Individual at Elmley

Investigation into the circumstances surrounding the
death of a man at HMP Elmley
in July 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
August 2009
This is the report of an investigation into the circumstances of the death of a
man at HMP Elmley. He was found hanging in his cell in July 2008. The man
came to Britain in the year 2000 and was subsequently granted indefinite leave
to remain as a refugee.
I extend my sincere condolences to all those affected by his loss.
The investigation was carried by my colleague. A clinical review was carried
out by the local Primary Care Trust.
I would like to thank the Governor of Elmley and his staff, for their help and
assistance during the course of this investigation.
At the time of his death, the man was serving an Indeterminate Public
Protection (IPP) sentence with a minimum tariff of five years. The tariff was due
to expire in July 2008, but he asked for a postponement of his Parole Board
hearing as he did not feel prepared. At that point he had done no work relating
to his sentence planning. One of the reasons was his comparatively recent re-
sentencing, having been originally sentenced to 12 years imprisonment.
Another factor was that in his last five years the man had spent a considerable
amount of time as a detained patient in a secure mental health in-patient unit.
The man left no note to explain his actions, but there are indications that he was
growing despondent about his prospects of release.
My report makes four recommendations. Three relate to the work of Elmley’s
lifer unit and the other concerns the prison’s personal officer scheme.
Stephen Shaw CBE
Prisons and Probation Ombudsman August 2009
2
CONTENTS
Summary 4
The Investigation Process 6
HMP Elmley 7
Offender Assessment, Offender Programmes and the Parole Board 9
Key Findings 10
Issues 20
Conclusion 25
Recommendations 26
3
SUMMARY
The man was born in 1975. He came to Britain in 2000 when he sought and
was granted indefinite leave to remain as a refugee.
In July 2003, the man was arrested and charged with murder. He was
remanded into HMP Elmley where staff soon became concerned about his
mental health. He moved into the prison’s healthcare unit and, towards the end
of 2003, was transferred to an NHS managed psychiatric unit.
Following his conviction for murder in September 2004, the man was sentenced
to life with a minimum of 12 years imprisonment. Meanwhile, he remained a
detained patient in the psychiatric unit. He was discharged from the unit in
October 2005 and returned to Elmley.
Claiming to have been mentally ill at the time of his offence, the man appealed
against his conviction. In December 2006, the Court of Appeal quashed the
conviction and ordered a retrial. While awaiting his retrial, his mental health
again began to deteriorate and he was transferred back to the psychiatric unit in
July 2007.
At his retrial in January 2008, the man was found guilty of manslaughter on the
grounds of diminished responsibility. He was given an Indeterminate Public
Protection (IPP) sentence with a minimum term of five years. (An indeterminate
sentence is given to dangerous offenders convicted of violent offences for
which the maximum penalty is ten years or more. The court sets the minimum
tariff to be served and it is then the Parole Board’s responsibility to decide
whether and when it is safe to release the prisoner.) His tariff expiry date was
July 2008.
With his mental health stable again, the man was transferred from the
psychiatric unit back to Elmley. This happened on the same day as his retrial.
To help demonstrate to the Parole Board that they can safely be released back
into the community, IPP prisoners will usually need to have shown that they
have addressed their offending behaviour. Much of this work will be done at a
training prison (known as a first stage prison) and not at a local prison (such as
Elmley), which is essentially a holding establishment for remand prisoners and
for convicted prisoners awaiting allocation.
The man’s first Parole Board hearing would have occurred a short while before
his expiry date, however he had asked for a postponement as he felt he needed
more time to prepare.
On 11 July 2008, the man attended Friday prayers and a discussion session on
Islamic teaching. After that he played table football with his friends. They all
thought that he was well, as did the Imam who had spoken with him.
At 5.30am on 12 July, staff began their morning roll check of the prisoners.
When the man’s cell was checked he was seen to be hanging from a ligature.
4
Staff went into the cell, cut the ligature and checked him for a pulse.
Unfortunately, it was clear from examination that he had been dead for some
time.
My investigation found that there were no clear indications to staff or other
prisoners that the man was contemplating taking his life.
5
THE INVESTIGATION PROCESS
1. The investigation was opened on 18 July 2008 when one of my colleagues
visited HMP Elmley. He met Elmley’s governing Governor. My colleague
also met a trade union representative. Notices were issued for staff and
prisoners notifying them of my investigation. No members of the
Independent Monitoring Board (IMB) were available that day.
2. My colleague subsequently met the Imam who knew the man and who
spoke to the man’s family after his death. My colleague later returned to
Elmley to interview a number of the staff. He also spoke to four prisoners
who were friends of the man.
3. A clinical review of the man’s care and treatment was carried out by an
appointed doctor on behalf of the Primary Care Trust.
4. My former senior family liaison officer, telephoned the man’s brother who
lives in their home country and she posted information to him about the
Ombudsman’s role and responsibilities. The family’s main concern was
about the arrangements necessary for the man’s body to be returned to the
home country. The family did not raise any specific matters that they
considered should form part of the investigation.
6
HMP ELMLEY
5. HMP Elmley is a modern purpose built male local prison on the Isle of
Sheppey serving all courts in the county of Kent. It holds both adults and
young men between the ages of 18 and 21. It has an operational capacity
of just under 1,000.
6. Elmley received a full announced inspection from Her Majesty’s Chief
Inspector of Prisons in December 2006. Her report said:
“… Like all local prisons at present, [Elmley] is overcrowded: holding
nearly 30 percent more prisoners than its certified normal
accommodation.
“In general, Elmley provided a decent environment for prisoners. Most
accommodation was in good condition, and staff-prisoner relationships
were in general respectful, though staff appeared too busy to engage
proactively with prisoners … There were extremely good race and
diversity arrangements, with strong senior management leadership,
and this showed itself in our prisoner surveys, which unusually showed
black and minority ethnic, and foreign national, prisoners reporting
better outcomes than white prisoners in some key areas, such as
treatment by staff …
“Elmley, like many local prisons, suffered a mismatch between the
number of prisoners and the number of activity spaces available; which
reflected the population it ought to have held, rather than the number it
actually did …
“Prisoner feedback on the personal officer scheme was poor, with few
prisoners reporting any meaningful contact with their identified
personal officer …
“… there were some effective systems for managing the large foreign
national population. These included … fortnightly surgeries led by staff
from the Immigration and Nationality Directorate [now UK Border
Agency] …”
7. In its annual report for the period November 2006 to October 2007, the
Independent Monitoring Board at Elmley reported a total of 773 applications
received in the year. This was an 8 percent increase compared to the
number received the previous year. (An application is a request by a
prisoner for assistance.) A breakdown of the applications made showed
that 12 were about immigration issues. In the previous year, the same
issue resulted in 14 applications.
8. Prior to the man’s death, there had been two apparently self-inflicted
deaths at Elmley since April 2004 when I took on the responsibility for
investigating all deaths in prison custody. The investigation into one of
7
8
OFFENDER ASSESSMENT, OFFENDER PROGRAMMES AND THE
PAROLE BOARD
9. The Offender Assessment System (OASys) is a standardised process for
the assessment and supervision of offenders. OASys takes a structured
research-based approach to assessing the offender. The aims of the
assessment include identification of the individual’s basic personality
characteristics and thinking deficits, assessment of their likelihood of re-
offending if released back into the community, and the linking up of
assessments with appropriate sentence planning. OASys assessments
should be completed periodically as appropriate to help inform sentence
planning.
10. Sentence planning will usually incorporate completion of appropriate
Offending Behaviour Programmes. These are rehabilitation programmes
designed to identify the reasons why prisoners offend and to reduce and
monitor these factors. Elements contained in specific programmes aim to
develop personal traits such as impulse control, values and moral
reasoning, inter-personal problem solving and anger control. Most
programmes comprise group work with other offenders.
11. Once a life-sentenced prisoner has served the minimum tariff of their
sentence as set by the trial judge, it is then the responsibility of the Parole
Board to decide on the prisoner’s release. Before directing release, the
Board must be satisfied that it is no longer necessary for the protection of
the public that the prisoner should remain confined. The test to be applied
is whether the prisoner presents a risk of committing further serious
offences. There is a presumption that release will not be directed unless
the evidence demonstrates to the Board’s satisfaction that the level of risk
is acceptable for release. The Board should refuse to direct release unless
it is satisfied that there does not exist a risk of serious violent offending.
12. The Parole Board may make its decisions about indeterminate sentence
prisoners on the papers alone, or by way of an oral hearing where the
prisoner appears before three panel members. The panel will often be
chaired by a judge, and where the circumstances of the case warrant it the
panel will include a psychiatrist or a psychologist.
13. My investigator asked Elmley for a copy of the man’s OASys records but
was told that none could be located.
9
KEY FINDINGS
14. The man was born in 1975. He moved to Britain some time in the year
2000. It seems his reason for moving might have been fear of his home
country’s regime and, in June 2001, he was granted indefinite leave to
remain in the UK as a refugee. He had worked as a baker in his home
country and, for a period of time, worked in that trade after settling in the
UK.
15. In July 2003, the man was arrested for questioning following the death of a
man two days previously. He remained in police custody for several days
until his remand into HMP Elmley on 22 July.
16. Within a few weeks of the man’s arrival in Elmley he began refusing meals
and, towards the end of August, he was moved into the prison’s healthcare
unit for observation. A note was made in his records that he believed it
would be irreligious to accept food from a non-Muslim. One of the prison’s
Imams explained to him that he was mistaken in his belief; even so, he
continued intermittently to refuse food, sometimes for several days on end.
On other days he was noted to have consumed large amounts of food.
Although there were days when he came out of his cell for association, it
was much more common for him to refuse to come out and on many
occasions he was noted to be totally uncommunicative. He spent much
time in prayer.
17. On 12 September, the man was reviewed by one of Elmley’s doctors and
by a consultant psychiatrist. Both deemed him to be suffering from mental
illness to a degree that warranted detention in a hospital for medical
treatment. He remained in Elmley’s healthcare unit until 16 December,
when he was transferred to a mental health unit (MHU) under section 48/49
of the Mental Health Act. (The MHU is a medium secure psychiatric in-
patient unit managed by the NHS and Social Care Partnership Trust.)
18. The man was still a patient in the MHU when his trial commenced the
following September. He was subsequently convicted of murder and, in
October 2004, was sentenced to a minimum of 12 years imprisonment.
19. The man remained in the MHU for almost two years. Over time, however,
his mental health stabilised, and on 7 October 2005 he was discharged and
transferred back to Elmley. During his time in the MHU, his IQ (intelligence
quotient) had been tested. His non-verbal IQ was estimated to be between
80 and 90 (putting him in the low average bracket).
20. The Muslim chaplain at Elmley told my investigator that he first met the
man in 2005 on his return to Elmley from the MHU. He said that the man
made himself known to him as a Muslim and came to the Friday afternoon
congregation. (This entails one hour of prayers followed by one hour of
Islamic teaching in the form of a question and answer session.) The
chaplain said that the man would not talk to many people but he did begin
to open up to him. He confessed that he had killed a person and so did not
10
21. The records provided to my investigator by Elmley contain no entries from
wing staff for the year 2006. There is no information on record about how
the man was filling his days, nothing to say whether he was or was not
complying with prison rules, and no evidence of any sentence planning or
engagement by lifer management staff. The clinical records for the year
suggest only two minor contacts with healthcare staff: a consultation about
nasal congestion in July, and then in December a healthcare worker
examined him to confirm that he was fit to go to court.
22. The reason for the man’s appearance at court in December 2006 was
because he had earlier lodged an appeal against his murder conviction.
The decision of the court was that the conviction should be quashed and a
new trial held. He was to remain remanded in prison while awaiting his
retrial.
23. From court, the man was taken to HMP Brixton (probably because Elmley
was full). He remained in Brixton until 15 February 2007 when he was
transferred back to Elmley.
24. From March 2007, sporadic entries in the man’s clinical records show that
he was beginning to suffer a recurrence of mental health problems. A
record made on 29 April by a consultant forensic psychiatrist indicated that
the psychiatrist found him to be acutely psychotic that day. He was
readmitted to the MHU on 31 July, again under section 48/49 of the Mental
Health Act.
25. At a case conference at the MHU in September, it was decided that the
man’s anti-psychotic medication should be changed from oral
administration to administration via depot intramuscular injection. (A depot
injection is a periodic injection where the formulation is released slowly into
the body over a number of weeks.)
26. Ahead of his retrial, the man had submitted a plea of guilty to manslaughter
on the grounds of diminished responsibility. His claim was that he was
mentally unwell at the time of the offence.
27. The case came to court in January 2008 when the man’s plea of guilty to
manslaughter was accepted. He was sentenced to life imprisonment with a
recommendation that he serve a minimum of five years. Taking into
account the time already served, the five year term would expire on 22 July
2008. However, in his address in court to the man the judge remarked that:
“This Court has come to the clear conclusion that the deterioration of
your mental state in the community, its frequency or otherwise, and the
consequent risk of serious harm to the public, which you would then
11
present, is entirely unpredictable at the present time … I, therefore,
reject the position made on your behalf that I can properly pass a
determinate sentence …”
28. The judge went on to say that, when the man’s case was to come before
the Parole Board, the Board would have an acutely difficult decision to
make.
29. On the same day as his fresh conviction, the man was discharged from the
MHU back to Elmley. At this point, he was within six months of his earliest
potential release date, ahead of which he would need to appear before the
Parole Board.
30. Shortly after his return to Elmley, the man attended an induction session for
a course in English for Speakers of Other Languages (ESOL).
31. An offender supervisor at Elmley, wrote a progress report on 12 February in
preparation for the man’s Parole Board hearing. The report commented
that his behaviour in prison had been very good. It also stated that he had
not yet carried out any Offending Behaviour Programme course work and
so was unable to demonstrate that he had reduced his level of risk. The
offender supervisor also wrote that the man had explained to him that he
was extremely sorry for his victim and was apologetic for the offence. He
expressed the wish, upon release, to return to his family in his home
country.
32. The offender supervisor told my investigator that he doubted if the man
would have been considered ready for release at the five year stage. He
believed a transfer to a ‘lifer prison’ was being considered where
appropriate courses would have been more readily available than at Elmley
(a local prison). Although the offender supervisor thought the man spoke
reasonably good English, he felt he would probably have needed to
complete an ESOL course in order to do the offender course work.
33. A psychiatric nurse working for the Prisons Mental Health In-Reach Team,
became the man’s primary nurse upon his return to Elmley from the MHU
January 2008. (The In-Reach team had had no direct involvement in his
care while he was in the MHU). The psychiatric nurse told my investigator
that, by the time of his return from the MHU, the man’s psychosis was
under control. The psychiatric nurse first consultation with the man was on
28 January. The psychiatric nurse said that at first he had fortnightly
consultations with the man, lasting between 20 minutes to an hour. As the
psychiatric nurse saw him on the prison wing, other events on the wing
could affect the length of a consultation. Otherwise, it would be his level of
engagement on the day that would affect the length of the consultation.
The psychiatric nurse said that the man was not the easiest person to
engage with as he would tend to give ‘yes’ and ‘no’ answers without further
elaboration. The psychiatric nurse thought that the man’s limited English
might have influenced his engagement, although he also seemed a person
who took a while to start trusting others.
12
34. The man’s second consultation with the psychiatric nurse was on 13
February 2008 after which the nurse noted that the man:
“… appeared to be stable and well within mood and mental health
presentation. He didn’t report any concerns or issues. He reported
good sleep and appetite. We briefly talked about his symptoms prior to
admission to MHU. He told me these were too much praying, not
eating or drinking or looking after himself. He is currently not
experiencing [any] of these. Feels a bit sad today, he is missing his
family in [his home country]. Would like to return [there] but no one has
given him any assistance with this …’’
35. At the next two consultations, in late February and in early March, the man
spoke of being bored and that no one had approached him about lifer
management or education issues. At the second of the consultations, the
psychiatric nurse noted that the man had been offered a job but had
declined it as it was a cleaning job. He said though that he was hoping to
start education and was waiting to hear about that. The psychiatric nurse
also noted that he had advised the man to take a job as it would help with
his boredom. He then started a job in an assembly workshop, but he was
dismissed soon afterwards for non-attendance.
36. The psychiatric nurses’ note following his consultation with the man on 2
April included:
“… Client appeared pleasant in mood. He came across stable in mental
state. Reported good appetite and sleep. Came across poor in energy
levels and client confirmed that he has poor motivation … He was given
a job, but gave it up after one day. Claims that being separated from his
family is hard for him …”
37. Having attended an ESOL induction session in the previous January, the
man was due to start classes on 10 April. He did not attend however, and
his name was subsequently removed from the class list. This information
was not noted in his wing history sheet and nothing was recorded to show
that he was asked about his reason for not attending.
38. An officer told my investigator that he was appointed as the man’s personal
officer from the time he returned to the prison from the MHU. (The
personal officer should be a prisoner's first port of call if they have
questions, complaints or need advice. The personal officer should also
usually contribute to sentence planning and should help the prisoner in
making the best use of their time in prison.) The personal officer made only
one entry in the man’s records and he estimated that he only met him about
three times in total. The personal officer explained that at the time he was
working on A spur, whereas all the prisoners for whom he was personal
officer were located on B spur. He said that the arrangement has now
changed so that the prisoners for whom he has personal officer
responsibility are located on the spur on which he works.
13
39. It was on 13 April that the personal officer made his one entry in the man’s
records: “Has been very quiet since I’ve known him. However, always
complies with staff and does walk about during association. Shows no
cause for concern.” The personal officer said that the man spoke English
well enough to be able to engage in conversation. The personal officer
said that, on the occasions they met, he asked the man how he was doing
to which he replied that he was fine, that he was doing okay. At no time did
the personal officer notice any signs to suggest that he might be at risk of
harming himself.
40. Since his return to Elmley from the MHU, the man’s clinical treatment
included fortnightly intramuscular injections of an antipsychotic medicine
(Flupenthixol Decanoate). On 2 May, he refused his injection. The
psychiatric nurse told my investigator that it is not unusual for patients who
have had a severe episode of mental illness to ask to come off their
medication after they have regained their health. When he came off his
medication he was transferred to Elmley’s healthcare unit so he could be
observed for any signs of a relapse.
41. A consultant psychiatrist visited the man in healthcare on 14 May. He had
been refusing his medication for the previous month and he explained that
the injections were causing him pain in his lower legs. He also said that he
now felt well and so did not consider that he needed the medication any
longer. The consultant psychiatrist advised that he risked deterioration in
his mental health by stopping the medication.
42. One of the nurses in healthcare made a note on 16 May of a discussion
with the man about medication:
“Mood appears brighter … Offered [one to one] session with named
nurse, stated that he is fine. Stated that he does not require his
medication at the moment because he is well. I suggested that feeling
well at the moment is a sign of the therapeutic effects of medication,
and he may relapse if he stops complying … he states that he knows
when he is feeling well and when he is not and he will start taking his
medication if his mental health deteriorates …”
43. An healthcare assistant (HCA) made an entry in the man’s records on 18
May that he was: “Often found pacing up and down the corridor. Never
appears aggressive in mood and smiles when asked [if okay]. No cause for
concern.” At interview, the HCA confirmed that the man had never caused
her concern that he might harm himself. When asked what she had meant
by the word ‘pacing’, the HCA said that the man often seemed restless or
distracted.
44. An entry made in the man’s clinical records on 25 May says: “… Mental
health assessment; no abnormal behaviours noted. Although he is quiet he
was observed interacting with others very well. Well behaved on the ward
14
45. With the approach of the five year minimum term, the man was sent a letter
to tell him that the Parole Board would be considering his suitability for
release. Part of that process included completion of a ‘sentence planning
and review’ report by a probation officer. In the probation officer’s report,
she noted that at that time the man had still not completed any sentence
planning work. She noted that the reason appeared to be because he was
unable to read or write English.
46. On 4 June, the man signed a letter to the Parole Board in which he said
that he needed more time to prepare for the review hearing. This letter was
written on his behalf, by his friend, and was countersigned by an officer.
47. The friend told my investigator that he had known the man for two years
and acted as his interpreter as his English was poor. He said that the man
was always depressed, saying that he missed his family and could not see
how he would be able to get out of prison. The friend understood that the
man had spoken to other prisoners serving indeterminate sentences about
what he needed to do to obtain release. From what he had heard, he
doubted that he would be able to complete the necessary courses. The
friend told him to discuss the matter with Elmley’s Medical Officer who
would confirm that the man would not be able to complete the courses due
to his mental health problems and poor English. He also spoke about the
early release scheme for foreign national prisoners, but said he had been
told that the British authorities would not sanction his deportation because
he faced possible persecution if he returned to his home country. The
friend said that it was obvious that the man was depressed. He would
either walk up and down the corridor with his head down or just lie in bed
with the sheets over his head.
48. The officer that endorsed the letter to the parole board told my investigator
that, although he worked on B spur, he had only limited interaction with the
man due to his very poor command of English. The only words he could
recall him using was commenting that he was bored. The officer said that
the man spent a lot of time walking up and down the landing, though he
added that it was more of a shuffle than a walk. He also said that he had
problems with his personal hygiene. The officer understood that the man
was receiving anti-psychotic medication and he was also under the
impression that he did not always accept it. The officer described him as
‘withdrawn’, although he was always polite and respectful and gave no
indications that he might be at risk of self harm.
49. The psychiatric nurses’ first consultation with the man following his
discharge from healthcare was on 11 June. He noted that the man:
“… appears to be stable in mood, pleasant upon approach. He reported
no symptoms of mental illness and none were observed despite him not
15
taking any form of medication at present. Good appetite and sleep and
energy levels observed and reported.”
50. From this point the psychiatric nurse increased the frequency of
consultations with the man from fortnightly to weekly. His reason was to
ensure closer monitoring of any signs of a relapse in his mental health due
to his continued refusal of medication. Potential relapse indicators, he told
my investigator, could be behaviours such as excessive praying, refusal of
food and pre-occupation with religion.
51. On 12 June, the man was visited by a probation officer. She found that he
appeared to have no information on file about the assessment of his risk
factors and sentence planning. She noted that it seemed that the man was
not engaging with the sentence planning process largely because of his
inability to read or write in English. She recorded that she had been told
that he had applied to attend an English course.
52. The man started a new job on 16 June. This was a packing job (an entry
made in the clinical records by the psychiatric nurse indicates that the man
gave up his previous job in the assembly workshop because he found it too
difficult). It is not clear how many shifts he completed in his new job. When
the psychiatric nurse attempted to visit the man on 25 June, he was not on
the wing and was apparently at work. However, when the psychiatric nurse
visited on 1 July, it appears that he was once again unemployed. A student
nurse accompanied the psychiatric nurse at that consultation after which
she made the following note:
“… Approximately [four] months ago [the man] stopped his depot
injection. Upon stopping he has remained mentally stable. Today he
was visited in his cell where we found him in bed. He appears to lack
motivation. Prison work was discussed and he told us that he would
apply for a job this evening … [the man] said sentence should expire on
22 July 2008 however [the psychiatric nurse] has spoken to [a
probation officer] who has informed him that this is not the expiry date
but [the] probation date … Today [the man] appeared lethargic and
unmotivated. He maintained good eye contact throughout the review
… No evidence of any deterioration in his mental health. [The man]
stated that he is due to be deported … Requires clarification … of this.”
53. The psychiatric nurses’ last consultation with the man was on 8 July. He
was again accompanied by the student nurse who made the following
record of the consultation:
“ … [the man] was seen in his cell. When we arrived he was on his bed
watching TV which seems to be a usual occurrence. As discussed last
week, he was due to look into possibly obtaining a job although this
does not seem to have been achieved ... He appears to lack
motivation. He does not appear to want to do anything and wants to
stay in his cell watching television. He has been strongly advised that
this is not healthy and that it is important for him to organise a better
16
routine. There was no evidence of any visual or auditory hallucination
whilst in conversation.”
54. The psychiatric nurse told my investigator that he was very surprised at the
man’s subsequent death. He said that uncertainty over his future certainly
affected his mood. His strong desire was to return to his homeland and he
asked a lot of questions about that. The psychiatric nurse said that he
asked some of the other foreign national prisoners whether they could
advise the man, but he did not seem able to clarify his situation. Despite
this, he did not seem significantly distressed or depressed. He did not
express any suicidal ideas or give any indication that he might harm
himself. The psychiatric nurse said that he did not notice any indicators to
suggest that he was becoming mentally ill again. Nor had wing staff
reported any concerns about him when he asked how he was faring
(something that he did as a matter of routine). The psychiatric nurse said
that, if he had had any concerns, he would have arranged either for him to
be monitored and supported through the ACCT process1 or would have
admitted him to healthcare.
55. My investigator spoke with a senior officer (SO) about her role as lifer
manager and offender management officer and about the management of
prisoners serving IPP sentences. The SO explained that a prisoner serving
a five year IPP sentence (as was the case with the man) would always
have to serve at least five years. The prisoner will be set objectives (for
instance, completion of courses such as victim awareness or enhanced
thinking skills). It is then for the Parole Board to consider whether the
prisoner should be released. The Board might decide that it is safe to
release the prisoner, or that the prisoner needed to do more course work
before their release could be sanctioned. Another option is for the prisoner
to spend some time in an open prison2.
56. The SO said that, when the man returned to Elmley from the MHU in
January 2008, he only had six months remaining of his IPP sentence. She
explained that that time span was insufficient for him to do the work
necessary to prove to the Parole Board that it was safe for him to be
released. However, she did not think it would have been detrimental to his
prospects of parole that he faced a number of potential barriers in
undertaking course work, such as his mental health problems, the amount
of time he had spent in hospital, and that English was not his first language.
She thought that the Parole Board would have made some allowances for
those factors. She added that, if the parole hearing concluded that the man
needed courses which he could not have in Elmley, they might have
recommended his transfer to another prison that could offer what was
1 ACCT (Assessment, Care in Custody and Teamwork) is the process used for monitoring and
supporting prisoners at risk of self-harm or suicide.
2 An open prison is one with limited physical barriers to prevent escape. They are used for
those who can be trusted to serve their sentence without likelihood of escape and of being a
threat to the public.
17
needed. However, he would not have been transferred before his parole
hearing.
57. My investigator spoke to several other prisoners who knew the man. One
prisoner said that he had known the man for four months. They spoke
every day in the last month before his death. The man was a quiet person
who tended not to make much conversation and the prisoner would always
be the one to introduce topics. He would tell jokes and the man would
laugh. The man always spoke about his release and mentioned that he
had only one month left of his sentence. The prisoner said that the UK
Border Agency visited Elmley on 28 June. However, prison officers failed
to collect the man so he did not see the immigration officers that day. The
prisoner understood that several months earlier the UK Border Agency had
told the man that they would only sanction his return to his home country if
he could prove that his life was not in danger. He was pessimistic about
ever being released from prison although the prisoner tried to reassure him.
They played table football on Friday 11 July and he seemed happy that
day. The prisoner said that he saw no signs that the man was mentally ill
or that he would harm himself.
58. A second prisoner had also known the man for four months. He described
him as a very quiet man who spent a lot of time walking up and down the
corridors not speaking to anyone. The man complained about immigration
matters but the prison never got back to him. He had said that: “all doors
were closed” to him and that he “cannot get out”. However, he also said
that he hoped he would be able to go home one day. He came to Friday
prayers on 11 July and played table football afterwards. He seemed fine.
59. A third prisoner said that he had known the man for many years as they
came from the same town in their home country. They were in different
houseblocks at Elmley but the third prisoner told the man that he would ask
for a transfer to his houseblock. Unfortunately, this did not happen before
the man’s death. The third prisoner said that the man could read and write
in his own language but thought the courses he would have to do in prison
were “a big wall” that he would never be able to break through. The third
prisoner saw him at Friday prayers on 11 July. He asked him how he was
and he replied that he was fine.
60. The Imam said that the man attended Friday prayers on the afternoon of 11
July. That was the first time in around two months that he had joined the
congregation. In the interval between prayers and the question and answer
session, the Imam went over to the man to say how nice it was to see him
again. He was drinking tea with his friends and he replied: “Thank you
Imam.” The Imam told my investigator that the man seemed fine. He
added that he was shocked when he heard of his death the following day.
61. The evening meal would have been served that day between around
4.30pm to 5.15pm. Nothing is recorded to show whether the man took a
meal or declined to do so. The cells were then locked for the night at
around 5.30pm.
18
62. At 5.30am on 12 July, an officer support grade (OSG) began carrying out a
prisoner roll check on B spur. When she reached the man’s cell she saw
him hanging by a ligature tied to the cell locker. The OSG shouted to her
OSG colleague. Her OSG colleague set off the emergency alarm and then
ran to the man’s cell. She broke the key pouch3 and, as the other OSG
supported his body, cut the ligature with her anti-ligature knife. A senior
officer, together with three officers, was in the administration office and they
all responded to the alarm. On arrival, one of the responding officer’s
checked the man’s neck and wrist for a pulse but found none. They told my
investigator that the man’s body was cold and it was clear that he was
dead.
63. In Elmley, nurses on duty at night time do not carry keys, so the second
responding officer went to healthcare to collect two of the nurses. The note
made by one of the nurses showed that the clinical signs were that the man
had been dead for some time. Ambulance paramedics and the out-of-
hours doctor were called. He was officially pronounced dead by the doctor.
He had not left a note explaining his actions.
64. All of the man’s family live in his home country. On the day of his death the
Muslim chaplain telephoned the man’s brother to inform him of the sad
news. Elmley made arrangements with a local funeral director for the
man’s body to be repatriated to his homeland and met the costs.
3 At night time, staff hold keys in sealed pouches. The seal is to be broken only in the case of
an emergency.
19
ISSUES
The man’s location in a local prison.
65. The man first arrived at Elmley (a local prison) on 22 July 2003 as a
remand prisoner charged with murder. And it was at Elmley that he died,
very nearly five years later, without having carried out any offending
behaviour work.
66. Ordinarily, the man would have been transferred to a (first stage lifer)
training prison following his conviction for murder. The Prison Service aims
to transfer prisoners to a first stage prison within approximately six months
of sentencing, subject to the availability of places. At that first stage prison,
a sentence plan would be formed to set out the offending behaviour that
would need to be addressed during the prisoner’s time in custody. In due
course, the prisoner would begin to carry out offending behaviour work until
he demonstrated significant and sustained improvement. The next move is
to a category C prison followed, in due course, by transfer to a category D,
open prison.
67. By the time of his death, the man had not progressed at all in terms of his
journey through the lifer system. There were several features about his
circumstances that contributed to this. One was the fact that during this
period he spent two separate and substantial spells in a mental health in-
patient unit having been sectioned under the Mental Health Act. He was in
the MHU from 16 December 2003 to 7 October 2005 and again from 31
July 2007 to 22 January 2008. In addition, he spent a reasonable amount
of time in Elmley’s healthcare unit either for close observation of any signs
that he was becoming mentally ill or because he was indeed mentally ill.
68. The other significant factor was that, following a successful appeal, the
man’s conviction for murder was quashed at the Court of Appeal in
December 2006. This meant that his legal status was again that of an
unconvicted remand prisoner. It was not until 22 January 2008 that he was
retried and convicted of the lesser charge of manslaughter with an IPP
sentence and a five year tariff. When that happened, he was within six
months of his first Parole Board hearing. It is deemed best to avoid a
prison transfer in that period as staff at the new prison will not have time to
get to know the prisoner and be able to complete reports for the parole
hearing. The day that the man was re-sentenced was the same day that he
returned to Elmley following his second spell in the mental health in-patient
unit. It is arguable, therefore, whether he would have been able to do very
much effective work in terms of sentence planning ahead of his parole
hearing regardless of which prison he was in at the time.
69. In fact, the man asked for a postponement of his parole hearing as he felt
he needed more time to prepare. If the hearing had gone ahead, the parole
panel would have paid regard to the remarks made by the trial judge that
January. The judge had said it was clear that a potential deterioration in his
mental state in the community and consequent risk of serious harm to the
20
70. My investigator made an enquiry of the Parole Board about how it might
have viewed a case such as this man’s. In particular, the fact that he had
done no offending behaviour work while, at the same time, having a
reasonably low IQ and poor command of English. The Parole Board were
not familiar with the man’s case, but from the basic facts my investigator
gave, said that offending behaviour work did not seem to be a significant
issue. This would be because completion of any such courses would not
necessarily demonstrate a reduced risk to the public. Instead, the focus
with him, the Parole Board suggested, would be past and future psychiatric
assessments.
71. Based upon those remarks, it is likely that the man was some considerable
way from any prospect of being granted release on licence. If that is the
case, it follows that he had not been materially disadvantaged by the fact
that he was still awaiting a move to a first stage prison after his conviction
for manslaughter in January 2008. Moreover, the evidence of the Parole
Board would indicate that the key factor for his prospects of release would
not be offending behaviour work but the likelihood or otherwise of the
recurrence of psychotic episodes.
72. What is very clear, however, is that the man remained confused about his
IPP sentence, about his potential progress through the lifer system and
about what work he should be doing and about his prospects of returning to
his homeland. I shall deal in the following section with contact with the man
by wing staff, but there seems to have been very little contact with him by
staff from the lifer unit and no evidence of any contact at all in the period he
served in connection with his original sentence. Whether or not the focus
for him would be his psychiatric prognosis rather than offending behaviour
work, it would seem that no proper plans were formulated. There does
appear to have been a half-hearted attempt to enlist him onto an ESOL
course, but when he failed to attend no more came of it.
73. As a minimum there would seem to be staff development needs within
Elmley’s lifer unit.
I recommend that the Governor ensures that relevant staff attend the
Management of Indeterminate Sentence Prisoners and Risk training
course.
I recommend that the Governor reviews and addresses any other
developmental needs within the lifer unit team.
I also recommend that the Governor reviews the arrangements for
provision of information to prisoners about the operation of the lifer
system. This should include a review of the effectiveness of delivery
21
of information to those with English as a second language or other
difficulties of understanding.
Staff interaction with the man
74. In total, the man spent around 24 months on the houseblocks at Elmley.
The remainder of his time he spent in the prison’s healthcare unit and in the
MHU. In addition, he spent two months in HMP Brixton during late 2006 to
early 2007 and he spent one night in HMP Pentonville. For all his time on
the houseblocks in Elmley, the records provided to my investigator included
less than one side of entries by wing staff in the man’s history book. (The
history book is meant to comprise a running record about the prisoner
where any matters of significance should be recorded.) All of the entries
were made in 2008 which suggests that previous history books have been
lost. Even if this was the case, the man seems to have remained an
extremely anonymous individual to those responsible for dealing with him
on a daily basis. (And I note that his personal officer from January to July
2008 only met him around three times during that period because he
worked on a different houseblock to that where the man was located.)
75. Elmley’s Personal Officer Scheme when the man first arrived in the prison
required that all prisoners be allocated a personal officer upon arrival on a
residential unit. The personal officer was expected to make initial contact
with newly allocated prisoners within 48 hours of the prisoner’s arrival4.
Thereafter, the personal officer was required to make contact with each of
their allocated prisoners at least weekly and to make a record of that
contact in the prisoner’s file. The Scheme espoused the principle that
comments about behaviour, attitude to sentence, and employment, help to
build up a picture of the prisoner. The Scheme also included a provision for
managerial checks to ensure that staff were making the contact as
prescribed.
76. Whether or not some of the man’s records have been lost, it is manifest
that Elmley’s Personal Officer Scheme was not operating properly at the
time and this would, or at least should, have been recognised at a
managerial level. Had the Scheme been operating as required, there
would have been at least one officer who should have established a
relationship with him and been better able to assist his understanding of
prison life, including the meaning of IPP sentences and sentence planning.
Such an officer would have been in a better position to notice if there was
anything to suggest he was becoming increasingly dejected about his
prospects. Such an officer would certainly have been able to speak to my
investigator with some authority about how the man appeared to be getting
on.
77. I hear repeatedly that a disproportionate amount of officers’ time in any
prison is taken up by a comparatively low number of the more demanding
4 Elmley’s Scheme as revised in December 2007 requires the initial contact to be made within
one week of the prisoner’s arrival on a residential unit.
22
prisoners. The unfortunate consequence is that prisoners who are quiet
and undemanding may not always receive the support they need. The
evidence of the other prisoners originating from the man’s home country,
and the Imam, was that the man was a quiet and reticent individual.
Moreover, although my investigator received mixed messages about the
standard of his spoken English, the evidence certainly points to him lacking
confidence in his ability to speak the language.
78. The inescapable conclusion would seem to be that the man received little
attention from staff because his behaviour was not disruptive to the running
of the wing. There is some evidence too that he was someone who could
easily grow discouraged. He had mentioned to the psychiatric nurse that
he was bored but, in addition to declining a wing cleaning job, he later
started a job in the assembly workshop and subsequently a packing job, in
neither of which he remained long. Similarly, he had been due to
commence an ESOL course in April 2007 but failed to attend and his name
was removed from the list. Nothing is recorded to show that he was ever
asked or challenged by wing staff about his reasons for failing to take up or
abandoning these opportunities.
79. A reticent prisoner, a prisoner such as this man, probably has the most to
gain from the proper operation of a personal officer scheme. All the
matters mentioned above are matters I would have expected a personal
officer to have pursued.
I recommend that the Governor satisfies himself that the Personal
Officer Scheme is now operating properly and in accordance with the
local protocol.
Were there any identifiable signs that the man was at risk?
80. A consequence of the man’s decision to refuse his depot medication was
that the mental health in-reach team began to monitor him even more
closely than was already the case – seeing him weekly rather than
fortnightly. I am pleased that the team recognised his vulnerability and so
increased their contact with him. The psychiatric nurse told my investigator
that he observed no signs that the man was at risk. Nor did the wing staff
bring any concerns to him which, he said, they would have done if
appropriate.
81. However, the psychiatric nurse told my investigator that the man’s mood
was affected to an extent by his preoccupation with his family and his
desire to return to his homeland. This is reflected in the records made by
the nurse, which also reflect the man’s lack of motivation to take up any
occupation.
82. The man’s friends also said that his hope was to return to his home
country. One friend in particular implied that the man was despondent
about his prospects of being able to do the necessary courses to obtain
parole. The evidence from his friends would suggest that he remained
23
83. Despite any possible frustration or despondency about his future, the man
seemed well to all his friends when he attended Friday prayers on the day
before his death. He had not attended the service for around two months
and the Imam spoke to him to say how nice it was to see him there.
Afterwards he played table football with his friends, and his subsequent
death came as a surprise to all of them.
84. I have already remarked upon the scant wing records for the man. It is
impossible from what little is documented to assess any potential warning
signs that might have been missed. I take a good deal of comfort,
however, from the evidence of the psychiatric nurse about his practice in
speaking to wing staff about any concerns they might have and the fact that
no concerns were relayed to him about the man. The nurse also said that
the man was a person with whom it took time to build a relationship.
85. I conclude that there were no obvious recognisable signs to suggest that
the man was about to take his life.
The man’s clinical care and treatment
86. As noted earlier, the man’s clinical care and treatment has been reviewed
by an appointed doctor on behalf of the PCT. In brief, the clinical reviewer
says that the man improved from the appropriate treatment and support
provided for his psychotic illness. The clinical reviewer adds that, in his
experience, the improvement produced by treatment in patients such as the
man often results in them believing that medication is no longer required.
Their refusal of medication in turn often results in a subsequent relapse.
However, the clinical reviewer identifies no evidence of an apparent relapse
of the man’s psychosis in the final months of his life following his refusal of
depot medication in May 2008. The clinical reviewer refers to the support
provided to the man through weekly assessments by the mental health in-
reach service, through referral for psychiatric assessment as deemed
necessary, and through the spiritual advice and guidance provided by the
Imam.
87. The clinical reviewer concludes that it would be difficult to find fault with the
very frequent thorough assessments, treatments and support provided by
the prison and particularly the prison mental health services.
24
CONCLUSION
88. There were a number of areas where support from Elmley to the man was
deficient. He clearly remained confused about his status as an IPP
prisoner and that it would have been advisable for him to have engaged in
at least some purposeful activity, in particular, taking ESOL classes. He
also suffered the effects of what was a poorly functioning Personal Officer
Scheme.
89. That said, the man received intensive input from a nurse from the Mental
Health In-Reach Team and his evidence indicated that the man was not an
easy person to get to know and nor, perhaps, an easy person to help.
Moreover, not even his close friends, nor the Imam, recognised that he was
at risk. It might therefore be that the ultimate outcome would have been the
same regardless of any further support that could have been provided.
25
RECOMMENDATIONS
The following recommendations were made in the draft version of this report.
The Prison Service’s responses appear in italics following each
recommendation:
1. The Governor should ensure that relevant staff attend the Management
of Indeterminate Sentence Prisoners and Risk training course.
Recommendation accepted: Management of Indeterminate Sentence Prisoners
courses and Introduction to Risk Assessment and Management courses will be
focussed at staff who have not received the Lifer in the 21st century training
which has now been superceded. Available dates are scarce so current
development issues are being addressed through the staff performance and
development system. Review date is December 2009.
2. The Governor should review and address any other developmental needs
within the lifer unit team.
Recommendation accepted: As in 1 above. Review date is December 2009
3. The Governor should review the arrangements for provision of information
to prisoners about the operation of the lifer system. This should include a
review of the effectiveness of delivery of information to those with English
as a second language or other difficulties of understanding.
Recommendation partially accepted: IPP sentenced offenders are managed on
the ‘Offender Management Model’. They have an identified officer available to
them to support the induction information and to answer any ad-hoc matters that
may arise. The OM team does on a rotational basis attend each House Block to
answer any OM related enquiries weekly. OM Phase 3 introduced contact
arrangements between the offender and his offender supervisor. Such
arrangements are in place.
When an offender whose first language is not English receives an IPP
sentence, the Head of Reducing Re-offending will endeavour to ensure that the
offender is provided with written information about his sentence in a language
he understands. Further support will be made available for the offender through
the use of the ‘Big Word’, peer advisors, Listeners and Foreign National
representatives across the establishment who speak a number of foreign
languages. Review date is December 2009.
4. The Governor should satisfy himself that the Personal Officer Scheme is
now operating properly and in accordance with the local protocol.
Recommendation accepted: While the recent (April 2009) HMCIP report is very
positive, it does criticise the working of the personal officer scheme. The
establishment does accept that the scheme needs revamping in Elmley and the
new Head of Residence is reviewing the scheme to make it fit for purpose.
Review date is October 2009.
26