Individual at Pentonville

Investigation into the circumstances surrounding the
death of a man at HMP Pentonville
in December 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
December 2009
The man was found hanging in his cell at HMP Pentonville just before 9.00am on 29
December 2008. He had used a torn bed sheet as a ligature and attached it to the
window bars. A prisoner, on his way to move into the cell, discovered the man and
called for staff to help. The officers on the landing and healthcare staff responded
quickly but they could do nothing to save his life. He had been in the prison for less
than a week. My colleagues and I would like to extend our condolences his family
and all those affected by his loss.
The investigation was carried out by one of my investigators. The Primary Care Trust
(PCT) were asked to carry out a review of the man’s clinical care. Following various
delays and the resignation of one clinical reviewer from the PCT, the Deputy Chief
Executive at East London Foundation NHS Trust completed the review on behalf of
the PCT. I am grateful to the clinical reviewer for her assistance. The clinical
reviewer experienced some difficulty interviewing and getting information from
relevant staff and this too contributed to a delay in completing her report. The final
review was received by the Ombudsman at the beginning of September and I
apologise for the delay this has caused in publishing my own report.
The Governing Governor of Pentonville appointed a governor grade as liaison officer
with the investigator. Another member of staff from Pentonville worked with the
appointed governor to ensure that the investigation process ran as smoothly as
possible. I would like to the Governing Governor and his liaison team for their
assistance and co-operation with the investigation.
I make seven recommendations including those made by the clinical reviewer.
Additionally, the clinical reviewer has recommended that staff from the wing and from
healthcare involved in trying to resuscitate the man should be commended for their
efforts. I am pleased to note that following receipt of the draft report, all the
recommendations have been accepted.
Deputy Prisons and Probation Ombudsman December 2009
2
CONTENTS
Summary 4
The Investigation Process 5
HMP Pentonville 6
Key Findings 8
Issues Considered 17
Conclusion 20
Recommendations 21
3
SUMMARY
The man was a foreign national prisoner who was seeking asylum in the United
Kingdom. In September 2008, he was arrested and remanded to Brixton prison. His
case was transferred from the magistrates to the crown court, following which he
was remanded to Pentonville prison. He had been in Pentonville for six days when
he took his life.
There is very little information in man’s prison files. He did not come to the attention
of staff for any adverse behaviour with the exception of an altercation with another
prisoner at Brixton. He was assessed as a low risk prisoner for cell sharing, he was
on standard regime and was not thought to be at risk of harming himself by either
prison.
However, following his death several sources of information suggested a history of
mental health concerns although there is no information as to what they might have
been. When the records from Brixton and Pentonville were collated further
references to mental health issues were found. Due to various reasons I explore
later in the report, they were never communicated between the relevant
departments. With the information from all sources being scant, I am unable to
comment on whether appropriate diagnosis and treatment for mental health
problems, if relevant, would have changed the outcome for him.
The post mortem concluded that his death was from hanging. The toxicology report
found that he had high levels of alcohol in his system. It has not been possible to
confirm how or why he drank this level of alcohol. As someone who was described
as a devout Muslim, the use of alcohol and the taking of his life is even more
inexplicable as both are prohibited in Islam.
Having only been at Pentonville for six days, and it being the Christmas period, it has
been difficult to get any significant information from staff about his behaviour and
demeanour. From the interviews with staff, who had little or no knowledge of the
man, there were no indications of self harm. More usefully perhaps, were the
interviews with two of his friends in prison. Both friends saw him the night before he
died and neither had any indication or concern that he was going to take his own life.
From what evidence there is, it appears that his death could not have been foreseen.
4
INVESTIGATION PROCESS
1. The office asked for all the relevant prison documents including man’s core
prison records and medical file. The investigator also visited the prison to carry
out interviews and met a member of the Independent Monitoring Board (IMB)
and Prison Officers Association (POA).
2. Notices to staff and prisoners were sent to the prison to be displayed. They
invited anybody with information to talk to the investigator. Apart from the staff
and prisoners whom the investigators identified, nobody else came forward with
information for the investigation.
3. A review into man’s clinical care in prison was commissioned and initially
started by a clinical reviewer on behalf of the PCT. However, she left her post
and the review was passed to the Deputy Chief Executive at East London
Foundation NHS Trust. There were various reasons for delay and the final
review was received by the office at the beginning of September. The reviewer
made several attempts to speak to healthcare staff at HMP Brixton and
interview a nurse at HMP Pentonville who was part of the emergency response.
The nurse was on a period of sick absence and could not be interviewed.
Additionally, a Staff Nurse did not attend her scheduled interview and an
agency nurse who attended the man’s cell during resuscitation no longer works
at the prison. Unfortunately, these attempts to interview staff added to the
delay and meant that the reviewer was not able to progress all lines of enquiry.
4. HM Coroner for Inner North London was informed of the investigation. The
Coroner has kindly shared the post mortem with the investigators. He will
receive a copy of this report. A pre inquest was been scheduled for 14
September 2009.
5. The man’s next of kin live in Pakistan. Through the efforts of the Imam and
Governor at Pentonville, two friends in England were identified and informed of
his death by the Prison Service. One of the Family Liaison Officers has been in
contact with one of the friends who kindly acted as a liaison with his family.
They were offered the opportunity to be involved in this investigation and, via
his friends, have asked the investigation team the following:
1. How did he die?
2. Why was he in prison?
3. Was he beaten? Is there any evidence of bullying/threats against him?
4. Could the people he had been involved with in connection with the
criminal charges have threatened him or got someone to harm him?
I hope that this report addresses their questions and tells them more about the
last week of his life.
5
HMP PENTONVILLE
7. Pentonville is a Category B prison in North London. It serves the local courts in
North East London and currently holds up to 1,152 adult male prisoners either
on remand, convicted but unsentenced or sentenced.
8. As with other local prisons there is a high rate of movement of prisoners
through reception. In their 2008-2009 annual report, the Independent
Monitoring Board (IMB) noted that there are often more than 100 prisoner
arrivals and departures on a single day and about 7,500 prisoners a year start
a period of custody at Pentonville. The IMB also wrote
“[The] No 1 Governor remains determined and clear in his objectives, and
has impressed us with his accessibility to prisoners and staff. We are
pleased to report that his sustained efforts and those of his staff over the
last two years have continued to yield significant benefits …”
9. In relation to areas which link to the man’s circumstances, the IMB report
comments,
“… the safer custody team has been very professional and supportive,
learning from each of these incidents [two previous deaths] with the aim of
reducing the risks of future cases. The number of prisoners on open
ACCTs1… has fallen, enabling better scrutiny of those who really should
be regarded as being at high risk. The second area is the First Night
Centre (FNC) and the IMB reports as follows, “The FNC opened in July
2008, continues to develop. New prisoners arriving at Pentonville are
particularly vulnerable to self-harm or suicide. The effort prison
management puts into improving the experience of prisoners arriving in a
prison for the first night and initial few days is crucial to keeping safe those
prisoners and preparing them for life inside. The FNC should demystify
the prison experience … and the risk of suicide or self-harm is highest at
this stage. The FNC enables prisoners who need support and to
understand and survive the process and direct prisoners to programmes
and prison initiatives to give the prisoner the hope of rehabilitation”.
The full IMB report, and previous reports can be found on their website:
www.imb.gov.uk.
10. Her Majesty’s Chief Inspector of Prisons, carried out an inspection of
Pentonville in May 2009, but her report is yet to be published. The last
inspection was an unannounced one in June 2006. I do not go into the details
of the report given the length of time since it was issued and the fact that the
latest report is imminent. Further information can be found on the
Inspectorate’s website: www.justice.gov.uk/inspectorates/hmi-prisons
1 Assessment, Care in Custody and Teamwork (ACCT). A monitoring form and process for
supporting prisoners at risk of harming themselves.
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11. Since this office took over responsibility in 2004 for investigating all deaths in
prison custody, there have been 14 deaths at Pentonville. There were four
deaths due to natural causes and nine apparently self-inflicted deaths prior to
this man’s death. Two previous deaths, in 2005, were similar to in that their
post mortem results showed the presence of alcohol and both had been at
Pentonville for a short time.
7
KEY FINDINGS
12. The man was arrested in September 2008. His police custody record shows
that he saw a doctor in relation to a foot injury for which he was taking
antibiotics. The record also shows that he said he had a mental health
condition for which he took medication. Although there is a note that his
antibiotics were packed in his property, there is no mention of the medication
he took for the mental illness, nor further explanation as to what this might have
been. The following day, he was remanded into custody at HMP Brixton in
London.
13. At Brixton, a member of staff completed the man’s Cell Sharing Risk
Assessment (CSRA) with. Part of the form asks about previous drug or alcohol
abuse and he answered ‘no’ to both questions. Additionally, there are
questions about previous self harm monitoring and again he responded ‘no’.
He said that he did not have any concerns about sharing a cell and was
assessed by the officer completing the operational sections of the form, as low
risk2. The officer suggested that he share with a Muslim prisoner. The medical
section of the form assesses him as medium risk but does not give any reasons
to substantiate this. There is no further information in the man’s medical
records. Indeed, in the records provided to the investigator, there are no
entries between his arrival at Brixton and 2 October.
14. On 29 September, as part of his prison induction the man was interviewed for
the London Initial Screening and Referral (LISAR) assessment, which assesses
any needs or issues for example housing, employment or health. It is carried
out by civilian members of staff known as LISAR clerks. The man answered
‘yes’ to a question about any mental health problems in the past or present, but
there is no further explanation. He also answered ‘yes’ to having a physical
health problem. In response to the question “what medication are you currently
on?” it is written “tablets – not sure what called. Not sleeping”. It is therefore
unclear whether the medication was for physical or mental health problems or
referred to the antibiotics. The LISAR form notes that the man was helped to
complete an application to see the doctor and dentist, although no copies of the
applications were provided.
15. The medical records from Brixton show 13 contacts with healthcare staff.
These contacts include treatment for headaches, dry skin, stomach ache and
an infected toe ulcer. There are also entries relating to smoking cessation.
More significantly there is an entry on 29 October. It records,
“Hx [history] of low mood and angry feelings. Poor communicant due to
language difficulty. Says he has been thinking a lot, court case due next
week. Cannot sleep well but has no thought of self harm and no previous
hx of DSH [deliberate self harm]. Appears agitated, mood low, no thought
disorder, no auditory hallucinations. Review in 4 weeks.”
2 Risk factors are based on the rate of risk of harm to others.
Low Risk – No current indication/evidence of risk, suitable for multi-cell location.
Medium Risk – No immediate risk, but situation will need to be reviewed regularly.
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16. The medication prescribed was Hydrocortisone cream (for dry skin) and
Mirtazapine (an anti-depressant).
17. The four week review date would have been 26 November, but the record on
that day, only shows information about smoking cessation. In fact the next
recorded appointment he had with a doctor after 29 October, was on 18
December and there is no mention of depression, mental health or the
prescription of Mirtazapine.
18. The wing history sheets do not give much information about his time at Brixton,
in fact there are only three entries. The first two, written in September, were
about his reception into prison and the wing. The third, written on 21
November, related to a fight that he had with another prisoner. His medical
record shows that he received some treatment for an injury he sustained.
19. Following the man’s death, an Assistant Ombudsman spoke to the Imam at
Brixton. The Imam told the Assistant Ombudsman that the man regularly
attended Muslim worship and would also normally go to the prayer and study
group. He described him as a quiet person but that he always appeared “to be
okay”. He added that whenever he asked him how he was, he would reply that,
“he was well”. The Imam did not feel, in his opinion, that there was anything in
his manner to suggest he was depressed. The Imam said he viewed the man
as an active person in that he took the opportunities offered to him, such as
education, and always came to the prayer and study group without having to be
“chased along”.
20. The man’s case was transferred from the magistrates court to crown court. In
December 2008, he attended Crown Court. His full medical record should have
transferred with him but it arrived without a copy of the electronic record which
held all his relevant information. Additionally, perhaps because of the
Christmas period, there is no evidence that it was requested by Pentonville.
21. On his reception to Pentonville, the man was placed on the third landing on ‘A’
Wing (A3). ‘A’ Wing is the induction wing where prisoners, whether transferring
in from another prison or arriving in custody for the first time, spend one to two
weeks. The ‘3’s’ landing is specifically for prisoners arriving for the first night in
Pentonville. Prisoners are then moved around the wing as space becomes
available and, after a week or two, they move to a main residential wing. ‘A’
wing has places for nearly 200 prisoners.
22. As part of the reception and induction process, the man was seen by
healthcare and officers. He had another CSRA in which he was assessed as
low risk and suitable to share with another prisoner. It was completed by an
officer who also completed other areas of the induction process. The man
asked to share with another prisoner, but that prisoner was sharing with his
cousin at the time and did not want to change. At interview, the officer thought
that she might have been the member of staff who allocated his cell, but she
could not remember anything specific about the man.
9
23. A Registered General Nurse (RGN) who is currently the Ward Manager at
Pentonville, was at the time of the man’s death the charge nurse responsible
for managing the staff on duty, and maintaining standards and quality of care.
The RGN completed the healthcare reception screening (also referred to at
Pentonville as Grubin 1) with the man. As mentioned, the record with his
medical history had not arrived from Brixton and so the RGN had only the
information from the man. The RGN did not feel the language barrier was a
problem when interviewing him and thought the man understood enough to
complete the assessment. He confirmed that other prisoners would sometimes
be used as interpreters if there were difficulties. The RGN also said that the
prison had a new contract for interpreting services with The Big Word, although
after interviewing several staff it did not appear that this was well known.
24. In the screening ‘history’ section of Grubin 1, it notes that the man had drug
misuse behaviour, drug addiction maintenance therapy in the form of
methadone and that he was under ACCT processes. It goes on to record that
he was not receiving medication at the time, that he had a depressive disorder
but no thought of self harm and was depressed. He also said he had epilepsy
but then said he did not have any medication for the condition.
25. This information was contrary to the information and evidence already given to
the investigator and clinical reviewer, and so the RGN was asked in interview if
he could explain his findings. He said that the record was incorrect. He
clarified that after the man’s death they discovered that, due to the way the
computerised system was set up, if you were to click the computer mouse too
quickly or move it accidentally after making a selection it could choose the
wrong option. That is what happened when the RGN selected the ACCT option
and he confirmed that the man was not on an ACCT. The RGN also explained
that there was no option to choose ‘low in mood’ and that was why he put
‘depressive disorder’. Although when asked, he did explain that there is a ‘free
text’ box where additional comments could be entered but that was not “normal
practice”.
26. The RGN said that in his view, nothing “alarmed” him about the man and he
just appeared to be “low in mood”, which he felt was quite normal for people
arriving in prison. The RGN said he did not have any concerns about the
man’s mental health and otherwise he would have referred him to the mental
health team. The clinical reviewer asked about a comment made by the man
which is recorded in his notes. When he was asked about his next of kin, the
man told the RGN that his wife was dead and that he had killed her. The
clinical reviewer asked if this comment had prompted further exploration. The
RGN said that it had not because it had come across as a “throw away
remark”, and he understood the man to be on remand for drug related offences
rather than murder. The RGN thought that in hindsight maybe he should have
explored the comment further.
27. The RGN referred the man to the doctor because he had not arrived with a
prescription chart and, in his experience, prisoners will sometimes tell the
doctor something different than they tell other healthcare staff. This seemed to
be the case when asked about drug misuse and epilepsy. The RGN said that
the man told him he had misused drugs and was taking methadone as a
10
28. The following day, 24 December, the man moved from the third landing to the
fourth (A4). He also completed another LISAR assessment. One of the
questions concerns disability. He answered ‘yes’ and told the staff he had a
mental illness but, as in Brixton, there is no further information. The LISAR
clerk who completed the man’s form told the investigator that they can
complete up to 40 a day and she could not remember anything specific about
him. She did however remember that he told her he could not work due to a
mental health problem. It was at this point that she ticked the box referring to
disability. LISAR staff are not medically trained and not qualified to diagnose
an illness. They rely on information given by the prisoner and then make
appropriate referrals. In this instance, the man was referred to an external
mental health agency. No referral was made to the prison’s healthcare. In the
interview with the RGN, the investigator asked for clarification between the
LISAR assessment information and healthcare assessments and information.
It was clear that the RGN was not aware of the LISAR clerks or the screening.
29. The Imam saw the man on his transfer to Pentonville. During a conversation
with the investigator the Imam said that he would have seen the man during his
induction so that he was aware of the facilities and activities for Muslim
prisoners. In a statement the Imam later provided, he reiterated that his
contact with the man was brief since he had not been in Pentonville for long but
he had been on list for the Muslim service on Friday 26 December. The Imam
said that the man had attended, along with approximately 180 other prisoners.
The Christmas period would have meant that there was a limited regime in
place.
30. Another registered nurse saw the man on 28 December to interview him for the
secondary health screening (Grubin 2). The investigation team have been
unable to interview the registered nurse and so have relied on written evidence.
In her statement following the man’s death, the registered nurse said that when
she saw the man he appeared to be “in good spirits and was smiling and
making good eye contact”. He had complained of an itchy head, stomach
pains and problems sleeping. The registered nurse told him he would need to
see the doctor and explained how to fill in an application to do this. She
explained that he would not be able to see a doctor that day because it was a
Sunday. The registered nurse added that the man spoke poor English but that
she had been able to communicate parts of the assessment and complete the
screening. The man denied any mental health problems and, in her view, was
not behaving inappropriately nor appeared to be depressed.
11
31. At approximately 10.30am on 28 December the landing officers carried out the
cell fabric checks (CFC)3. An officer signed for the checks on the man’s
landing. The officer signing the checks could not remember if it had been
himself or a colleague working on the landing or both who checked the man’s
cell. The CFC checklist only records the state of the landing as a whole and
not the individual cells. On 28 December, the checklist showed that the cells
on A4 were ‘clear when checked’ (CWC) suggesting that there was nothing to
report.
32. One of the man’s friends in prison told the investigators that the man had
visited him in his cell during the evening of 28 December. He did not have a
kettle and the man did and had brought him some hot water. They had a cup
of tea and a cigarette. The friend said he did not notice anything different in the
man’s mood or behaviour. The friend had told prison staff that he believed the
man was waiting for a response to a bail application and was surprised that he
had taken his own life. (No information regarding a bail application was found
in his records.)
33. Prison staff also spoke to another associate of the man. The associate has
since been released from prison and the investigator was unable to interview
him. He told prison staff that he also saw the man on the evening of 28
December and had no indications or concerns that he would harm himself.
34. The man would have been locked back into his cell with the rest of the unit after
the evening meal time and association. He was alone in a double occupancy
cell. Once all prisoners are locked in their cells for the night a roll check is
carried out to ensure that everybody is accounted for. According to the roll
check log, a check was made at 9.00pm by an officer. (During the interview it
was explained that, although the roll check log states “21h00”, the checks
actually take place around 8.00pm so that the roll check count is confirmed
before staff go off duty at 9.00pm.) The officer who did the roll check told the
investigator that, although she remembered carrying out the roll she could not
specifically remember the man.
35. Two officers were on night duty. The night officer should make a roll check
once during their shift and again in the morning before handing over to day
staff. Both night duty officers have provided the investigator with a statement to
say that they were on duty and carried out the roll checks but cannot remember
which landings they each checked. The man did not press his cell bell during
the night nor come to the attention of staff in any other way.
36. Two further officers arrived on the wing at the start of the day shift on 29
December. One signed for the 7.30am roll check. However, when the
investigator spoke to him, he said that it was his night duty colleague who
checked the man’s landing. The night duty colleague has provided a statement
to say that he checked the fourth and fifth landings on A wing at approximately
3 The purpose of CFCs is to check the locks, bars, bolts of a cell as well as ensuring fittings etc. are in
working order and secure. Officers may look around the cell for unauthorised items but this is not the
main purpose of the CFC.
12
6.45am and did not find anything of concern. It can be assumed from this
statement that the man was still alive at the time.
37. Two further officers were both on duty on A wing that morning. This would
have been shortly before 8.50am. The officers were unlocking prisoners who
were due to move cells. In interview the officers said that another prisoner on
A wing was due to move into the man’s cell. One of the A wing officers told the
prisoner to make his way to A4 landing and wait for cell 15 to be unlocked.
38. The two A wing officers then moved to the next cell and were talking to some
other prisoners when they heard the prisoner who was due to move, shouting
down to them that somebody was hanging in the cell. Both officers made their
way quickly to the man’s cell. A third officer was also on the wing and
responded when he saw his colleagues running to A4 landing. The officers
arrived at the cell, the third officer unlocked the door and they went in. The
man was hanging from the window bars. The second A wing officer alerted
staff by using her whistle and in the meantime, the third officer lifted the man to
take his weight off the ligature, a bedsheet, while the second officer cut it with
his anti-ligature knife4. The officers laid the man on the floor and put him in the
recovery position and the first A wing officer used his radio to call for
assistance. The third officer said in interview that as he was taking the ligature
from the man’s neck, healthcare assistance arrived.
39. The registered nurse who carried out the second healthscreen (Grubin 2) was
in the adjacent wing when she heard the alarm over the radio. She collected
the medical emergency bag and arrived within a few minutes. The registered
nurse checked the man’s vital signs, observing that he was not breathing and
she could not find a pulse. She started chest compressions and was joined by
an agency nurse a few seconds later. The two nurses continued to administer
cardio pulmonary resuscitation (CPR). A senior healthcare manager was on
his way to a morning meeting when he responded to the call for assistance.
After assessing the situation he called for an ambulance and went to get a
defibrillator5.
40. The acting charge nurse heard the call over the radio and responded to the
wing with the staff nurse. The healthcare manager arrived at the cell with them
and applied the defibrillator. The acting charge nurse gave oxygen to the man
and then took over the chest compressions while the acting charge nurse
managed his airways. The defibrillator did not advise a shock, so CPR was
continued by healthcare staff until the London Ambulance Service paramedics
arrived at 9.06am. Timings vary in the records but the air ambulance (HEMS)
arrived between five and ten minutes later and their staff helped with the
resuscitation attempt. At 9.30am the emergency services staff could do
4 Also referred to as a ‘cut down’ or ‘anti-ligature’ knife. It is a knife designed make the
cutting of a ligature easier.
5 A defibrillator can restart the heart in some cases of cardiac arrest by giving an electric
shock. It detects the electrical activity in the heart and gives automated instructions to the
rescuer.
13
nothing more and stopped resuscitation. The air ambulance doctor
pronounced the man’s death.
41. The death in custody contingency plans were carried out including a hot debrief
for staff involved in finding and resuscitating the man. His cell was sealed, as
required by the plan, for the police to attend, but nothing suspicious was found.
There was no suicide note. The man’s family were concerned that he had
been threatened or hurt by somebody or at the request of somebody outside of
prison. There is no evidence to suggest that this was the case. He was on his
own in his cell when he died.
Events after the man’s death
42. The Governing Governor attended the prison. He carried out the ‘hot debrief’
for staff who had been involved in responding to the man’s death and later held
a full staff meeting to inform all staff of the man’s death.
43. All prisoners on open ACCTs were reviewed and all those who had ACCTs
closed in the previous three months were assessed as well. The man’s known
co-defendants at Pentonville were interviewed and any risk was considered.
44. The prison could not immediately identify the man’s next of kin. Their extensive
efforts included speaking to his co-defendants, speaking to the Imam at
Brixton, contacting UKBA, contacting the numbers on his pin phone and visiting
his last known address. Eventually the prison was able to contact two of his
friends. The Imam acted as a liaison between the prison and man’s friends and
accompanied them to view his body. The man’s friends have since visited the
prison and were liaising with his family. The prison Governor offered financial
assistance for the repatriation of the man’s body and for one of his friends to
accompany him home.
45. The man’s friends told the Governor that he had previous mental health
problems but that they were not “routinely visible but did occur when under
some pressure”. They confirmed that the man had been actively seeking
asylum. The information provided to the prison from UKBA referred to his
health problems being physical rather than mental. This would not have been
first hand information to the person providing the information and may have
been incorrect.
46. The man’s associate in prison who had spoken to staff, told them that he had
heard what sounded like a cell fight in the vicinity of man’s cell at approximately
11.00pm on the night of 28 December. The member of staff checked the wing
observation book, as did the investigator, but there is no record of any
incidents. One of the night duty officer’s also said she could not recall any
sound or noise.
47. The man’s friend who spoke to the investigator could not believe that the man
had taken his life particularly because he had spoken of his love for his
children. The prisoner thought that the man’s cell was open in the morning of
29 December and that there were prisoners walking about. He added that
there were two white prisoners on the landing near to the man’s cell. The
14
48. The investigator spoke to the prisoner who was in the cell next to the man. The
second prisoner said that he did not know him. He said he did not hear any
fighting or shouting the night before his death. He also heard nothing during
the morning until he heard the officers responding to the emergency call. The
man was in the cell on his own and it is unlikely that the noise was from his cell.
49. The investigator also spoke to a prisoner who shared a cell with the man for
one night. The third prisoner could not remember the specific night, but said he
did know the man. The third prisoner said that the man’s English was good
enough to get by, but the two of them spoke in Urdu which they could both
understand. The man had told him about his alleged offence and the third
prisoner remembers writing a letter for him to his solicitors. The man had told
him that he could not understand the law in Britain and wanted his solicitors to
arrange an interpreter for his court proceedings.
50. The third prisoner also explained how the man told him about his enemies in
Afghanistan and how it was they who sent a parcel of drugs to him so that they
could get him sent to jail and deported back to Afghanistan where they could
kill him. The investigator asked about the man’s general behaviour. The third
prisoner thought that the man always looked sad, which he thought was
because of the risk of deportation and his enemies in Afghanistan. He added
that he did not associate much with him at first. He said the man would not
make the first contact with others although he would talk to anybody. He added
that the man was not used to ‘prison etiquette’ and so would ask questions of
other prisoners that would not normally be asked. The investigator asked if this
led to any bullying or threats. The prisoner did not respond fully to this, but
spoke more generally about his dealings with the man. He wished that, as a
fellow Muslim, he had offered the man more support, explaining that in the
community he would have treated him as an elder and with more respect.
51. The post mortem gives the man’s cause of death as “Hanging”. His family
were concerned that there had been some violence, but the post mortem
comments that there were no significant marks of violence other than the
ligature mark. The toxicology report shows high levels of ethanol (alcohol) in
his system. He showed levels of 2.8g/L in his blood. The interpretation given
is that the legal limit of blood ethanol for driving is 0.8g/L and concentrations
above 3g/L are associated with serious toxicity.
52. There is no firm evidence to indicate how the man obtained the alcohol.
However, on 25 December 2008, another prisoner, who was a cleaner on B
wing, was removed from A wing on several occasions. Later he was
discovered to have been drinking and was placed on report by staff. The B
wing cleaners often go to A wing as part of their duties. One of the
investigator’s liaison officers said that he had spoken to the prisoner regarding
the man’s use of alcohol. The prisoner from B Wing said that he took alcohol
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53. A record of cell searching on A Wing, shows that the cells searched on 21, 22,
26 and 30 December 2008 found no unauthorised items. Security records
show five entries of potential ‘hooch’ finds in December. One of these, on 1
December, was on A Wing.
54. During a conversation with the investigator, the Imam said he was surprised
that alcohol had been found in the toxicology results. He was of the opinion
that the man was a devout Muslim and the use of alcohol is prohibited in Islam.
Likewise, when the Imam spoke with the investigation team about the
prohibition of alcohol in Islam, he thought it was out of character and could not
comment on why the man had consumed it. He added that he was unaware of
any issues in his private life that the man was trying to overcome.
55. The investigator spoke with the Principal Officer (PO) who has been in charge
of A Wing and Reception (Admissions) since November 2008. The PO
explained the new work he was implementing on the First Night Centre. At the
time of the man’s death only new prisoners, rather than those transferring from
another prison, completed a first night induction checklist. The PO could see no
rationale for not carrying out this process with prisoners transferring in as their
circumstances might have changed and it would familiarise them with the
systems in place at Pentonville.
56. The PO also redesigned the induction checklist so that it now includes more
questions to prompt fuller discussion as well as a column to note any action
which needed to be taken. A team of five dedicated induction officers has been
formed. At least two officers will be on duty to work with new prisoners. The
rationale is that the officers will have more knowledge and expertise in this area
and thus be a better and more consistent source of information. This should in
turn make the process of arriving at Pentonville easier for prisoners. There is
no suggestion that the procedures in place before these new initiatives
contributed to the man’s death but I am pleased to note that work is being
carried out which should improve the information obtained by and given to
prisoners entering Pentonville.
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ISSUES CONSIDERED
Clinical care
Medical records
57. The man’s full medical record did not transfer with him from Brixton to
Pentonville. Additionally, when the computerised printout of his medical history
was sent from Brixton, there was no information about his first week in prison,
including the reception screening information. This meant that Pentonville did
not have his medical or prescription history and were working only with what
the man told them.
58. That said, there is no evidence to suggest that his records were requested
promptly by Pentonville staff either. Whether this would have made a
difference to an appropriate assessment of any mental health concerns is
difficult to tell. Nevertheless medical records should transfer with a prisoner.
The Head of Healthcare (at Brixton) should satisfy herself that medical
records are transferred with all prisoners leaving Brixton.
The Head of Healthcare (at Pentonville) should ensure that systems for
chasing medical records either from another prison or community GP’s
are adhered to.
59. The details entered onto the man’s medical file during his reception into
Pentonville were incorrect. This was explained as being a combination of
computer error and lack of adequate list choices on the computer system.
These records are essential for the care and treatment of prisoners and should
always be accurate. Whilst I appreciate that room can be made for human
error, there was more than one false or misleading entry in his reception
screening assessment.
60. Additionally, from what the investigator and clinical reviewer were told, there
are no adequate alternatives in the drop down lists. However, even if this is the
case, there are free-text boxes where further explanation or clarification should
be recorded. Saying that it is not “normal practice” to use the box is not
acceptable when dealing with a person’s health.
The Head of Healthcare (at Pentonville) should ensure that all staff are
fully trained and competent in the use of computerised medical records
and the use of free text boxes should be encouraged.
Mental Health
61. The clinical reviewer thought that the remark the man made about killing his
wife during the reception screening was significant enough to warrant further
exploration. However, it was perceived as a ‘throw away remark’ by the RGN
who had no other information about the man’s mental health or his family
circumstances. We will never know why the man spoke in this way. It might
have been a random expression or it could have been an indication of mental
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The Head of Healthcare (at Pentonville) should explain the importance of
exploring unexplained issues or unusual comments made during the
assessment processes.
62. There is mention of mental health problems in the police custody record and
the LISAR form from Brixton, but this would not have been known to
Pentonville staff in reception. The man’s friends also mentioned a history of
mental health problems, but again this only came to light after his death.
63. The LISAR clerk at Pentonville noted a mental health issue and referred the
man to an outside agency. After speaking to the clerk and a member of
healthcare it was obvious that there was no joint working between the two
departments or with the operational staff. Given the length of time the man was
in Pentonville, he would probably not have had any significant mental health
input, but there is a clear gap in communication.
64. A variety of people had information that the man might have had mental health
problems. No further exploration was made and it is impossible to know what
type or to what extent he had a diagnosable or treatable mental health illness.
Had all the available information been shared, he might have been assessed
earlier and received treatment if it was appropriate.
65. It is important that all departments share information to ensure continuity and
appropriate care for prisoners.
The Head of Healthcare (at Pentonville) and LISAR clerk manager should
ensure that there are systems in place to share information within the
prison.
Consumption of alcohol
66. The toxicology tests after the man’s death showed a very high level of alcohol
in his system. From speaking to the Imams, this would seem to have been
very out of character particularly because of his Islamic faith which prohibits
alcohol. There is no information to suggest that he consumed alcohol at any
other time of his life.
67. No alcohol was found in the man’s cell when it was searched after his death. It
is known ‘hooch’ was available on A wing during in December, but I am unable
to confirm whether or why he decided to obtain it. It is also not possible to say
when he would have consumed the alcohol. The clinical reviewer has
commented that she was surprised that nobody realised he was intoxicated.
However, after the 7.30am roll check (which is said to have taken place at
6.46am), there would have been no need for any staff to see him until later in
the morning. Without knowing when the consumed the alcohol it is difficult to
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68. The manufacture and consumption of ‘hooch’ within prisons is unfortunately an
age-old tradition, particularly around the festive season. However, that he was
able to obtain and consume such a considerable amount raises safety and
security issues. The Ombudsman made similar comments in two previous
Pentonville deaths in custody reports in 2005. I do not doubt that action was
and is being taken to control the problem but nevertheless repeat the
recommendation here.
The Governor should investigate the extent of alcohol production at
Pentonville and establish a plan to deal with the findings.
Use of interpreters
69. The man’s first language was Pushtu. The general understanding from staff
interviewed was that he knew enough English to ‘get by’. There are systems in
place for staff to use interpreters through a contract with The Big Word. The
staff who the investigator spoke to seemed generally unaware of the service
and were not using it, preferring to rely on other prisoners who could speak the
relevant language. This will not always be appropriate, particularly in medical
situations, and staff should be aware of the professional services available.
The Governor should ensure staff have up to date knowledge of the
services available to assist those prisoners whose first language is not
English.
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CONCLUSION
70. The man was in Pentonville for six days. With close to 200 prisoners on A
wing, and many moves on and off the wing, it has been difficult to find anybody
who knew him well or staff who had any significant contact with him. As a
result, it is also difficult to know whether or not there was any obvious change
to his mental health over the short time he was in Pentonville. None of the staff
or prisoners interviewed for this investigation thought that he was at risk of
suicide.
71. The man was not subject to ACCT either at Brixton or Pentonville. He was
assessed as low risk for sharing a cell. There was no security intelligence that
raised any concerns about his behaviour.
72. It is a sad fact that, in busy local prisons, unless prisoners stand out for good or
bad reasons, staff have limited opportunities to have any meaningful interaction
with them. The population in a prison such as Pentonville is high and transient,
particularly in the first night centre. From the information available, there does
not appear to have been any visible indication that the man planned to take his
own life. Notwithstanding my recommendations about information sharing, I do
not believe that prison or healthcare staff could have prevented him doing so.
His reasons are unclear and may be linked to worries about spending a long
time on remand.
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RECOMMENDATIONS
Brixton
1. The Head of Healthcare should satisfy herself that medical records are
transferred with all prisoners leaving Brixton.
This recommendation has been accepted.
Pentonville
2. The Head of Healthcare should ensure that systems for chasing
medical records either from another prison or community GP’s are
adhered to.
This recommendation has been accepted.
3. The Head of Healthcare should ensure that all staff are fully trained
and competent in the use of computerised medical records and the use
of free text boxes should be encouraged.
This recommendation has been accepted.
4. The Head of Healthcare should explain with staff the importance of
exploring unexplained issues or unusual comments made during the
assessment processes.
This recommendation has been accepted.
5. The Head of Healthcare and LISAR clerk manager should ensure that
there are systems in place to share information within the prison.
This recommendation has been accepted.
6. The Governor should investigate the extent of alcohol production at
Pentonville and establish a plan to deal with the findings.
This recommendation has been accepted.
7. The Governor should ensure staff have up to date knowledge of the
services available to assist those prisoners whose first language is not
English.
This recommendation has been accepted.
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