeds in July 2006. He had been recalled to
prison on 7 June. He was 48 years of age.
I extend my sincere condolences and those of my colleagues to the man’s
family and friends for their loss. I know that the man came from a close
family and that he will be sadly missed.
The investigation into the man’s death was carried out on my behalf by one of
my investigators. A clinical review was conducted by a doctor from the local
Primary Care Trust. I am most grateful to the then Governor of Leeds and his
staff for their cooperation and assistance with my investigation.
As a consequence of an increase in the number of prisoners who are recalled,
the Release and Recall Section of the National Offender Management Service
has seen its workload increase substantially. It seems likely that a delay the
man experienced in receiving his recall paperwork, and uncertainty over his
release date, preyed on his mind and may have been a contributory factor in
his death.
My investigation has established that the man had probably been dead for
some time when he was discovered by staff at Leeds. However, I have been
saddened to learn that his body was then left suspended for some time.
My report makes a number of recommendations reflecting my concerns about
the delay in forwarding the man’s recall appeal paperwork, and the response
by staff when he was discovered in the early hours of 6 July. More generally,
I wonder if the assessment tool currently used to help medical staff judge a
prisoner’s risk of self harm sufficiently reflects the particular needs of
prisoners who have been recalled to custody. It has become increasingly
clear to me that recalled prisoners are an especially at risk group. It is
therefore of the greatest importance that the procedures of the Release and
Recall Section of the National Offender Management Service are as efficient
as possible.
Stephen Shaw CBE
Prisons and Probation Ombudsman
CONTENTS
Summary 4
The Investigation Process 6
HMP Leeds 7
Key Findings 8
Issues 22
Recommendations 28
SUMMARY
In September 2004, the man was remanded into custody at HMP Leeds. He
was monitored as being at risk of self harm on several occasions, and was
seen a number of times by a member of the Mental Health In Reach Team
(MHIRT) at the prison.
The man was transferred to HMP Lindholme on 24 February 2005. His
records show that over the coming months he experienced a number of
emotions, from being high in spirits to feeling depressed.
On 15 September, the man was found in his cell with a ligature around his
neck and was taken to hospital for treatment. He told staff that he had heard
voices in his head. Later that day, the man was transferred to HMP Moorland,
before being sent back to Lindholme on 19 September. On 5 October, the
man was seen by a mental health nurse at HMP Wealstun who noted that
there were no concerns at that time. The man was released on licence from
HMP Wealstun on 9 December 2005.
After his release from prison, the man moved into a flat. He made good
progress in the community. He attended meetings with his Probation Officer
regularly, and undertook a number of courses addressing his offending
behaviour. During this time, the man and his girlfriend began to experience
relationship problems. In May 2006, he was arrested for allegedly driving
whilst under the influence of alcohol. As a consequence of his behaviour, his
Probation Officer made a recommendation to the Release and Recall Section
of the National Offender Management Service that his licence should be
revoked and that he should be recalled to prison.
The man was returned to HMP Leeds on 7 June. During the reception
process the man was screened by healthcare staff. He gave no indication
that he was at risk of self harm. Within days of his arrival at Leeds the man
was seen by a Registered Mental Nurse and a member of the MHIRT. The
Registered Mental Nurse had been in professional contact with the man
previously. Over the coming weeks, the Registered Mental Nurse saw the
man on a number of occasions. On 16 June, he noted that the man appeared
more settled, and during a meeting on 30 June he reached the view that the
man was not at risk of self harm or suicide.
When the man was recalled to prison, the Release and Recall Section should
within 24 hours have sent him documentation outlining the reasons for his
recall and information explaining how he could appeal. However, the
necessary paperwork was not sent until 27 June, nearly three weeks after his
return to prison. A further delay in forwarding this documentation occurred at
the prison, with the man eventually receiving part of his recall paperwork on 3
July.
The man’s prison record says that he was notably upset, and was extremely
frustrated about not receiving all of his recall paperwork on time. He threw the
paperwork over the landing and paced his cell in an aggressive manner.
However, the man received assistance from an Officer who submitted a wing
application on his behalf in order to seek an explanation for the delay.
On 5 July, the man received the remainder of his recall paperwork. He told
the Officer who delivered it that he wished to appeal against the recall
decision. That evening, the man spoke with his mother, telling her that a
prison officer had told him that he would not be released until March 2007. In
reality, the man would have been released on his licence expiry date (LED)
which was 26 July 2006. During the conversation with his mother, the man
told her that he had nothing to live for.
In the early hours of 6 July, the man was found hanging in his cell.
THE INVESTIGATION PROCESS
1. The investigation into the man’s death was opened by one of my senior
investigators. Another of my investigators, took the lead in the
investigation and was further assisted by the opening investigator when
interviewing staff at Leeds.
2. Notices announcing the investigation were issued to both staff and
prisoners, informing them of the investigation and the terms of
reference. These were displayed around the prison and invited staff
and prisoners to contact the investigators should they wish.
3. My colleagues visited HMP Leeds and were given full access to all
areas of the prison. My investigator met with the then Governor, the
Independent Monitoring Board (IMB), and made himself known to a
representative of the local branch of the Prison Officers’ Association.
The investigators obtained documentation relating to the time that the
man spent at Leeds and records relating to his previous period of
imprisonment. Interviews were conducted with a number of staff who
had had contact with the man at the prison.
4. I commissioned a clinical review from the Primary Care Trust. My
investigator spoke with the local police who confirmed that they had no
concerns with regard to the circumstances of the man’s death. I would
like to thank the Police Liaison Officer and Principal Officer (PO) for
their assistance to my investigators. A copy of this report will be sent to
the Coroner to assist him with his enquiries.
5. My investigator and one of my Family Liaison Officers, met with the
man’s parents and family at their home on 24 August 2006. During the
meeting, the family raised a number of questions with regard to my
investigation, including:
 Why was the man recalled to prison, and was his ex-girlfriend
involved in the decision to recall him?
 Who informed the man that his release date was to be
changed?
 Was the prison aware of the man’’s history of mental health
problems, and did they have access to his medical records in
order to provide him with the most appropriate care?
I trust that my report will answer these and other concerns raised by the
man’s family.
HMP LEEDS
6. Leeds is a category B local prison and accepts adult male prisoners
from courts in West Yorkshire. Built in 1847, the prison has six wings,
with 680 cells, plus room for 26 prisoners in the healthcare centre. A
new gate complex opened in September 2002, providing better access
and facilities for both visitors and staff.
7. Leeds has a maximum operational capacity of 1,254 prisoners. The
prison always functions at or near this figure.
8. Leeds was last inspected by HM Chief Inspector of Prisons in August
2005. She identified that the prison faced a number of difficult
challenges because of chronic overcrowding and a high turnover of
prisoners.
9. Since April 2004, when my office started investigating all deaths in
custody, there have been seven apparently self-inflicted deaths at Leeds.
KEY FINDINGS
13 September 2004 to 9 December 2005
10. On 13 September 2004, the man was sent to Leeds on remand
awaiting trial. In December, he was convicted of possessing a firearm
with intent to cause fear of violence. He was sentenced to two years six
months imprisonment.
11. After arriving at Leeds on 15 September 2004, an F2052SH booklet
was opened as a consequence of the man’s low mood and thoughts of
self harm. The booklet was closed eleven days later. (The F2052SH is
a document which was then used to assess and observe prisoners at
risk of self harm. The F2052SH has now been replaced by the
Assessment Care in Custody and Teamwork (ACCT) document. This
document carries out a similar function to the F2052SH, but additionally
highlights the problems, and possible trigger points of a prisoner at risk
of self harm, and develops a multi disciplinary plan to give him support
and help him through a period of crisis.)
12. On 18 November, the man was seen by a Registered Mental Nurse.
The Registered Mental Nurse told my investigators that his contact with
the man during this time was fairly positive. He said that the man spoke
honestly and openly.
13. On 27 January 2005, shortly after being sentenced, the man was again
considered to be at risk of self-harm and staff opened another
F2052SH. The booklet recorded that he was low in mood as a
consequence of being given a longer sentence than he had anticipated
and the loss of his home. Over the following days, the man was seen a
number of times by the Registered Mental Nurse. During these
meetings, the man reiterated his intention to take his own life.
14. On 8 February, the man’s F2052SH booklet was closed. The review
board, attended by two members of the mental health team, recorded
that the man had made a vast improvement in his mood and that a
positive frame of mind shone through. A transfer request to HMP
Lindholme was approved. The man was looking forward to this
transfer, believing that the worst was now over.
15. The man was transferred to Lindholme on 24 February. On 29 March,
he approached an officer at the prison, telling him that he was mentally
ill, had run out of medication, and was having suicidal thoughts. As a
consequence the man was again placed on an F2052SH. This booklet
was closed, with the man’s agreement, on 6 April.
16. On a number of occasions over the coming months, staff noted in the
man’s wing history sheets that he was experiencing a mixture of
emotions. A number of entries state that he was settled and high in
spirits. However, other entries over the same period record that he was
very depressed and not taking his anti-depressants. In an entry of 28
August, it was noted that he: “keeps his distance from staff, is either up
or down, there doesn’t appear to be any middle ground with him.”
17. On the morning of 15 September, the man told his mother that after his
release he was to be sent to a hostel. He said that he was very
depressed and that he had voices in his head telling him to kill himself.
18. At approximately 2.00pm that afternoon, the man was found in his cell
with a ligature around his neck and with cuts to both his wrists. After
receiving emergency medical treatment, he was taken to hospital. At
the hospital, the man told staff he was disappointed that he had failed to
take his own life and that the thought of leaving prison frightened him.
He said that he was following the voices in his head, and it was the
devil who told him to do terrible things to himself. An F2052SH booklet
was immediately opened. Due to staff shortages on the healthcare
centre, the man was transferred to HMP Moorland later that day before
being transferred back to Lindholme on 19 September. Ten days later,
during a review of his F2052SH, the man acknowledged that when
feeling depressed he would use the support mechanisms available to
him. The man recognised that he was a manic depressive and said that
he had no intention of self-harming at that time. It was agreed by those
present to close his F2052SH.
19. On 5 October, the man was transferred to Wealstun. On 17 October,
he was seen by a member of the mental health team who noted that
there were no concerns at that time. He was released on licence from
Wealstun on 9 December.
December 2005 – May 2006
20. After his release from Wealstun, the man moved into a new flat. During
a home visit from his Probation Officer on 13 December, the man talked
about his offending, alcohol problem and his determination to make a
fresh start. At a further meeting on 30 December, the Probation Officer
recorded that the man had had a good Christmas. He spent New Year
with his girlfriend but, because of his mood, he left early, afraid that he
might get into an argument and start drinking. In early January 2006,
he started an anger management course and decorated his flat. During
this time, he continued to have contact with mental health services.
21. Towards the end of January and at the beginning of February 2006, the
man and his girlfriend experienced relationship problems. The man
apparently became low and depressed. During this period, his doctor
prescribed mild anti depressants. The man continued to see his
girlfriend once or twice a week, and told his Probation Officer that they
were both happy with the arrangement. However, at the end of
February the man’s relationship with his girlfriend ended.
22. Towards the end of February 2006, the man’s ex-girlfriend made a
complaint against him, saying that she felt harassed by him. However,
the Probation Officer believed that the accusations made against the
man did “not add up”. During a discussion with the Probation Officer,
the man’s Community Psychiatric Nurse (CPN), agreed that the man
did not appear to be harassing his ex-girlfriend. Both were of the
impression that he genuinely wanted to get on with his life. However,
the man was advised not to have any further contact with his ex-
girlfriend. The Probation Officer advised the man that, if his ex-girlfriend
were to present herself at his flat, he should call the police and not let
her in.
23. During March 2006, the man continued to make good progress, coming
to terms with the end of his relationship. However, towards the end of
March, the man’s ex-girlfriend made it known that she intended to
obtain a letter from her solicitor barring any further contact by him.
However, it was pointed out to her by her own caseworker that this
action might be seen as provocative, and that it would be inappropriate
if the letter were to be sent to the man’s support network.
24. At the beginning of April 2006, the man became upset at an Alcoholics
Anonymous meeting and went drinking. The Probation Officer
explained to him that this might not mean a relapse, and that he need
not throw away everything for which he had worked so hard. At the end
of April, the man received a letter from his ex-girlfriend’s solicitor,
barring contact with her. The CPN felt that the letter was
counterproductive and damaging, and noted that the man took the news
harder than he had initially admitted to, missing an appointment with his
doctor due to a drinking binge.
25. Towards the end of April 2006, the man suffered a loss of money from
his bank account for which he blamed his ex-girlfriend. It was recorded
on his probation record that he was very upset, angry and “down” as a
consequence. However, the man did not let his feelings get the better
of him, and it was felt by his Probation Officer that he had handled the
crisis well and not turned to alcohol.
26. At the beginning of May 2006, his Probation Officer reported that the
man was very well. She noted that he had decided to leave his ex-
girlfriend and money issues behind him, enjoying the good weather and
his motorbike rides instead.
27. During the investigation, my investigator spoke with the man’s solicitor.
The Solicitor forwarded a copy of an attendance note that he had made
during a visit to the man on 23 June. In the note, he records that the
man had told him that on the morning of 20 May he had awoken with
deep depression. He had gone out shopping on his motorbike, skidded,
and fallen off. Instead of returning home, he went to the pub for a drink,
before going onto another pub for further drinks. After leaving the pub
he went to the home of his ex-girlfriend, in order to establish why she
was behaving the way that she had been. He shouted through her
letterbox, but there was no response. The man said that he returned
home, buying more alcohol on the way. After the man had been
recalled to prison he admitted to the CPN that he had made a mistake
in knocking at his ex-girlfriend’s door.
28. On the evening of 20 May, the man was arrested on suspicion of
driving his motorbike whilst over the prescribed alcohol limit. The arrest
was made in order that the man could undergo further tests at the
police station, and to allow for the effective investigation of the alleged
offence. The alleged offence had been witnessed by a member of the
public at a pub in which the man had been drinking.
29. Whilst at the police station, the man became verbally abusive and
physically aggressive, attempting to punch one of the officers present.
The following day he was bailed until 5 July.
30. On 22 May, the man contacted his probation office expressing concern
that his actions might cause his recall to prison. On 25 May, the
probation service learnt that the man’s ex-girlfriend had said that he had
attended her home, although the police said that there had not been
any witnesses and it was not recorded as a crime. At a meeting on 26
May, the Probation Officer advised the man that he would be recalled to
prison. The Probation Officer explained that the recall would only be
until the end of his licence in July. The man agreed for the Probation
Officer to call his mother to explain the situation.
31. On 31 May a Senior Manager from the appropriate Probation Area,
made a recommendation to the Release and Recall Section that the
man should be recalled to prison.
The man’s recall to Leeds
32. My investigator obtained the man’s recall file. It records that his recall
had been agreed on 6 June. In a memorandum to New Scotland Yard
on the same day, a request was made for the police to arrest the man
and return him to custody. He was arrested and taken to HMP Leeds
on 7 June.
33. A first night reception healthscreen was completed by a nurse. The
First Reception Nurse wrote that the man was a diagnosed alcoholic,
who avoided alcohol unless he lapsed, and that he had been doing very
well for the last few months. She recorded that he had been diagnosed
with depression and had self harmed in the past, having made several
attempts on his own life. She added that he found it difficult to cope
with being in prison and that his mood was up and down. The Clinical
Review Doctor notes that the man’s suicide screen score was only four.
(The suicide screen is a number of questions relating to a prisoner’s
mental and physical well being. These questions are put to all
prisoners during the first night reception healthscreen, and are scored.
Any score of ten or more means an ACCT document must be opened.)
The man’s score of four did not trigger an ACCT document to be
opened.
34. The First Reception Nurse told my investigators that the man gave her
no indication that he was likely to self harm at that time. The First
Reception Nurse wrote on his Cell Sharing Risk Assessment (CSRA)
that she had no concerns. (A CSRA is a document used to gauge the
level of risk that a prisoner may pose to other prisoners if sharing a
cell.) She said that, had she been concerned, she would have
considered opening an ACCT document. The First Reception Nurse
had little further contact with the man, other than when issuing his
medication.
35. The man spent his first night at Leeds in the first night centre. Whilst
there, the CSRA was completed by an Officer. The CSRA Completion
Officer told my investigators that she could not recall her interview with
the man. However, she said that as he was a recalled prisoner she
would have been reliant on him to provide her with personal information
when making her assessment. She added that she would only have
had access to a limited amount of recorded information at the time. As
a consequence the Officer indicated on the CSRA that the man was not
on an open F2052SH/ACCT, or that there was any evidence that he
had been on one previously. (When a prisoner is transferred from one
prison to another, they should be transferred along with their complete
prison and medical records. If a prisoner is recalled to prison, and
therefore arrives without any old prison records, a request is later made
for the records from the prison where an individual was released from.
Although there is no record as to when the man’s record was requested
by Leeds it was received by the prison on 6 July 2006.) The man’s old
prison record would have contained his previous F2052SHs. However
the Officer was not aware of these when she completed the CSRA.
36. On 7 June, the man was prescribed tablets for backache, cream for his
dermatitis and escitalopram for his depression by the Locum Medical
Officer. However, no notes were made in the man’s continuous medical
record. The First Reception Nurse explained to my investigators that
locum doctors sometimes had a problem in accessing the computer
system (EMIS) that holds the electronic medical records of prisoners at
Leeds, as they might not have access to the necessary passwords. I
conclude that this is the most likely reason why no record of the
consultation was made on the man’s electronic medical record.
37. On 8 June an administrator in the discipline office at Leeds, faxed a
request for the man’s recall paperwork to the Release and Recall
Section (RRS) at the National Offender Management Service. The
administrator made a note of the request in a log book at the prison.
38. When a prisoner’s licence is revoked and he is recalled to prison, a
request is made by the receiving prison to the RRS for his recall
paperwork. The recall paperwork sent to a prisoner is called the
Representations against Recall Dossier and is more commonly known
as the “reps pack”, “recall dossier” or simply “dossier”. The reps pack
must be issued within 24 hours of the RRS being notified of a prisoner’s
return to custody. The pack is made up of a number of documents and
information, and primarily advises a prisoner as to the reasons for his
recall to prison. This includes information from the probation office
giving details for the recall. Annex A of the reps pack is a section that
sets out a prisoner’s right to appeal to the Parole Board against recall to
prison. This includes a form which prisoners must return to the RRS
within five days, should they wish to appeal against the decision to
recall them to prison.
39. The same day (8 June), the man was moved from the first night centre
to E4 36, a single cell on E wing. Here he was seen by a nurse, a CPN
at the prison. She wrote in his medical record that he experienced
auditory hallucinations, and was presently very frustrated at being
recalled as he had just got things sorted out for himself. The prison
CPN noted that the mental health team would be informed that day,
adding that the man denied any thoughts of self-harm. However, the
man told her that he felt very depressed and had difficulty queuing. He
had refused to pick up his medication that morning.
40. On 9 June, the Senior Psychiatric Nurse with the MHIRT, made contact
with the man again. During his interview with my investigators, the
Senior Psychiatric Nurse said that the man was quite reactionary, and
saw his recall as being unfavourable to himself. He said it was:
“… a case of seeing [the man] just to re-introduce myself as a familiar
face, because we’d already got a very good established relationship,
and it was a case of trying to allay any anxieties that [the man] may well
have at that time.“
The Senior Psychiatric Nurse noted in the man’s prison record that he was:
“Somewhat disappointed and angry at his recall saying that it was due to him
‘having a drink’ and posing a risk to people as a result.” He said that the man
went on to say how well things had gone for him during his time out of prison,
and that now it just felt like he had lost everything. The Senior Psychiatric
Nurse told the man he would see him again the following week.
41. On 15 June, the man was visited by a Probation Officer who was
covering for his usual Probation Officer whilst she was on leave, and
the CPN, his community CPN. During the meeting the man expressed
anger and frustration, admitting that he had made a mistake in knocking
at his ex-girlfriend’s door. The CPN told the man that the mental health
team at the prison were fully aware of the effects on his mental health
that his recall to prison was likely to trigger.
42. The Senior Psychiatric Nurse saw the man again on 16 June. He said
the man was “looking a little more settled”, and was expressing a lower
degree of anger about his recall. Due to time restraints, the Senior
Psychiatric Nurse was unable to discuss matters at length with the man,
but promised to see him again the following week. The Senior
Psychiatric Nurse had no concerns that the man would self-harm at that
time, saying: “[The man] was able to work things out for himself in
terms of anger, reasons for anger, [and] reflect on that a little bit for
himself.”
43. An entry in the man’s RRS, National Offender Management Service
file, dated 23 June, simply records, “proceed”.
44. On 23 June, the covering Probation Officer wrote in the man’s
probation records that he had completed the risk management plan
requested by RRS. He wrote as follows:
“We rang the RRS section earlier this week, they have a backlog
and are unable to process anything at the moment. In the
meantime the man stews in prison. This is the first chance I
have had to complete this despite the fact it should have been
sent a week or so ago, I think”
45. On 23 June, the man also received a visit from his Solicitor. In his
attendance note, the Solicitor noted that the man had been told that his
sentence expiry date (SED) was 10 March 2007. The man was
concerned that this would be the date of his release. The solictor
advised the man that, under “the old legislation”, the expiry date for his
licence was 26 July 2006. He assured the man that he would make
representations to the Parole Board suggesting that this was the correct
date, and told the man that he would hopefully be released in one
month’s time.
46. On 27 June, the recall file notes that the man’s ‘reps pack’ was sent to
Leeds. The pack was received at Leeds on 29 June.
47. On 30 June, the Senior Psychiatric Nurse met with the man again.
They spent a good deal of time talking about his situation. The Senior
Psychiatric Nurse told my investigators that during the meeting the man
described himself as up and down, believing this to be more about the
environment than himself. The man talked about working with
Alcoholics Anonymous and about his positive approach to life during his
time in the community. He spoke about his ex-girlfriend and the fact
that he had been issued with a “non molestation order”. The man also
talked about the incident involving his motorcycle for which he was
subsequently arrested. He concluded the meeting by indicating that he
would be receiving information about his arrest from his Solicitor in the
next few days. The Senior Psychiatric Nurse told the man that he
would see him again the following week.
48. During the meeting, the Senior Psychiatric Nurse completed a mental
health risk profile, indicating that at that time the man was not at risk of
self harm or suicide. The Senior Psychiatric Nurse told my
investigators: “… having known [the man] previous and the relationship
that the man and I shared, because he’s been honest with me, I had no
reason to think otherwise.”
49. Following the meeting, the Senior Psychiatric Nurse completed an
initial care plan. He identified the man’s problems as being his
fluctuating anxiety levels, due to his recall from the community, and
issues with regard to alcohol use. Intervention was identified as
“exploring the issues further at the next meeting”. This was scheduled
for 6 July.
50. My investigators asked the Senior Psychiatric Nurse whether the man
mentioned anything about his recall paperwork. The Senior Psychiatric
Nurse said that the man did not know why he had been recalled, and
that he had not seen the recall papers.
51. On the same day (30 June), an officer introduced himself to the man as
his Personal Officer. He wrote in the man’s history sheets that the man
had concerns about being recalled and was expecting to be advised of
the reasons any time. In his statement to the police, the Personal
Officer said that the man was optimistic about his recall being revoked,
and expected to be released from prison within days. The Personal
Officer allowed the man to phone his solicitor, but said that the man did
not appear to have been encouraged by the solicitor, feeling that he had
been “fobbed off”. The Personal Officer sought advice before informing
the man that the recall paperwork could take up to six weeks to come
through. The Personal Officer told the police that he saw the man
briefly on a number of occasions over the next few days. The man
seemed quite normal and gave the Personal Officer no cause for
concern.
52. At 11.10am on 3 July, the man rang his Solicitor. He asked his Solicitor
if he had heard from the Parole Board about his release date. The
Solicitor advised the man that he had not. The lady dealing with his
case was currently on sick leave and no one could review the file.
However, the solictor told the man that there was a good chance of him
being released on 26 July. When the man enquired as to why it was
only a good chance, the solictor said that he did not want to build his
hopes up unduly. The solictor said that as far as he was concerned the
release date would be 26 July 2006, the licence expiry date.
53. Also on 3 July, the Personal Officer recorded that the man had received
his ‘reps pack’ but that parts of it were missing. The part that the man
received contained the various reports, but not the annex A which
notifies the prisoner of the reasons for his recall and provides him with
the necessary forms to appeal. The Personal Officer told my
investigators that the man was frustrated and angry about not receiving
all the papers. The Personal Officer said that he delivered the man’s
‘reps pack’ to him on the same day that it arrived on the wing, although
he was unable to remember at what time. He remembered that the
man was very upset as he only had five days in which to appeal and he
was already out of time. The Personal Officer said that the man threw
his papers all over the floor and, on returning to his cell, paced up and
down in an aggressive manner. The Personal Officer could not get any
sense out of the man, so left him to calm down before trying to talk with
him again later. During interview, the Personal Officer described the
man as being “absolutely furious” on learning that some of the recall
papers were missing. The Personal Officer and another prisoner tried
to calm him down. They made a wing application on his behalf asking
that the man be allowed to speak with someone about an appeal
against his recall.
54. The Personal Officer said that the application was to look into why the
man had not received the correct paperwork. The Personal Officer said
that, even if all the papers had been there, it would have been out of
time anyway. The Personal Officer explained how, after this incident,
the man made no eye contact with him but just paced up and down. He
said that he did not want the man:
“… to do any sort of violence at all. I didn’t want that, I didn’t
want him being dragged down to the segregation block and I felt
confident, given a few days, I could turn him around.”
The Personal Officer said that he continued to keep an eye on the man.
55. In his police statement, the Personal Officer said that on 5 July, during
the wing’s morning briefing, he warned officers to be careful with the
man because of his outburst. He said that the officer to whom the
application had been made entered the meeting, with the application
that had been marked urgent, saying there was nothing he could do
with it. All he could do was pass it to legal services.
56. On 5 July, there were 17 ‘reps packs’ to be distributed amongst
prisoners at Leeds prison: An officer who works on the legal services
desk in OCA (the unit within the prison which organises the transfer of
prisoners between establishments), told my investigators that on
Wednesday 5 July he had a number of licence recall papers to
distribute. He explained that he would have collected them from the
administration block at around 11.00am that morning. The Legal
Services Desk Officer said:
“… rather than go around the jail and try and find all the
prisoners in their work or in their classroom, or whatever, I
decided to wait to lunchtime when all the prisoners were in their
cells. Then it would be easier and quicker to go round and see
them.”
The Legal Services Desk Officer said he saw the man at about midday,
seeing him for five minutes at the most. He said that he opened the
man’s cell door and advised him that he was about to serve him with his
recall papers. The Legal Services Desk Officer that:
“I opened his door, told him who I was, where I was from, and
that I was going to serve him his licence recall papers. He
seemed quite happy. I explained to him what they were about. I
asked him if he wanted to make representations to the Parole
Board against his recall and he replied ‘yes I do’. I filled in
Annex A, which we have here, got him to sign it. I counter-
signed it and explained to him that I would send that off to the
early release and recall section in London for him that day,
which I did, or I took it over to the clerk that does that, and he
said he was quite happy, and that’s fine, and I put him back in
his cell and shut the door.”
57. The man did not tell the Legal Services Desk Officer that he had
already received other parts of his recall paperwork. The Legal
Services Desk Officer was not aware that the man’s paperwork was out
of date when he received it. The Officer said that there was some
contention as to whether it was five days from the date of the letter, or
from when the paperwork was issued, that a prisoner had to lodge an
appeal.
58. The Legal Services Desk Officer said that, prior to 5 July, the previous
time that he had been on legal services duty was on Wednesday 28
June. My investigators asked the Legal Services Desk Officer whether
the man had discussed any release dates with him on 5 July. The
Legal Services Desk Officer said that, if he had, he would have given
the man the sentence expiry date as it appeared on the prison’s Local
Inmate Database System (LIDS – a computer system used by prisons
to record the personal and sentence details of prisoners). However, the
Legal Services Desk Officer said that he did not tell the man of his
release date because, if he had, he would have noted it.
59. The man was sentenced under the Criminal Justice Act 1991. As such,
he would have been released on his licence expiry date, (LED) which
was 26 July 2006 as he had been advised by his solicitor on 3 July.
However, a representative from the Release and Recall Section
explained to my investigators that, under the Criminal Justice Act 2003,
prisoners recalled to prison can, at worst, be detained until their
sentence expiry date. Had the man been sentenced under the 2003
Act, his release date would have been 10 March 2007. The
representative explained that the Prison Service’s database only allows
the recording of one release date. As a consistent date needs to be
entered for all offenders, whether they have been sentenced under the
1991 Act or 2003 Act, it was the sentence expiry date that was
recorded, reflecting the requirements of the latest legislation.
60. This was confirmed by the Discipline Office Manager at Leeds, who
said that there had been an instruction from the National Offender
Management Service that the release date that had to be logged,
pending receipt of the notification from the Parole Board, was the SED.
As a consequence, it was the SED that would have appeared on the
local database as the man’s date of release. He said that, if an officer
were to enquire on the system, it is the SED that would be seen. The
Discipline Office Manager said that an officer would not necessarily be
aware that the prisoner would actually be eligible for release on LED, if
sentenced before the 2003 Criminal Justice Act. It is clear that the man
was told by someone that his release date would be 10 March 2007.
However, my investigators have been unable to establish who this was.
61. I make no recommendation in respect of the limitations of the Prison
Service database revealed in the paragraph above. However, the
Governor may wish to share them with relevant colleagues in Prison
Service Headquarters.
62. At 3.16pm on 5 July, the man telephoned his solicitor’s office and
spoke to someone there for two and a half minutes. It has not been
possible to establish what was said during this call, and to whom the
man spoke. Telephone calls to legal advisors are not recorded by the
Prison Service, and no note of the call appears to have been made by
the man’s solicitor or his office.
63. At 3.44pm, the man made a phone call to his mother. He said he had
just been told by a prison officer that he would be in prison until his
SED, which was March 2007. The man explained to his mother that his
flat would only be kept for 13 weeks and that she should let everything
go into a skip. He asked his mother to sell his motorbike, and told her
that there was nothing for him to live for any more. The man said: “I
can’t stand this waiting for an appeal, I can’t stand being in here another
day.” He went on to say that he would take his own life and that there
was only one way out. The man told his mother that they would not be
able to do anything more to him now. The man’s mother told him “not
to be so daft”, and not to do anything stupid. The man ended the
conversation by saying: “I mean it mum, they are not doing anything
more to me now. I will have to go. I will see you later, but I tell you they
have drove me to this.”
64. The Personal Officer said that he continued to keep an eye on the man
during the rest of the day, adding that “on that particular day he [the
man] was very polite”. During ‘lock up’, he deliberately left the man out
on the landing until last. The Personal Officer said:
“I left him there while I went round and did all the others. I came
round to the centre and I said to him, “will you bang your door
for me”. He put his thumbs up and I felt we had turned a corner
at that point, and I thought well he’s obviously ready for some
interaction so I’ll try and engage him in the next few days. I was
really pleased at that because I expected him, I visualised him,
going in and banging his door and not saying anything, but he
actually gave the thumbs up when he went in.”
6 July 2006
65. At approximately 4.45am on 6 July, a Checking Officer completed his
early morning check of prisoners on E Wing. On reaching the man’s
cell, the Checking Officer opened the cell door observation flap, using
the natural light coming from the cell window to check the cell. The
Checking Officer closed the flap then, doing a double-take, reopened it
straightaway. On the second time of looking into the cell he put the light
on and saw the man facing forwards, hanging from the window bars.
The Checking Officer told my investigators that the man’s arms were
stiff and that it appeared as if rigor mortis had set in. The Checking
Officer said that his response was to take several steps away from the
door. He called for assistance on the radio, asking for the Night Orderly
Officer and healthcare to attend immediately.
66. My investigator asked the Checking Officer whether he was aware of
any policies with regard to officers entering cells at night. The Checking
Officer said that he was not aware of any policy. He said:
“I have always been told, and I have always been taught, you do
not enter a cell unless you have got a member of staff with you.
[You] do not enter a cell under any circumstances unless you
have got somebody there with you.”
When asked if he was aware of the policy, with regard to attending a
cell where a prisoner had been found hanging, that officers should enter
the cell immediately and cut the body down, the Checking Officer said
that he was. When asked if it crossed his mind that the man should
have been cut down, the Checking Officer said “no”.
67. My investigators spoke with the Officer who was working on F Wing
that night. The F Wing Officer was asked to explain what happened
that morning and whether he heard the call by the Checking Officer on
his radio. The F Wing Officer said that he had just come out of the
centre office when he saw the Checking Officer. He was walking down
the wing whilst on the radio saying that he required staff assistance.
The F Wing Officer said the Checking Officer was trying to contact the
control room on the radio. He said that the Checking Officer told him
that he thought he had a suicide. He and the Checking Officer returned
to the cell, “looked through the hatch, closed it down and waited for the
staff to arrive.”
68. The F Wing Officer said that, when he first looked into the cell, he saw
the man at the far end by the window. He was apparently standing up
with his head hanging down, as if resting, and there was a ligature
around his neck. The F Wing Officer said that other staff arrived and
the cell door was opened. He said that the Nurse who entered the cell
confirmed that the man was dead. The F Wing Officer said that he only
stepped in and out of the cell briefly.
69. My Investigator asked the F Wing Officer if he and the Checking Officer
had discussed whether or not to enter the cell, by breaking into their key
pouches, before the SO and Nurse had arrived. The F Wing Officer
said that they had not. When asked if there was any reason why he did
not enter the cell before the other staff had arrived, the F Wing Officer
said: “More or less by the time we got back to the cell, the staff were
there anyway, you know, so it didn’t enter my mind I have got to be
honest.” When asked about the prison’s policy on entering cells, the F
Wing Officer said that it was a bit of a grey area, and he was not aware
of any written policy on the matter. When asked if he was surprised
that the man was not cut down, or if it occurred to him that the man
should have been cut down, the F Wing Officer said that it had never
crossed his mind.
70. The Checking Officer said that, about one minute after he made the call
for assistance, a Nurse arrived at the man’s cell with a Senior Officer
(SO) the Night Orderly Officer. The Checking Officer did not break into
his sealed key pouch as the SO, who was approaching the cell, carried
a full set of keys. The SO unlocked the cell door. The Nurse entered
first, followed by the SO. The Checking Officer remained in the cell’s
doorway and did not enter the cell or attempt to cut the ligature. The
Checking Officer said that another officer arrived at the cell
approximately five or six seconds after the Nurse.
71. The SO was in the Regime Monitoring Unit office. At about 4.45am,
she was alerted on the radio to a “blue call” by the Checking Officer. (A
blue call is a code used by staff to warn healthcare staff that the
incident they are attending involves a prisoner with breathing
difficulties.) Whilst making her way to the man’s cell, the SO was joined
by the Nurse who had also been alerted by the Checking Officer’s call.
72. The SO said that, when she arrived at the man’s cell, the Checking
Officer and the F Wing Officer were standing outside. She said that, on
looking into the cell and seeing the man hanging, she immediately
opened the cell door. The SO said that the Nurse entered the cell and
proceeded to check for signs of life. The Nurse told her that rigor mortis
had set in and that the man was dead. Whilst the Nurse was attending
to the man, the SO spoke to the police who advised her not to cut the
man down. The SO said she was surprised that the officers had not
entered the cell before she got there.
73. The Nurse told my investigators that her night shift was coming to an
end when she heard the call for assistance, at about 4.46am, asking the
Night Orderly Officer to attend E Wing immediately. She said by the
sound of the Checking Officer’s voice she knew something was not
right. The Nurse said she arrived on E wing at the same time as the
rest of the staff. They were directed to the man’s cell by the Checking
Officer and another member of staff, although she could not remember
who this was. The Nurse recalled looking through the cell flap, and
within a few seconds the door was opened by the SO. During her
interview with my investigators, the Nurse expressed surprise that the
officers already present had not entered the cell before her arrival.
74. The Nurse entered the cell and checked the man for any signs of life.
She checked his pupils, which were dilated, and searched for a pulse.
The man was cold to the touch. The Nurse said it was obvious that the
man had been dead for some time.
75. My investigators asked the Nurse if any attempt was made to cut the
man down. The Nurse said she had considered cutting the ligature, but
that there had been conflicting views as to whether this should be done.
She explained that she had been told that, “police prefer them to be left,
you know, obviously where they are but there is the dignity side of it.”
The Nurse said she asked the SO if the man should be cut down, but
was told no. The Nurse said that the paramedics were also content for
the man to be left where he was.
76. A member of staff was deployed to start a movement log at the cell,
and the Checking Officer ensured privacy by placing a piece of
cardboard across the cell door’s observation flap. The man’s cell was
sealed at 4.50am and the prison post incident log records that an
ambulance was also called at 4.50am. In her post incident statement,
the SO wrote that the paramedics attended at 5.05am and pronounced
the man dead at 5.10am.
77. A hot debrief was held at approximately 6.40am. It was attended by
staff who had been involved in the discovery of the man. A full review
of all prisoners on open ACCTs was completed, and staff were offered
the facilities of the welfare team at the prison.
78. Amongst the personal property that was left in the man’s cell was the
Notification for Reasons for the Revocation of his Licence Form, which
had formed part of his recall paperwork. On the notification form, the
man had, in what is assumed to be his own hand, recorded his
thoughts. These included several sentences expressing his anger at
‘the system’, the ‘mental turmoil and abuse’ he had suffered, and his
belief that he had ‘died for freedom’.
79. The prison’s Family Liaison Officer, along with the Deputy Governor,,
and a colleague from the IMB visited the man’s parents at about
9.15am to break the news of their son’s death. The man’s family
subsequently visited HMP Leeds on 14 July and were met by the
Deputy Governor and the prison FLO. During this visit, the man’s family
spent some time alone in the cell he had occupied. The man’s personal
property was returned to his parents on 25 July.
ISSUES
Clinical Review and Post Mortem Report
80. The clinical review looked at the level of health care the man received
during his time in prison. In particular, the review considered the man’s
time at Leeds after his recall to prison.
81. The clinical reviewer noted the man’s history of depression, alcohol
misuse and self harm. He observed that the man’s medical notes were
not available to healthcare staff at the prison. The man was seen by
mental health professionals on a number of occasions. The clinical
reviewer concluded that the man was promptly referred to and seen by
the mental health in reach team. In his opinion, it was “difficult to see
what further steps could have been taken to prevent the final incident.”
82. A post mortem was conducted on 6 July. The post mortem report gave
the man’s cause of death as “hanging”.
Healthcare
83. The man was assessed correctly by a nurse during the reception
process at Leeds. The First Reception Nurse noted the man’s history of
depression, alcohol abuse and self harm. As part of the healthcare
reception process, a suicide self harm assessment was completed. As
noted above, the man scored four out of a possible 22. A score of ten
would have triggered the opening of an ACCT document.
84. As with other recalled prisoners, I believe the man was in fact at greater
risk of self harm than the self-harm assessment indicated. The first
reception healthscreen document used at Leeds is a good example of
how a medical snapshot of a prisoner’s past and current health status
can be obtained. However, I judge that the self-harm assessment does
not take adequately into account the particular problems of recalled
prisoners, and their increased risk of self harm
The Prison Health Partnership should review the first night
reception healthscreen to take into account the particular
circumstances and issues presented by recalled prisoners.
85. At Leeds, the man was seen by a locum doctor. However, no note of
the Locum Doctors assessment was recorded on the man’s electronic
medical record (EMIS). The First Reception Nurse explained that
locum doctors sometimes had a problem in accessing the EMIS
system. I am unable to ascertain whether or not a full medical
assessment of the man took place due to the lack of documentation.
However, it is clear that the man was seen by the Locum Doctor as he
prescribed the medication the man had been receiving in the
community.
The Prison Health Partnership must ensure that all locum doctors
and healthcare professionals have access to security
codes/passwords, allowing them full access to electronically held
medical records.
Psychiatric Care by Mental Health In-Reach Team
86. Although it is not clear what input the locum doctor had with regard to
an assessment of the man’s mental health, it is evident that the man
did have immediate access to psychiatric services at the prison. The
man was reviewed by an RMN the day after his recall to prison. He
was seen by the Senior CPN with whom he had previous contact, the
following day. There was no suggestion to any of these mental health
care professionals that the man was at risk of self harm.
87. I concur with the clinical reviewer’s finding that the man’s mental
healthcare needs were identified promptly.
Reason for the man’s Recall to Prison
88. During their meeting with my Family Liaison Officer, the man’s parents
asked why the man was recalled to prison, and whether or not his ex-
girlfriend had been involved in the decision to recall him. Although the
reasons for the man’s recall are beyond my remit, I trust that some of
the family’s questions have been addressed in this report.
89. My investigator was able to establish that after release from Wealstun
on 9 December 2005, the man made good progress in the community
whilst on licence. He moved into a new flat, he bought himself a
motorbike and attended various courses to assist him with his
rehabilitation. In her reports, his Probation Officer noted the excellent
contact she had with the man and the good progress he made.
90. However, the man’s relationship with his ex-girlfriend appears to have
placed a strain on his efforts to rehabilitate. The man turned again to
alcohol on several occasions. On 20 May 2006, he was arrested for
driving whilst over the prescribed alcohol limit. A complaint was also
made by the man’s ex-girlfriend that he attended her home that
evening, although the police said that there were no witnesses and that
it was not recorded as a crime.
91. The man was advised by his Probation Officer that he would be
recalled to prison. She told him on 26 May 2006 that the recall would
only be until his licence expiry at the end of July.
92. On 31 May, the man’s Probation Officer made a recommendation that
he should be recalled. It was recorded that:
“Despite his good progress on licence to date, [the man’s] recent
alleged actions demonstrate a continuing risk to the general
public, particularly the motoring public, and to known adults –
i.e. his ex-fiancée in the verbal domestic violence incident.”
93. The probation service is required to notify the Home Secretary of any
breach of licence, and to provide information in order that a decision
can be made whether to recall an offender to prison. It is evident that
the decision to recommend the man’s recall to prison was not taken
lightly, bearing in mind the progress he had been making and that his
licence was about to expire. However, given the circumstances of his
initial offence and recent behaviour, I do not think the decision to recall
the man to prison was wrong procedurally or on its merits.
Recall Paperwork
94. During her interview with my investigators the administrator from the
discipline office at Leeds, explained how prisoners received their ‘reps
packs’. She explained that each day she would contact the Release
and Recall Section with the names of prisoners who had been returned
to custody as licence revokees, noting in her own logs when the licence
was revoked, and when the request for the recall pack was faxed. As
already established, the administrator made the request for the man’s
pack on 8 June.
95. The Discipline Office Manager explained that a prisoner is not formally
aware of the official reasons for their recall until the ‘reps pack’ is
forwarded. During interview the CRSA Completion Officer confirmed
what the Discipline Office Manager had said. She said that many
prisoners, who had been recalled to prison were unaware of the
reasons. She added that prisoners were advised to contact their
landing or Personal Officer if they had not received their reps packs
within a week.
96. The Discipline Office Manager told my investigators that prisoner reps
packs should be sent out within five days of an offender’s recall to
prison. However, he explained that the Release and Recall Section
was experiencing a backlog. The Discipline Office Manager said that, if
a prisoner was approaching his SED, then staff would chase for the
recall pack. Prison Service Order 6000 on Parole Release and Recall
(PSO 6000) states at chapter 7 that:
“When ERRS [Release and Recall Section] is notified that a
prisoner has been received into custody, it will issue the
representations against recall dossier’ to the establishment
within 1 day. The parole clerk must ensure that it is disclosed to
the offender immediately upon receipt.”
97. The discipline office administrator went on to tell my Investigators: “…
they had a backlog in the Release and Recall Section. We were waiting
for revocation packs from December 2005 as far back as that.” The
Discipline Office Manager said that, the issuing of the man’s reps pack
by the RRS was “quick”, considering that he was returned to prison on 6
June.
98. On 29 June, the man’s recall pack arrived at Leeds and the discipline
office administrator logged its arrival at the prison. The Discipline Office
Manager and administrator have told my investigators that, at around
this time, annex A of the reps pack (the part the prisoner completes in
respect of his representations) was faxed to the establishment together
with the reasons for recall. The main dossier, which included the
previously faxed annex A, would follow by post. When asked by my
investigators whether reps packs had ever been split before being sent
to prisons the Head of Casework in the RRS, and a Senior Manager in
the RRS, said that the pack would not have been split and that there
would be no point in doing so.
99. In the man’s case, annex A and the reasons for recall were not faxed in
advance of the main dossier. However, the discipline office
administrator explained to my investigators that, in order to maintain the
system then in operation at Leeds, it was at this point that the reps pack
was split into two sections. She explained that section one, including
annex A “reasons for revocation”, was picked up by the Legal Services
Desk Officer in the observation, classification and allocation unit (OCA)
at the prison, and that the remainder of the recall pack was placed
separately in a pigeon hole to be sent directly to the man’s wing. The
discipline office administrator said that annex A was usually collected
every morning and afternoon. However, since the beginning of July
2006, due to staff shortages, they had not been collected at all and staff
from OCA had not organised any other system for collecting the packs.
100. The discipline office administrator told my investigators that the
problem with OCA not collecting the packs had happened before. She
said she had advised them previously of the importance of the
document. In her police statement, the administrator said that she had
made contact with the OCA department with regard to the annex As not
being collected between Friday 30 June and Wednesday 5 July. She
was told that the department had no staff to collect them.
101. The discipline office administrator explained that the annex A should be
returned to her from the prisoner within 24 hours. It is unfortunate that
no note was made when the man’s annex A was eventually returned to
the parole clerk. During interview, the Legal Services Desk Officer said
that on 5 July he explained to the man that he would either return the
appeal paperwork directly to the Release and Recall Section or to the
parole clerk.
102. Chapter 7 of PSO 6000 clearly states at page 2 that on receipt of the
pack:
“The prisoner must consider whether they wish to make
representations against the decision to recall. The parole clerk
must confirm to ERRS [Release and Recall Section] that the
reps dossier has been disclosed and whether the prisoner
wishes to exercise their right to make representations within 5
days.”
103. My investigation has established that there was a failure in providing
the man with this documentation. Records indicate that on 6 June
notice was given to the police that the man should be arrested and
returned to prison. However, nothing further is recorded until 23 June
where an entry simply notes “proceed”. The man was arrested and
returned to prison on 7 June. A log kept by the licence revokee clerk at
Leeds clearly indicates that a request for the man’s recall pack was
made on 8 June.
104. On 23 June, the man’s Probation Officer completed the recall risk
management plan. Although there is no definitive note on the man’s
file, I suspect that it was the covering Probation Officer’s phone call,
several days earlier, which prompted action from the Release and
Recall Section in the form of a request for the risk management plan.
Given the evidence available, I conclude that on receipt of the plan on
23 June the Release and Recall Section proceeded with the issue of
the man’s pack.
105. The pack was subsequently sent to Leeds on 27 June. At around the
time of the man’s recall, the team covering the region concerned were
issuing only 22.3% of recall requests within 24 hours. The
representative from the Release and Recall Section acknowledged to
my investigators that at the time there were staffing issues within this
particular team. The representative said that substantial improvements
had recently been made with 70.7% of requests now being met within
24 hours.
106. the man’s pack was received at Leeds, as one complete document, on
29 June. Staff at Leeds say that, because of the backlog at the
National Offender Management Service ‘reps packs’ had previously
arrived at the prison in two parts. Annex A was sent by fax, with the
remainder being sent by post.
107. However, as previously noted, to maintain the system operated by
Leeds, the man’s pack was split into two when it was received by the
prison. My investigation has established that between Friday 30 June
and Wednesday 5 July the annex A’s were not collected, and
consequently not received promptly by prisoners. The man eventually
received the second part of his recall pack on 3 July, with annex A
being issued on 5 July, six days after it had arrived at the prison.
108. It is quite clear that the Release and Recall Section failed to provide
Leeds with the man’s paperwork within the required 24 hours,
appearing only to issue it when alerted by the probation service. This
was further compounded by staffing shortages in OCA in late June and
early July. The man’s pack was further delayed by six days once it had
reached the prison.
109. The man was evidently troubled by not knowing the full reasons and
circumstances of his recall to prison. He had made a number of calls to
his solicitor and to his family and was obviously upset in the days
leading up to his death. It is evident, given the man’s contact with
mental health services and probation, that he was somebody who had
fluctuating anxiety levels. It seems he was not good at handling
uncertainty.
110. As a consequence of Leeds’s failure to provide the man with his recall
information, he had missed the five day deadline to confirm his wish to
appeal. His Personal Officer noted that the man was “absolutely
furious” on learning that some of the papers were missing, and he tried
to assist him with this. This anger and frustration with the system is
reflected in the comments that he made before his death on the
revocation licence form found in his cell.
111. The Legal Services Desk Officer, charged with distributing the reps
packs on 5 July, was unable to spend more than a few minutes with
each of the 17 prisoners whom he saw over the lunch period that day.
However, since the man’s death a number of changes have been made
at Leeds with regard to the way in which the packs are distributed and
how recalled prisoners are advised of their expected release dates. I
understand that prisoners at Leeds are now issued with their entire
pack by the Legal Services Desk Officer. Recalled prisoners at Leeds
are now also issued with a standard letter, devised locally, in advance
of their recall information which outlines the recall process and sets out
provisional dates of release.
112. PSO 6000 sets out a number of actions to be followed by staff when
dealing with recalled prisoners. It is clear from my investigation that
both the Release and Recall Section of the National Offender
Management Service and HMP Leeds failed to comply with these. I
also note that the Parole Board was not told of the man’s death,
reviewing his case on 7 August, one month after his death.
The Release and Recall Section should issue reps packs to
prisoners within 24 hours, the time target set out in PSO 6000.
The Governor of Leeds should review local policy and procedures
with regard to the issuing and returning of reps packs, ensuring
compliance with PSO 6000.
All legal services staff at Leeds should be adequately trained to
deal with the legal problems and concerns of prisoners recalled to
the prison.
The Governor must ensure that all relevant agencies and
authorities are notified promptly in the event of a death in custody.
The discovery of the man’s body
113. The man was found in his cell by the Checking Officer at approximately
4.45am. The Checking Officer told my investigators that he did not
enter the cell, but took several steps away from the cell door to call for
assistance. The F Wing Officer said that the Checking Officer had left
the cell and was walking towards the centre of the prison when radioing
for assistance. The F Wing Officer said that he and the Checking
Officer then returned to the man’s cell together. There is no other
witness to confirm one or other account.
114. In his interview with my investigators, the Checking Officer said that the
first staff to arrive at the cell were a Nurse and SO. However, the SO
and Nurse said that, on arriving at the man’s cell, both the Checking
Officer and the F Wing Officer already present. The F Wing Officer
himself concurs with this account. I think it most likely that both the
Checking Officers and F Wing Officer were present at the cell before
assistance arrived, and that the Checking Officer was mistaken in
believing that the F Wing Officer arrived after the SO and Nurse.
115. Annex C of Prison Service Order 2700 on Suicide and Self Harm
Prevention (PSO 2700) clearly states that, upon discovering an
apparent suicide, officers should: “Enter the cell as soon as possible,
following the local strategy for safely doing so.” Prison Service Order
2710 on Follow up to Deaths in Custody (PSO 2710) section 2.3
reiterates this policy stating that:
“If the apparent death has taken place in a cell, the first person
on scene must enter the cell as soon as possible, following the
local strategy for safely doing so. Local protocols must contain
clear instructions covering cell entry, especially for Night
Patrols.”
116. Leeds’s local protocol, Leeds Policy Document on Caring for the
Suicidal and Those Who Self-Harm, says that after summoning help
staff should:
“Enter the cell as soon as possible. Staff can do so alone,
taking into account any risk factors that may exist for their own
safety by doing so.”
117. My investigators have established that upon discovering the man, the
Checking Officer called for assistance promptly. But he did not
immediately enter the man’s cell and cut him from his ligature. I am
further concerned that, upon the arrival of the F Wing Officer, no
consideration was made by either of the officers to enter the cell as per
national and local Prison Service instructions.
118. Annex C of PSO 2700 says that, when confronted with a hanging, staff
should support the body to reduce constriction, cut the prisoner down,
release the ligature and immediately place the prisoner on his back or a
flat/solid surface, check for signs of life and commence resuscitation, if
appropriate. This guidance is also reflected in Leeds’s own local policy
document.
119. The Nurse made a clinical decision not to resuscitate the man as she
believed that he was already dead. Indeed, its seems apparent from
the statements of staff that the man had been dead for some time
before he was discovered. However, whilst I entirely accept the Nurse’s
decision not to commence resuscitation, it is difficult to see how a full
assessment of the man’s condition could have been made without
cutting the ligature.
In response to the draft report the Prison Service made the following
comment:
“Notwithstanding the fact that the correct procedures were not
followed upon the discovery of the man’s body, the criticism that
the Nurse could not have made a full assessment without cutting
the ligature could be considered unfair when read in
conjunction with the information in paragraph 79. It was clear
that the man had been dead for some time and the decision not
to attempt to resuscitate was appropriate.”
120. In an earlier investigation into a self inflicted death at Leeds in August
2004, I reported that the prisoner had not been cut from his ligature on
being found by staff. As with the man, a medical assessment was
completed whilst he was suspended by a ligature. While I am
conscious of the need to preserve potential evidence, it is both
disrespectful and a breach of PSO 2700 to leave a prisoner suspended
from a ligature.
The Governor should remind all staff of the need to comply fully
with PSO 2700, PSO 2710 and Leeds’s local policy document on
self-harm. In particular, he should draw attention to the mandatory
action that must be taken by staff upon discovering a prisoner
who has made an attempt on his life.
Quality of Post incident Logs
121. My investigators have noted that a number of the post incident logs
kept by Leeds have been poorly completed, thus diminishing their
usefulness.
The Governor should remind all staff of the importance of
completing accurate, contemporaneous and comprehensive logs
after any death in custody.
Previous Medical Notes and Files
122. My investigators also drew my attention to the apparent delay in Leeds
obtaining the man’s previous prison records and medical records. (I
believe this had no bearing upon his subsequent death.)
The Prison Health Partnership should review the systems
employed at Leeds to obtain previous prison and healthcare
records of prisoners who have been recalled to prison, in order to
ensure that in future all records are obtained promptly.
Family Liaison Issues
123. The man’s family raised a number of concerns with my investigator and
my Family Liaison Officer about the way they were treated by staff
when informed of the man’s death and during their subsequent visit to
Leeds on 25 July. My investigator has raised these issues with Leeds.
I remind the Governor of the importance of Family Liaison Officers
being given the resources to complete their duties appropriately and
sensitively.
124. I note that a member of the Independent Monitoring Board attended
with staff when the news of the man’s death was passed to his parents.
I am sure this was well intentioned, but I do not believe it was
appropriate to the role of the IMB. Nor was it in line with the advice of
the IMB National Council. I do not judge that a formal recommendation
is required, but the Governor will wish to discuss this matter with the
IMB at one of their forthcoming meetings.
RECOMMENDATIONS
The Prison Health Partnership should review the first night
reception healthscreen to take into account the particular
circumstances and issues presented by recalled prisoners.
Partially Accepted – “The screening tool used ‘The Grubin
Assessment Tool’ is primarily a validated risk assessment tool. A
Forensic Psychiatrist under-took research with HMP Leeds to develop
this tool. Any assessment only assesses the patient at that specific
time so by the nature of assesses there are limitations but work has
been carried out on the tool to ascertain more information.”
“Since the concerns raised over prisoners being recalled to prison the
Healthcare Department ensures all prisoners undergo a full
assessment rather than a shortened Change of Circumstances
assessment.”
The Prison Health Partnership must ensure that all locum doctors
and healthcare professionals have access to security
codes/passwords, allowing them full access to electronically held
medical records.
Accepted – “All regular locums and consultants have passwords and
access to EMIS. At present consultants that only come in on an ad hoc
basis do not have access to the system. There is also and
administration limitation in that to put clinicians onto the EMIS system
and allocate passwords we have to go through the EMIS company to
put them on the system. So whilst we endeavour to log all
professionals onto the system at short notice this cannot always be
achieved. This does not mean they cannot use the system though as
they can make entries using the assisting nurses log in protocols
clearly documenting that they are entering under the nurses protocol
and free texting their name.”
The Release and Recall Section should issue reps packs to
prisoners within 24 hours, the time target set out in PSO 6000.
Accepted – “Whilst performance against the target has improved over
the past 12 months, the Release and Recall Section acknowledge that
there needs to be further improvement. Arrangements have been put
in place to manage performance more tightly and they are in the
process of recruiting additional caseworkers to increase casework
capacity.”
The Governor of Leeds should review local policy and procedures
with regard to the issuing and returning of reps packs, ensuring
compliance with PSO 6000.
Accepted – “Policy and procedures have been completely reviewed.
Packs are no longer split and legal services staff now deliver to
prisoners and advise as appropriate. Now compliant with PSO6000.”
All legal services staff at Leeds should be adequately trained to
deal with the legal problems and concerns of prisoners recalled to
the prison.
The Governor must ensure that all relevant agencies and
authorities are notified promptly in the event of a death in
custody.
Accepted – Verbally – New Recommendation.
The Governor should remind all staff of the need to comply fully
with PSO 2700, PSO 2710 and Leeds’s local policy document on
self-harm. In particular, he should draw attention to the
mandatory action that must be taken by staff upon discovering
a prisoner who has made an attempt on his life.
Accepted – “Guidance to be issued to staff via Staff Information
Notices (BD).”
The Governor should remind all staff of the importance of
completing accurate, contemporaneous and comprehensive logs
after any death in custody.
Accepted – “Guidance to be issued to staff via Staff Information
Notices (BD).”
The Prison Health Partnership should review the systems
employed at Leeds to obtain previous prison and healthcare
records of prisoners who have been recalled to prison, in order to
ensure that in future all records are obtained promptly.
Partially Accepted – “in view of the fact that there is no central
organisation that collates electronically the Healthcare records of any
person, the systems that are employed by the H/C department are as
robust as possible under the circumstances.
The following morning after a prisoner is placed in HMP Leeds
administration staff fax the given GP to request information if that
prisoner is indeed registered with a GP.

The system of choice is if the prisoner was released from HMP Leeds
then old notes will be searched for, bearing in mind the prisoner will
have been allocated a new prison number each time they enter prison.
Due to storage and staffing issues for the last 12 months healthcare
records at HMP Leeds have been almost impossible to retrieve we are
hopeful this situation will be resolved in the near further. As the H/C
department has been fully utilising the clinical IT system EMIS for 18
months then it is possible electronic records can be accessed
immediately.
If prisoners were discharged from another prison then the paper
records are again requested within a very short period of time, it is
simply a matter of waiting for the records to be found and posted on to
the receiving prison.
Until all health records are electronic and the Prison Services H/C
departments have access then the systems in-place work in an
adequate manner.”