Individual at Lincoln

Investigation into the circumstances surrounding the death
of a man
at HMP Lincoln in October 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
June 2009
This is the report of an investigation into the death of a man at HMP Lincoln in
October 2007. At 1.40pm on the day of his death, the man was found suspended by
a ligature in his cell in the prison’s segregation unit. A post mortem examination
carried out that day confirmed the cause of his death as hanging. A toxicological
analysis revealed the presence of a sub-therapeutic level of temazapam
(benzodiazepine) in the man’s body. However no opiates were present.
I offer my sincere sympathy and condolences to the man’s family and friends for their
sad and untimely loss.
The investigation was conducted by my colleague.
I also commissioned a clinical review of the management of the man’s health needs
while he was in custody. This was conducted by a representative of the local Primary
Care Trust. I should like to thank the clinical reviewer for her significant contribution
to the investigation.
My thanks also go the Governor and his staff at Lincoln for their help and co-
operation during the investigation. I pay particular tribute to the investigation liaison
officer whose help was invaluable.
On 14 December 2007, my colleague and one of my Family Liaison Officers met the
man’s parents in order to ascertain whether there were any matters they wanted the
investigation to address. They raised a number of points of concern which I trust
have been adequately dealt with in this report.
The investigation found the man’s health needs were satisfactorily met while he was
in custody. I hope that the recommendations I make will help to prevent similar
further tragedies at Lincoln and elsewhere in the Prison Service.
In April 2006, I published the report of my investigation into the death of another
prisoner at Lincoln that had occurred 17 months earlier. In that report I made a
number of recommendations including three that related to the management of
segregated prisoners. The Prison Service accepted all the recommendations.
Although similar issues have arisen in this investigation, I am pleased that I have not
had to repeat any of my earlier recommendations.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman June 2009
CONTENTS
Summary
Investigation process
HM Prison Lincoln
Key events
Issues
Recommendations
SUMMARY
The man was born in Nottingham in July 1982. As a young boy, he behaved well,
and became popular at primary school, where he played football and sang in the
choir. He enjoyed family life. Later, he moved to a comprehensive school, but left at
age 16 with no qualifications. He worked with his father for a while and later took a
job delivering coal. During this time, the man started to use drugs and took to crime
to feed his habit. He frequently appeared in court and was given numerous prison
sentences.
The man was arrested in June 2007 for interfering with a vehicle and was taken into
police custody in Nottingham. He told a doctor he had ingested a large number of
wraps of heroin. His police medical notes indicated that he did so as an attempt to kill
himself, but he told prison staff he wanted to avoid detection by the police. He was
bailed so that he could be admitted to hospital for examination and observation. His
records show he passed the wraps naturally and caused himself no harm. The next
day the man discharged himself.
As he was leaving the hospital premises the man tried to break into a car in the
hospital car park and was caught and arrested. The next day he appeared in court
and was sentenced to 14 days imprisonment. The man served this sentence in HMP
Nottingham. Here he displayed no signs of being at risk of suicide and was released
on 5 July.
A fortnight later the man was arrested for breaching an Anti-Social Behaviour Order.
He appeared before Nottingham magistrates and was remanded in custody at
Nottingham. Again, during the reception procedures the man was not considered to
be at risk of self-harm or suicide. However, he admitted he had used drugs during
the previous month. He said he had been placed on a methadone detoxification
programme when last in prison and agreed to comply with a methadone treatment
plan during his current sentence.
On 23 August the man was sentenced to four months imprisonment for theft from a
vehicle and a further consecutive sentence of four months for breach of his Anti-
Social Behaviour Order.
In September, evidence came to light that the man was behaving improperly towards
a female member of staff. As a result, he was transferred to HMP Lincoln. Upon his
arrival there on 27 September, he was not assessed as at risk of self-harm or suicide.
Initially the man settled at Lincoln. He engaged with the Counselling, Assessment,
Referral, Advice and Throughcare (CARAT) service and with the Substance Misuse
Team, agreeing a care plan to reduce the harm he was incurring by his drug
dependency.
On 13 October the man asked for his detoxification medication to be changed from
methadone to subutex. It was from this point that his behaviour started to deteriorate.
On 19 October, he was found in possession of a drug smoking implement. At a
subsequent disciplinary hearing, he was given a punishment of loss of various
privileges. On 24 October the man was rude to an officer. That same day, he
allegedly assaulted a senior officer. As a result he was taken to the segregation unit.
The next day the man was given three days’ cellular confinement for being rude to
the officer. During the morning of 26 October, the deputy governor opened an initial
hearing in relation to the man’s alleged assault on the senior officer. She decided
that an independent adjudicator should deal with the case. The man was therefore
kept in the segregation unit to complete his period of cellular confinement and to
await the hearing by the independent adjudicator. At 1:40pm that day, he was found
hanging in his cell.
The investigation found that the man displayed no obvious signs that he was at risk of
suicide either at Nottingham or at Lincoln. There were therefore no grounds upon
which staff could reasonably have been expected to subject him to formal self-harm
monitoring procedures.
The marked deterioration in the man’s behaviour in the fortnight before his death
could, in my view, be linked to the fact that he may have taken cannabis at the very
time he was on a rapid methadone detoxification programme. It may also have been
linked to the change from methadone to subutex at this own request. The clinical
reviewer points to the fact that rapid detoxification from methadone can result in both
physical withdrawal symptoms and the precipitation of psychosis with abnormal
behaviour patterns. However, the reviewer draws the conclusion that in the man’s
case there was no reported evidence of physical withdrawal symptoms during the
detoxification process and nothing to suggest the development of a mood disorder or
psychosis.
My report shows that, in general terms, the man’s mental and physical health needs
were adequately met while he was in custody. I believe the decision to segregate
him on 24 October was justified by the circumstances of his behaviour. I take the
view that the requirements of Prison Service Order 1700 (The Management of
Prisoners in Segregation Units) were satisfactorily met.
My report nevertheless makes recommendations about the management of prisoners
on detoxification programmes. I also make recommendations about record keeping,
the availability of emergency first aid equipment and the need to encourage prisoners
to disclose details of their next of kin during the reception process.
I commend the staff who attempted to save the man’s life in harrowing
circumstances. I also congratulate the establishment’s family liaison officer for the
fact that she informed the man’s family of his death within three and a half hours,
despite immense difficulties in tracing them. I draw attention to an example of good
practice in healthcare.
INVESTIGATION PROCESS
1. The investigation was conducted by my colleague. On 30 October 2007 my
colleague formally opened the investigation at Lincoln by meeting the deputy
governor, the chair of the local Independent Monitoring Board and the
investigation liaison officer. The local branch of the Prison Officers’
Association were invited to the meeting but no-one was able to attend.
Notices to staff and prisoners were posted that day inviting anyone with
information about the man to make themselves known to my colleague. No-
one came forward.
2. Twelve members of staff and two prisoners were formally interviewed at
Lincoln. Informal discussions were held with eight other members of staff. My
colleague also exchanged correspondence with the Governor of HMP
Nottingham about events that occurred while the man was there.
3. I also commissioned a clinical review of the management of the man’s health
needs while he was in custody. This was undertaken by the clinical reviewer
on behalf of the local Primary Care Trust.
4. On 14 December 2007, my colleague and one of my Family Liaison Officers
met the man’s parents in order to ascertain whether there were any matters
they wanted the investigation to address. His parents were particularly
concerned to discover whether he had been treated fairly by the Prison
Service in relation to suspicions that he had behaved improperly towards a
female member of staff at HMP Nottingham. This matter is dealt with in the
report.
HMP LINCOLN
5. Lincoln is a local prison of Victorian design, situated about two miles from the
city centre. The prison receives convicted and remanded adult male prisoners
from Magistrates and Crown Courts in Lincolnshire and Nottinghamshire.
6. The accommodation comprises A, B, C, D and E Wings. A Wing holds
prisoners on induction as well as those participating in detoxification
programmes. One of its landings is for enhanced remand and convicted
prisoners. Another landing is the first night centre. B and C Wings hold
sentenced and convicted prisoners. D Wing is the segregation unit. E Wing is
for vulnerable prisoners. At the time of the investigation, the prison held nearly
700 prisoners, a number well in excess of its accepted operating capacity.
7. At the time of the investigation, healthcare at Lincoln was provided by the West
Lincolnshire Primary Care Trust (PCT). (It is now provided by the Lincolnshire
PCT.) The healthcare centre offers 24 hour nursing and medical care and has
in-patient facilities.
8. The prison was last visited by Her Majesty’s Inspectorate of Prisons in
December 2007. The following are relevant extracts from the report of that
inspection, published in March 2008:
“On our last visit, we noted that both the fabric of the
prison and the morale of staff remained damaged by the
effects of a serious riot in 2002. On our return for this
full announced inspection, we were pleased to find that
not only had the damaged accommodation been
repaired and brought back into use, but that in most
obvious respects, the prison had returned to normality ,
although there remained plenty of scope for further
improvement.
“Fortunately, caring staff - well supported by prisoner
Insiders – made good efforts to help prisoners through
their early days and a new first night centre had just
opened. Suicide and self-harm arrangements were
sound, as was clinical support for detoxification.
However, prisoners told us that illegal drugs were readily
available. This no doubt added to an evident bullying
problem, which was a particular issue on the poorly
managed vulnerable prisoner unit. The segregation unit
was grubby and badly in need of refurbishment.
“The environment was generally clean and bright,
particularly the refurbished A Wing, and access to
telephones and showers was good. Staff-prisoner
relationships were positive. They were supported by an
effective personal officer scheme, which is not
something we often find in busy local prisons with
transient populations….Health services were good, but
healthcare staff were not sufficiently into the work of the
prison.
“Lincoln prison has gone through a difficult period, but
this inspection found that normality had returned, with
both accommodation and staff morale repaired following
the disturbances. In effect, the prison had successfully
turned a particularly unfortunate page in its history.”
9. The following are extracts from the annual report by the Independent
Monitoring Board for the period 1 February 2007 to 31 January 2008:
“Prisoners can be placed on the Assessment, Care in
Custody and Teamwork (ACCT) document that is an
effective method of recording and caring for prisoners
who may be at risk of suicide or self-harm. During the
reporting period, 457 documents were opened and 412
closed. Board members monitor these documents on
every rota visit and are satisfied that the procedure
works well.
“Sadly, it has to be recorded that there were two deaths
in custody during the reporting year. It must however be
recorded that a large number of lives are saved due to
the diligence of staff of all grades. Records show there
were 226 incidents of self-harm reported (which do not
include prolific self-harmers).
“The Samaritan led Listener scheme trains some
prisoners to provide an essential listening service for
other prisoners. There are dedicated Listener suites
used for this purpose and the scheme is well used to
great effect.
“There is a well-regulated anti-bullying/violence
reduction policy.
“Prisoners in segregated conditions are located in D
Wing staffed by a professional team of officers. Despite
many changes in the personnel working in this area,
they continue to achieve a high level of care. IMB
members attended 100 Good Order and Discipline
reviews in accordance with PSO 1700 that considers
circumstances surrounding a prisoner being held in
segregated conditions.”
KEY EVENTS
Background
10. On 27 June 2007, the man was arrested for interfering with a vehicle and was
taken to Bridewell police station in Nottingham. The police doctor examined
the man at 1.25pm that day and made a note of his findings in a Detained
Person’s Medical Form. He concluded that, although the man was showing
signs of the effects of drug abuse, he was not currently withdrawing. The
police doctor prescribed anti-nausea medication and advised that the man
should undergo “routine observations”. He judged the man to be fit for
detention and interview in police custody. He recommended that the man
should be reviewed again at 9.00pm. Although the man was detained
overnight, there is no evidence to show whether the recommended review took
place.
11. A second Detained Person’s Medical Form shows the man was examined
again at 11.05am the next day, this time by a second police doctor, who made
the following note:
“D/p is oriented to person place and time sia (sic) well
perfused and has no obvious injuries at present. Dp has
self discharged from QMC after ingestion of 10 bags of
heroin 17 and requires immediate return to A&E for
further assessment as dp isn’t fit for detention at
present. QMC are expecting dp today. Medical advice-
half hourly observations and further assessment at QMC
today.”
12. In spite of the above comments, the form shows that the second police doctor
ticked the boxes showing that the man was again considered to be detained
and interviewed.
13. The man was bailed by the police so that he could attend the Acute Medicine
Unit at the Queen’s Medical Centre in Nottingham. A consultant made the
following note in his file:
“Yesterday swallowed 10 heroin wraps - intention to kill
himself. Self d/c (discharge) -court- returned to
complete period of obs. No effects clinically of
absorption of opiate. Main diagnosis at discharge:
Intentional heroin overdose. Follow up: GP.”
14. After having discharged himself, the man tried to break into a car parked near
the hospital premises. He was seen and later arrested.
HMP Nottingham: 29 June to 5 July
15. On 29 June 2007, the man appeared at Nottingham Magistrates court charged
with interfering with a vehicle. He pleaded guilty and was given a sentence of
14 days imprisonment. He was taken to Nottingham prison that day, arriving
at about 5.50pm. The Prison Custody Officer (PCO) who escorted the man
between the court and prison, completed a self-harm warning form. This form
is used to draw attention to a perceived risk of self-harm of suicide so that the
various agencies involved in managing an offender can take steps to monitor
the individual concerned. The PCO wrote on the form, “DP (detained person)
swallowed 19 bags of heroin yesterday (28.6.07). Seems in good frame of
mind at present.”
16. A prison reception officer was on duty in reception at Nottingham when the
man arrived. He signed the warning form to acknowledge that he had seen it.
First reception health screen
17. The warning form was also signed by the prison reception nurse who carried
out the man’s first reception health screen. The man told her his date of birth.
He said he had been living in Nottingham and was registered with a doctor in
Kirkby-in-Ashfield. The man disclosed that he had been released from HMP
Ranby earlier in the year. He also said he had seen a doctor recently after
swallowing “large quantities of drugs”. He had no outstanding medical
appointments and was not receiving any prescribed medication. He said he
had sustained no physical injuries in recent days and had no concerns about
his physical health. The prison reception nurse recorded that the man was
“healthy in appearance”. She then turned to the subject of substance misuse.
The man told her he did not drink alcohol but had taken heroin at a daily cost
of £15. He said he had last used heroin three days earlier and had taken
cannabis every day.
18. As far as his mental health was concerned, the man told the prison reception
nurse he had received psychiatric treatment in the community because of self-
harm issues but had never actually harmed himself. He said he had never
been in a psychiatric hospital and did not have a psychiatric nurse or care
worker. He had never received any medication for mental health problems.
The man told the prison reception nurse he did not feel suicidal. The prison
reception nurse recorded that the man’s behaviour seemed calm and
appropriate. At his own request the prison reception nurse referred the man to
a doctor for detoxification and to the CARAT (Counselling, Assessment,
Referral, Advice and Throughcare) Service. At 6.00pm, the prison reception
nurse made the following entry in the man’s medical record:
“Inmate seen on reception. Known drug user. Has just been
discharged from Queen’s Medical Centre (QMC) after
swallowing 10 (sic) of heroin to conceal them from cops.
Was given laxatives and says he passed them BD. Appears
fit and well. No mental health issues. No self-harm/suicide
ideation expressed. For substance misuse team and MO
(Medical Officer).”
19. As there were no current concerns about self-harm, the man was not made
subject to self-harm monitoring procedures. Following his referral to the doctor,
the man was placed on the detoxification regime shown in the following tables.
Stabilisation:
Day Given by (signed)
AM PM Date AM PM
One - 20mls 29.6.07 - Officer
Two 10mls 15mls 30.6.07 Officer Officer
Three 25mls - 1.7.07 Officer -
Four 30mls - 2.7.07 ? -
Five 30mls - 3.7.07 ? -
Detoxification:
Day 25mls - 4.7.07 UHH
six
Day 25mls - 5.7.07 ?
seven
Signed Illegible
Name Illegible
Date 29.6.07
20. At 7:00pm the prison reception nurse made the following further entry in the
man’s medical record: “Contacted ward B3 to confirm about care given. They
will look for the notes and get back to us.”
21. The next entry was made by a doctor whose signature is illegible. The doctor
wrote, “On examination, withdrawal. Plan: methadone detox.”
22. The man was released from Nottingham in July. Arrangements were made for
him to be given a 25 ml dose of methadone in the morning prior to his release.
He was also advised to contact a Drug Abuse Clinic in Nottingham. However,
only a little over a fortnight later, the man was back in prison.
Nottingham: 23 July to 27 September 2007
23. In the early hours of 22 July the man was arrested for breaching an Anti-Social
Behaviour Order. He was detained overnight in Bridewell Police Station in
Nottingham. Whilst there, he underwent a urine test that showed he had taken
a Class A drug. An appointment was made for him to undergo a mandatory
initial assessment with a drugs worker from the Criminal Justice Intervention
Team (CJIT). The investigation found no evidence to show whether that
appointment materialised.
24. The next day, the man appeared before Nottingham Magistrates. He was
remanded in custody at HMP Nottingham and ordered to return to court on 30
July via video link. He was taken back to Nottingham later that day, arriving at
approximately at 2.40pm.
25. During the reception procedures, the man told staff he was single and had no
occupation. He said he had been living in the Radford area of Nottingham
prior to his arrest. He gave no details of his next of kin.
First reception health screen
26. The prison reception nurse, who had seen the man when he was last received
at Nottingham, carried out his reception health screen. The man told her he
was not registered with a doctor, but had consulted one during the previous
few months. The man disclosed that he was currently taking prescribed
medication but did not have any outstanding medical appointments. He said
he had not sustained any physical injuries recently and had no concerns about
his physical health. The man said he did not drink alcohol but admitted he had
used drugs during the previous month. The table below shows which drugs
the man said he had used.
Drug Frequency Last used
Heroin On and off 21 July 07
Methadone Daily 21 July 07
Benzodiazepine
Amphetamine
Cocaine/Crack On and off 21 July 07
Cannabis Daily
Other
The following table shows the results of a urine test the man underwent the
same day.
Heroin Positive
Methadone Positive
Benzodiazepine Not tested
Amphetamine Negative
Cocaine/Crack Positive
Other Positive
27. As far as his mental health was concerned, the man told the prison reception
nurse he had never been a psychiatric outpatient or inpatient. He said he did
not currently have a psychiatric nurse or care worker and had never received
any medication for mental health problems. He said he had never tried to
harm himself either in prison or in the community and did not feel like harming
himself now that he was in prison again. The man did not wish to see a
doctor. The prison reception nurse recorded that she had no concerns of any
note about the man’s behaviour or his mental state. She gave him a health
care services leaflet and referred him to a doctor with regard to his substance
misuse. The prison reception nurse also referred the man to CARATs. She
considered that he was fit for normal location (i.e. for location in a wing rather
than in the healthcare centre). As there were no current concerns about his
risk of self-harm, formal self-harm monitoring procedures were not invoked.
Substance misuse assessment
28. On 23 July, the man underwent a full assessment by the joint substance
misuse team and CARATs. After giving a urine sample, the man tested as
follows:
Drug Result
Amphetamine Negative
Cocaine Positive
Morphine Positive
Cannabis Negative
Subutex Positive (One off)
29. The record of the assessment shows the man presented signs of shivering,
aches, back pain, watering eyes and yawning. He disclosed that he was used
to smoking or taking heroin intravenously at a daily cost of £30 and crack at a
cost of £100 each day. He said he had last taken both drugs on the previous
Tuesday. Finally, the man told the assessors he smoked cannabis daily and
had taken subutex on one occasion. He said he had been placed on a
methadone detoxification programme when last in prison and agreed to
comply with a methadone treatment plan during his current sentence.
30. A prison officer conducted a cell-sharing risk assessment in conjunction with
the prison reception nurse. After interviewing the man they concluded that
there were no indications of any risk of self-harm and that it was safe for him to
share a cell.
31. On 30 July, the man appeared before Nottingham Magistrates via video-link.
As a consequence of the fact that he had offended whilst on bail the
magistrates decided to refuse bail on this occasion. The man was therefore
remanded in custody and ordered to return to court on 23 August.
32. At about 11.45am on 2 August, the man’s cellmate assaulted him in their cell
during a game of backgammon. The man sustained minor bruising to his face
and lower lip. He was examined by a nurse who gave him a paracetamol
tablet but decided no treatment was required.
33. The Legal Services department for Nottingham City Council applied in August
for the man to be produced at Nottingham City Magistrates Court for a hearing
at 2.15pm on the next day. The council wished to apply for a further ASBO as
the man’s current interim order was due to expire that day.
34. The man was taken to Nottingham Magistrates court on 23 August. He was
sentenced to four months imprisonment for theft from a vehicle and a further
consecutive sentence of four months for breach of his Anti-Social Behaviour
Order. He became eligible to be released from custody under the Home
Detention Scheme on 23 October 2007. His sentence would have expired on
22 December that year.
Alleged inappropriate behaviour towards a female member of staff
35. On 16 September, the following information was entered into the man’s
security file by a female CARATs worker at Nottingham:
“Over the past two weeks the man has been making
inappropriate comments to me with reference to females of
interest to a female member of the CARATs team (sic). Initially
I thought it was another member of the team. He did not
mention names but he stated that he had feelings for and could
change for. This was challenged on several occasions.
However, on 10 September, he stated his interest was in me. I
feel his comments made to me were inappropriate.”
36. A security manager later made the following entry in the man’s core prison
record: “Spoke to prisoner re inappropriate behaviour with female staff.
Warned re this and staff to monitor his behaviour and SIR (security information
report) any inappropriate behaviour.”
37. A prison Senior Officer recorded the following:
“The man has been put on the risk to females register…as his
behaviour is not deemed appropriate. I have also informed the
man that he will be moving wings. The man stated he knew he
was on the risk to females register. However, did not comment
on anything else at this time.”
38. On 20 September, the prison Senior Officer wrote:
“On informing prisoner to pack his own kit as he is being
allocated to D Wing, he has issues there with two other
prisoners. They will end up fighting. States he cannot go
to D or E Wings because of following inmates: (names
withheld).
39. The Governor of Nottingham later told my investigator that on 14 September,
the CARATs worker reported that the man had kissed her. A meeting was
convened later that day to decide how to manage the issue. Present at the
meeting were the woman concerned and three members of staff, including the
woman’s line manager. It was decided the man should be warned about his
inappropriate behaviour and a male CARATs worker should be assigned to
him. On 19 September, it came to light that the man was still trying to see the
member of staff. A further meeting was therefore convened that day at which
it became apparent that the man was exploiting every opportunity to make
contact with her.
40. On 21 September, the man submitted a formal complaint about being placed
on the ‘risk to females’ register. In her response to the complaint, the Head of
Residence justified the decision.
41. It was later decided the man should be transferred to another prison. Initially
HMP Ranby was chosen but this was later cancelled for operational reasons.
As a result of the cancellation, it was decided to move the man to another wing
so that he could not see the woman any more. When staff attempted to move
him, he became aggressive. He was therefore re-located to the segregation
unit. The next day, 27 September, the man was transferred to Lincoln.
Lincoln: 27 September to 26 October
Reception health screen
42. The only evidence in the man’s medical record to show that a health screen
took place upon his arrival at Lincoln in September is contained in the following
entry made that day: “Transferred in from Nottingham on maintenance
methadone. To continue. Referred to detox. No dsh (deliberate self-harm)
suicide or mh (mental health) issues. In good humour.”
Cell-sharing risk assessment
43. A cell sharing risk assessment was carried out by a prison officer and prison
nurse as part of the reception procedures. After interviewing the man they
considered that he presented a low risk of harming others and they had no
concerns about self-harm.
Induction
44. The Chaplain, a CARATs worker and an officer conducted induction interviews
with the man. He admitted to using illegal drugs and said his offending
behaviour was linked to his drug addiction. He said he had sought help for his
drug abuse by using the CARAT service during previous periods of
imprisonment. A referral was therefore made to the CARAT service at Lincoln.
45. As far as his domestic circumstances were concerned, the man said his next
of kin was his best friend. It is not clear what, if any, contact details were
disclosed about his friend. The man said he had no contact with his family
since his arrival at Lincoln but did not want anyone to contact them on his
behalf.
Interview with Substance Misuse Team
46. On 28 September a member of the Substance Misuse Team at Lincoln,
interviewed the man in order to assess what support he needed in relation to
his drug abuse. The member of the Substance Misuse Team decided he
should continue with his methadone programme until his release from prison.
Application to become a Listener
47. On 8 October, the man applied to become a Listener. In his application form
he wrote, “I would like to be a Listener as I’ve been one before and was
waiting to be one at Nottingham and I’m very interested. Check my wing
record. Thank you.”
48. The man’s wing manager commented upon his application as
follows:
“The man arrived at HMP Lincoln on 27.9.2007. Since his
arrival he has not to come to the attention of staff. He has no
adjudications at HMP Lincoln and is always polite to staff and
other inmates. He shows a willingness to become a Listener
at Lincoln and states he held this position at HMP Notts
though this is not confirmed.”
49. There is no evidence in the man’s record to show what, if any, action was
taken in respect of his application. The investigation found no evidence to
show whether the man became a Listener.
CARATs interview
50. On 11 October the man’s CARATs worker made initial contact with him and
opened a Drug Intervention Record. A copy of the record was sent to the
Criminal Justice Intervention Team (CJIT). The man told the CARATs worker
he liked socialising, football and using the gym. He said his life was “not just
about drugs”. He had been expelled from school when he was 13 and again at
15. At the age of 16 the man had been employed for 18 months as a coalman.
This had been his only experience of employment. He told the CARATs
worker he was keen to get a job on release but did not know what type of job
he wanted.
51. The man disclosed that his drug use was always out of control. He would
worry about the prospect of missing a “fix”. He said he wished he could stop
taking drugs but knew it would be very difficult. He said he depended on
committing crimes to fund his drug use. He lived with friends who were aware
of his drug use and who would support him if he stopped. He was intent on
returning to live with them on release.
52. The man told the CARATs worker he was fully aware of the risks involved in
injecting and sharing needles. However, he said he did not inject himself often
and was careful when he did. He said he valued his health and had “just
finished detox ”. He said he was currently drug free (i.e. he was not using
illegal drugs) and on a subutex “script” (prescription).
53. The CARATs worker told my investigator the man was keen to give up drugs
and wanted to join a short duration drug programme. (This is a month-long
course designed to counsel those prisoners whose sentence length is too
short to enable them to undertake more comprehensive courses.) The
CARATs worker set out a care plan for the man in which his attendance on a
short duration programme was the principal aim.
Cell-sharing
54. On 13 October another prisoner was located in the same cell as the man. The
two prisoners shared the same cell until 24 October when the man was moved
to the segregation unit. At interview the prisoner explained he had not met the
man before they were co-located. He said the man appeared to him to be a
happy sort of person. The prisoner was a drug addict and knew the man was
addicted to heroin and was struggling to become drug free by the time he was
due for release. The prisoner stressed he thought the man was not the sort of
person to take his own life.
Conversion from methadone to subutex
55. On the same day, the man asked for his detoxification regime to be changed
from methadone to subutex. His request was referred to the duty doctor for
approval but the investigation found no evidence that this was documented.
The nurse from the Substance Misuse Team who discussed the matter with
the man told the clinical reviewer that the man wanted to change to the rapid
detoxification programme so that he could “work with his partner to assist
other drug abusers and addicts”.
56. The methadone prescription was terminated on 14 October and detoxification
with subutex was started the next day. Thereafter, the man was given
gradually reducing doses of subutex until 23 October when he was due to
receive a final dose of 0.4mg.
Comprehensive Substance Misuse Assessment
57. The man underwent a Comprehensive Substance Misuse Assessment
(CSMA) on 18 October. The assessment was carried out by the CARATs
worker. On this occasion the man said he had used drugs about one month
before going to prison. He had only been able to remain drug free in the
community when he was employed and in a stable relationship between the
ages of 16 and 17. When asked whether there were any situations made
worse by his substance misuse, the man said “crime and going to prison”. He
told the CARATs worker he used ecstasy and cannabis when he was 13. At
age 16 he used heroin but did not like it. He said he therefore avoided its use
for 18 months. When he was 17, he started to use heroin again, at times
taking it intravenously. By the time he was 20, the man had begun to take
crack cocaine. The CARATs worker wrote in the assessment form,
“Though the man has used a variety of substances, they
appear to be more of an outward expression of his aggression,
anger and frustration (his youthful rebellion) rather than
masking deeper emotional difficulties as is so often the case in
this client group.”
Telephone calls
58. On 19 October, the man made two telephone calls to different numbers.
These were the only two calls he made while he was at Lincoln. Each call was
monitored by a member of staff who reported that he sounded happy while on
the phone and optimistic about his future.
Found with drug smoking equipment
59. At approximately 10.00am that day, a wing prison officer carried out a routine
cell search of the man’s cell. During the search, the officer found an inhaler to
which was attached some tin foil. (This is the sort of equipment used by
prisoners to smoke illegal drugs.) The officer placed the man on report and
charged him under Prison Rules for having an unauthorised article. On the
notice of report issued to the man, the officer wrote as follows:
“At approx 10.30 hours on Friday 19 October 07, whilst
conducting a routine search, I found an insulin needle, five
pieces of burned silver foil, an inhaler with foil stuck on the
front and a plastic bottle containing an unidentified liquid.”
Disciplinary hearing
60. The adjudication (disciplinary hearing) in relation to this charge was opened on
20 October by the adjudicating governor. In his evidence to the adjudicating
governor, the man admitted that the inhaler was his and that he had used it to
smoke cannabis. However, he said his cell mate had told him the liquid was
orange juice. The adjudicating governor adjourned the hearing so that he
could take evidence from the man’s cell mate.
61. On Monday 22 October, the hearing was resumed. A second adjudicating
governor on this occasion wrote on the record of the adjudication as follows:
“To clarify, you have owned up to using the inhaler to smoke cannabis, that
your padmate was aware of the bottle found, but know nothing about the foil or
needle”.
62. The man agreed with the second adjudicating governor who then wrote,
“I will adjourn to consult the Discipline Manual. Reconvened.
After referring to PSO (Prison Service Order) 2000 paragraph
6.72, it allows me to delete items from the list of unauthorised
articles found in your cell. I am therefore deleting the
following items found: an insulin needle, five pieces of burned
silver foil and a plastic bottle containing an unidentified liquid.
This therefore leaves one item – the inhaler – to which you
have pleaded guilty. Have you anything to say or add?”
The man said he did not.
63. The second adjudicating governor found the charge proved and gave the man
the following punishment:
(cid:127) 14 days’ stoppage of earnings at 50%
(cid:127) 14 days’ forfeiture of facilities to use his private cash
(cid:127) 7 days’ loss of association
(cid:127) 7 days’ forfeiture of the use of his television.
This punishment meant the man could return to his wing.
64. At interview the second adjudicating governor told my investigator that the
drug smoking implement found in the man’s cell was not sent for forensic
analysis. Thus there is no evidence to show what drugs had been used and
when. The second adjudicating officer said the man told him he had used the
implement to smoke cannabis earlier in his time at Lincoln. The second
adjudicating officer also told my investigator that during the adjudication he
saw no signs in the man to suggest he was suffering from drug withdrawal or
that he was contemplating suicide. The wing officer also said the man showed
no such signs during the cell search and during the ensuing adjudication.
Detoxification programme completed
65. On 23 October an entry made in the man’s medical record shows he had
completed his detoxification programme. However, he refused his last dose of
0.4mg subutex that day.
Events on 24 October
Altercation with prison officer
66. Shortly after 3.00pm on 24 October a prison officer noticed the man leaning
over the railing on A4 landing. Knowing that five days earlier, he had been
given a punishment that required him to remain in his cell at certain times of
the day, the prison officer asked the man to return to his cell. The man replied,
“You’ve got to remember I’m out soon and I know where
Gainsborough is.” (This is where the man believed the prison officer
lived. The investigation found that this was not the case.)
67. The prison officer placed the man on report for using abusive and threatening
language. A Senior Officer made the following entry in the man’s core prison
record that day:
“Very poor attitude especially to the prison officer. He is
arrogant to staff and not a person who should be enhanced
(i.e. the enhance level of privileges under the Incentives and
Earned Privileges scheme). Poor, poor attitude.”
The record does not show what time the entry was made.
Alleged assault on a senior officer and transfer to segregation unit
68. At about 8.00pm that day the man rang his cell bell. The Senior Officer
responded and later submitted the following report of what happened
thereafter:
“I went into A4-10 and asked him (the man) what he wanted.
He said he wanted a shower. I explained it was 20:05hrs and
he had time for a shower in the afternoon. He became
aggressive towards me and made an aggressive move towards
my direction. Two prison officers then restrained him. A third
prison officer had his head. I asked him if he was OK and he
would be removed to D Wing (the segregation unit). I received
a cut to my left hand which was caused by the man assaulting
me.”
69. A form F213 (report of an injury to a prisoner) was completed. Information
about how the injury was sustained should be written in sections one and two.
Comments should be written by a medically qualified member of staff about
the prisoner’s injuries.
70. A fourth prison officer wrote in section two,
“At approx 20:05 hrs on 24.10.07 in cell A4-10, PV9382 the
man lunged at the SO and was restrained. When first asked
in D Wing if he had any injuries, he replied no but after a few
moments pointed to his right wrist.
71. A healthcare nurse, who witnessed this incident from the outset, completed
section 3 of the form. He wrote,
“The man relocated to seg under restraint. Patient was not
on front for longer than 3 mins. Whilst in cell in seg I asked if
he was injured which he replied no then maybe. I asked him
if he was in pain he pointed to his right wrist and stated it was
a little sore. He refused examination stating he would contact
his solicitor. On observation, there was no localised swelling
or obvious deformity and he was displaying full range of
movement.”
72. My investigator interviewed the nurse about this and other matters. The nurse
explained that where possible it was the practice of healthcare staff to attend
from the outset any incident involving the restraint of a prisoner so that the
event can be monitored from a healthcare point of view.
73. The Senior Officer placed the man on report for assaulting him. The Senior
Officer made the following entry in the man’s record:
“Inmate located in D wing after altercation on A wing. Brought
down in restraint given a strip search and placed in D1-11 not
happy very cocky and surly individual who has no respect for
staff.”
Segregation safety algorithm
74. Before a prisoner can be segregated, his ability to cope with the effects of
segregation has to be assessed through the use of a segregation safety
algorithm. The algorithm requires a number of questions to be answered by
the assessor. These are set out below.
Question 1: Is the prisoner awaiting transfer to/being assessed for a bed in an
NHS Secure setting?
Question 2: Has the person self-harmed in this period of custody/are they on
an open F2052SH/ACCT form? Or is the person currently taking any anti-
psychotic medication?
Question 3: Does the prisoner show signs of being acutely unwell (e.g.
psychotic/withdrawal from drugs/significant physical injury) at the present
time?
Question 4: Do you think that the prisoner will be unable to cope with a period
of segregation?
The healthcare nurse marked the “no” box in answer to each of those
questions. Thus, he judged that the man could cope in the segregation unit
and signed the algorithm to this effect.
75. The duty governor of the day telephoned the segregation unit at 8.55pm
provisionally to authorise the man’s segregation. The duty governor
countersigned the algorithm at 7.30am the next day, thereby formally
confirming his authorisation. He noted on the algorithm that he had read the
assessment completed earlier by the healthcare nurse.
76. The Night Patrol officer on duty in the segregation unit, made the following
entry in the man’s core prison record: “Blocked cell obs window. I had to
remove it due to him refusing. Very bad language towards Night Patrol
demanding his stuff to be collected so he can have a smoke. Very rude.”
Events on 25 October
77. During the morning of 25 October, the duty governor conducted an
adjudication in relation to the charge brought against the man by the prison
officer. The duty governor found the man guilty of the charge and gave him
three days’ cellular confinement. This punishment was to be completed in the
segregation unit. During that period he could not watch television but could
have reading and writing materials and have a daily shower and exercise.
78. After the adjudication, the duty governor spoke to the man in his cell. The duty
governor later wrote in the man’s record,
“Seen on rounds after adjudication. Received 3 days cc.
Made allegations of assault by staff and requests contact with
his solicitor. Seg S/o to allow special letter. I will contact
PLO (Police Liaison Officer) and security re allegation.”
79. A second entry was made by a member of the security staff, who wrote,
“Advised that the police will not be following up on his complaint. Advised that
if he wishes to make a complaint he should write to the Governor. 3 x photos
taken.”
80. Another entry was made by a member of staff in the segregation unit. She
wrote,
“Started day off at adjudication. A little unsettled but soon
advised by staff the choices he can make if he accepts help
from staff. He was given guidelines and realised his
boundaries. Tries constantly to be THE BIG MAN and if
allowed could become demanding both in his nature and of
staff’s time. He was given his property on E.D. (evening
duty) plus all missing items and medication given by nurse.
Does not seem to appreciate anything but has shown his
attitude can change when he understands clearly what staff
are trying to achieve. Did show smiles throughout afternoon
and subsequently keeps a clean and tidy cell which he again
likes to be on top of.”
Events on 26 October
81. A second Senior Officer was deployed to manage the segregation unit
between 8.00am and 5.00pm on 26 October. The second Senior Officer was
normally employed as the Voluntary Sector Co-ordinator at Lincoln. She was
not therefore a regular segregation unit manager. The second Senior Officer
told my investigator that as soon as she arrived in the unit that day, she was
given a handover briefing on the prisoners in the unit by a member of staff in
the segregation unit who had been on duty since about 7.15am. Apart from
the fact that the man was already in the unit and was awaiting an adjudication
for an assault to be conducted that morning, nothing of particular note was
mentioned during the briefing.
82. The second Senior Officer explained that prisoners in the segregation unit
have to apply for showers, telephone calls and exercise so that the staff can
coordinate the activities during the day. She recalled that at about 8.30am, the
man asked to be allowed to make a telephone call. The second Senior Officer
remembered that he said he needed to ring again later on as the person he
rang was not available.
83. The second Senior Officer said she saw the man once or twice later that
morning. At one stage the man told the second Senior Officer he “had messed
up” since being at Lincoln and wanted a fresh start in another prison. The
second Senior Officer asked him which prison he would prefer. The man said
he had no preference, saying he simply wanted to move away from Lincoln as
he had got into too much trouble. The second Senior Officer said the man was
smiling at her as he talked to her on that occasion. She emphasised that she
had not come into contact with the man before that day. She therefore knew
nothing of his background. She told my investigator that at no stage that day
did the man give her any reason to think he was contemplating suicide. She
said his demeanour was neither odd, nor subdued, nor pre-occupied. The
second Senior Officer said he was not pale, sweating, impulsive or moody (the
classic symptoms of opiate withdrawal). She described the man as perfectly
normal. My investigator put to her the suggestion that it is not uncommon to
find that prisoners who appear to be completely normal before they die may
have been suffering from the effects of withdrawal. In such circumstances,
they may not be in charge of their mind. The second Senior Officer said that
the man gave no such indication.
84. At 9.00am, in keeping with the provisions of PSO 1700, the prison doctor
briefly interviewed the man to assess his ability to cope with segregation as he
was about to face a further adjudication. The prison doctor signed a further
segregation safety algorithm to confirm his opinion that the man was able to
cope with segregation. At interview the prison doctor told my investigator this
was the first time he had met the man. He said,
“I remember seeing the man as a person in good mood and he
was sensible in his answers. I asked him whether he feels fit
for adjudication and asked about previous mental history,
history of previous mental disorders but he denied any previous
problems. So I didn’t feel any concern about his current
physical or mental health in the morning before the incident.”
85. At 9.35am the deputy governor opened an adjudication to hear the charge of
assault brought two days earlier by the Senior Officer. The deputy governor
remanded the case for hearing by an independent adjudicator.
86. At interview the deputy governor told my investigator that at no stage did the
man’s demeanour give her any cause for concern. She said,
“He didn’t seem depressed, he didn’t seem down. The main
concern he had was…telling me that he wasn’t guilty of the
charge that had been laid before him and that he’d got injuries
to his hand and his head. His main concern was telling me
about those.”
87. My investigator asked the deputy governor if she saw any injuries. She
replied,
“No. He had no injuries and I also asked him if he had been
seen by the nurse and he said he had but he hadn’t reported it.
I did have a conversation with the nurse at a later stage to say,
‘when you saw him initially, did he have any injuries’ and he
said ‘no’. And then when they saw him on the morning of the
adjudication, I believe he’d got an injury then and they
suspected that he may have done it himself, but at the time of
the restraint, when seen immediately afterwards, he didn’t
present with any injuries at all.”
88. My investigator reminded the deputy governor of the fact that on 19 October,
the man had been found in possession of a drug smoking implement and that
during the subsequent adjudication, he had admitted using the implement to
smoke cannabis. At the time the man was subject to a detoxification
programme. My investigator put to the deputy governor the suggestion that
when the man was transferred to the segregation unit, he might have been
affected either by his use of cannabis or by a change in his detoxification
programme. He asked the deputy governor to explain whether wing staff
would have alerted the segregation unit staff of the details of the man’s
detoxification regime. The deputy governor replied,
“…It wouldn’t necessarily be the wing because the wing staff
might not know or wouldn’t know the details of what medication
they are on. It would be Medical in Confidence. For me as the
duty governor or the Governor signing somebody on for good
order or discipline or making the decision that they can stay in
the segregation unit pending adjudication, my expectation
would be that healthcare staff would advise me of any
issues…that I’d need to be aware of. That should be in addition
to what goes on the algorithm, because obviously we go by the
algorithm as to whether there’s been any history of self harm, if
there any mental health issues, whether it’s on this sentence,
the last sentence or previously in custody etc.”
89. At 11.10am, after completing the adjudication, the deputy governor completed
a further segregation safety algorithm. When asked about her reasons for
doing so, she replied,
“My practice is that if somebody is in segregation and is going
to continue and I’ve got an algorithm there, the doctor or a
mental health nurse has to see all the prisoners before the
adjudication and complete their part of an algorithm, regardless
of whether they are on one already, because it might have
been a week. So on the morning of the adjudication, I’ll look at
that and make sure they are ok and I’m satisfied that the
medical staff are saying to me there is no cause for concern as
to why they can’t come on adjudication…”
90. The deputy governor confirmed that she saw no signs in the man’s behaviour
to suggest he was suffering from either the effects of taking drugs or from the
effects of withdrawal. She described him as quite cheerful and articulate
during the adjudication.
91. A segregation unit officer who was also on duty in the segregation unit that
morning, confirmed that throughout the morning the man appeared to be in
good spirits, making jokes and interacting well with staff. The segregation unit
officer said the man was talking positively to staff about his future.
92. In a statement later provided to my investigator a prisoner employed as a
cleaner for the unit, said,
“I spoke to the man at dinner time, 11.20. He was talking to
me, saying he was leaving tomorrow from the block. I said you
must be buzzing. He said can you please get me some fag
papers. I said I promise I will get you some after dinner. After
dinner I went to the inmate’s cell and looked into the spy hole
and saw it was dark. I was going to put the light on but I said to
myself, he might be asleep so I left him…….”
93. At about 11.30am, the man rang his cell bell. A second segregation unit officer
responded. The man asked the second segregation unit officer what would
happen now that his period of cellular confinement was about to come to an
end and his case had been remanded to be heard by the independent
adjudicator. The second segregation unit officer told him he would be
assessed for his suitability to be returned to normal location but that it was
unlikely that he would be returned to A Wing. The second segregation officer
added that if the man could not be returned to any of the wings, he might be
kept in the segregation unit for the good order or discipline of the prison.
94. During the morning, the man was visited in his cell by the chaplain who noted
no concerns about him.
95. My investigator was presented with no evidence to show that a lunch time roll
check was conducted.
96. The final entry made in the man’s core record was as follows: “Seen on
rounds. No problems. Asking about TV. Wing staff to look into this.” It is not
clear who made that entry or at what time.
Discovery of the man hanging
97. At about 1.40pm, the second Senior Officer went to the man’s cell in order to
see him about the matters she had discussed with him earlier. The second
Senior Officer opened the observation hatch and noticed the cell was in
darkness. On closer examination, she saw the man hanging from the cell
window, suspended by a ligature made from his bedclothes. The second
Senior Officer called for assistance and then entered the cell with the
segregation unit officer. The second Senior Officer lifted the man’s legs and
tried to support his body. She noticed a mark around his neck from the
ligature. The second Senior Officer told my investigator the man’s eyes were
half open and colourless. She said his skin was grey and he did not appear to
be breathing. She asked the segregation unit officer to cut the ligature. At the
same time, the segregation unit officer used his radio to call for assistance
from the healthcare centre. He did so by using a code system in use for life
threatening situations. He and the second Senior Officer then placed the man
on the floor and began to administer cardio-pulmonary resuscitation (CPR).
The second Senior Officer applied chest compressions while the segregation
unit officer breathed into the man’s mouth. At one stage, the second Senior
Officer heard a noise and thought the man was breathing.
98. Moments later, the Orderly Officer arrived at the cell. The second Senior
Officer asked the Orderly Officer to call an ambulance. (The log of events kept
by the prison shows that an ambulance was requested at 1.44pm.) At the
same time three nurses arrived and relieved the second Senior Officer and the
segregation unit officer.
99. The prison doctor also arrived at the cell with emergency first aid equipment at
about the same time. He later made the following record of events:
“Arrived approx 13.46 to the cell in the segregation unit and
found members of healthcare doing CPR. On examination,
pupils fixed dilated no signs of breathing or pulse. Face was
cyanosed. I made an effort to cannulate his left hand but
unsuccessfully. Cardiac rhythm was assessed with defibrillator
and it showed asystole which did not indicate defibrillation.
Paramedics arrived 13.57 and took over the resuscitation.
After about 27 minutes of resuscitation, with no signs of life, at
14.07 I pronounced him dead.”
Death was also confirmed by one of the paramedics.
100. At interview the prison doctor told my investigator,
“When I entered the cell, there were no signs of life and I could
not recollect whether rigor mortis was present, but after
assessing him, I could find no pulse. Dilated fixed pupils,
cyanotic skin on his face probably due to strangulation more
than suspecting other cause, and I remember seeing a mark
from strangulation as well. So on entering the room, there
were signs of clinical death and it’s difficult to predict about
length of it, so most likely it happened within the last half an
hour.”
101. The second Senior Officer told my investigator that no-one had brought a
defibrillator to the cell. My investigator asked the prison doctor whether the
initial absence of a defibrillator might have affected the outcome. He said he
did not think so as there were signs of clinical death on his arrival at the cell.
Informing the man’s next of kin
102. As the man gave no details of his next of kin when he was first received in
prison, difficulties were experienced in ascertaining who his next of kin was
and where they lived.
103. The prison’s Family Liaison Officer (FLO) was the Governor’s secretary. She
was on leave at home when the man died. However, at about 2.00pm, she
received a call asking her to attend the prison. The FLO arrived at 2.10pm.
104. At about 2.48pm, the FLO telephoned the man’s probation officer and asked if
she knew who was the man’s next of kin. The probation officer was able to
confirm that the man’s mother lived in a town in Derbyshire but did not know
her address. The probation officer said she knew the telephone number of the
man’s uncle. She gave the FLO two addresses from the man’s probation file
but emphasised that she did not know who lived at either place.
105. The FLO decided to take advice from the Police Liaison Officer (PLO) for the
prison as to who occupied the addresses given by the probation officer. The
enquiries made by the PLO revealed only the family name of four people who
occupied one of the addresses given. However, the PLO could not confirm
whether they were related to the man. The FLO therefore rang the man’s
solicitor who gave her the telephone number of a relative. The FLO rang that
number but there was no reply. By this time over two hours had elapsed since
the man was pronounced dead.
106. The Governor decided that attempts should be made to contact the man’s best
friend whose mobile telephone number was recorded in his prison file. At
about 4.45pm, the FLO rang the friend. She explained that she needed to
trace the man’s family and asked him if he could help. The man’s friend said
he was the next of kin and said the man had not had any contact with his
family for some time. The FLO therefore broke the news of the man’s death to
his friend. He became very distressed and asked to be allowed to collect
himself and to ring the FLO back. Five minutes later, he rang back. He told
the FLO he had received a letter from the man only that morning and had
visited him a week earlier. He said the man had given him no indication that
anything was wrong. The man’s friend suggested to the FLO that she should
call two other friends of the man’s who might be able to help her trace his
family.
107. At 4.54pm, the PLO telephoned the FLO to confirm the correct address and
two telephone numbers for the man’s uncle. The FLO rang both numbers but
again there was no reply. The FLO was then called by the person operating
the prison switchboard who told her he had been telephoned by the man’s
cousin. The FLO called that number and spoke to the man’s brother-in-law.
The FLO asked him to pass a request to the man’s uncle to ring her as soon
as he could. At 5.35pm, the man’s uncle telephoned the FLO. She broke the
news of the man’s death to him. He agreed to pass the news to other family
members in his own time.
108. Arrangements were made for members of the man’s family to visit his cell at
their convenience.
Support for staff and prisoners
109. A member of the prison’s care team made herself available to speak to the
second Senior Officer, the segregation unit officer and all other staff who had
been involved in discovering the man hanging and in attempting to save his
life.
110. At about 2.30pm the deputy governor convened a meeting of the staff in order
to allow them an opportunity to explain what they had done. At the end of the
meeting all those present were offered the services of the care team and were
reminded of the telephone number of the “Care First” confidential facility. The
staff my investigator interviewed expressed their satisfaction with, and
gratitude for, the care they were offered.
111. One of the Senior Managers personally informed every prisoner located in the
segregation unit of the man’s death. All prisoners were offered an opportunity
to speak to a Listener or to the Samaritans, or to the Chaplain. The senior
manager also arranged for any prisoner currently subject to formal self-harm
monitoring procedures to be reviewed that day in light of the man’s death.
Funeral arrangements
112. The man was cremated in November 2007. With the agreement of the man’s
family, representatives from the prison attended the service. Flowers were
sent from prisoners and staff. The full costs of the funeral were offered by the
Governor.
ISSUES
113. Here I examine the following:
(cid:127) Whether the man’s health needs were properly met whilst he was in
custody at Nottingham and at Lincoln
(cid:127) Whether the decision to transfer the man from Nottingham to Lincoln was
appropriate and fair
(cid:127) Whether the man was appropriately managed while he was in the
segregation unit at Lincoln
(cid:127) Whether the man’s risk of suicide was properly assessed at Nottingham
and at Lincoln
(cid:127) Whether the response to the discovery of the man hanging was prompt and
effective
(cid:127) Whether appropriate courtesies were extended to the man’s family in the
aftermath of his death.
Were the man’s health needs properly met while he was in custody at
Nottingham and Lincoln prisons?
114. Here I rely heavily upon the findings of the clinical reviewer whose report can
be found at Annex 1. The reviewer’s key findings and conclusions are:
(cid:127) The man had a well documented history of multiple drug abuse and was
managed for most of his period in custody with methadone maintenance
therapy.
(cid:127) There was no past evidence of self-harm or suicidal ideas and no history of
mental health problems.
(cid:127) Two weeks before his death the man requested and underwent rapid
detoxification from methadone using buprenorphine (subutex).
(cid:127) There is published evidence that rapid detoxification from methadone can
result in both physical withdrawal symptoms and the precipitation of
psychosis with abnormal behaviour patterns.
(cid:127) There was no reported evidence of physical withdrawal symptoms during
the detoxification period and nothing to suggest the development of a mood
disorder or psychosis.
(cid:127) There was a reported deterioration in the man’s behaviour during the
detoxification period, culminating in the alleged physical assault of a male
Prison Officer and verbal aggression towards a female officer. This
behaviour resulted in the man being transferred to a segregation cell.
(cid:127) The man’s aggressive behaviour appeared to be directed towards Prison
Officers and not towards other prisoners or members of the substance
misuse team.
(cid:127) It has been suggested that the man’s aggressive behaviour was
precipitated by frustration relating to his request for a prison transfer.
(cid:127) Drug smoking equipment was found in the man’s cell shortly before his
death but there was no evidence of illicit drug use in the toxicology report.
(cid:127) The standard of documentation in the prison medical records was
adequate, with a daily evaluation and report of the man’s physical and
mental wellbeing.
(cid:127) All daily contacts with the substance misuse team were recorded and there
was repeated reference to the man’s contentment with his drug
management. There was no documentation of the reason for converting
him from maintenance therapy to detoxification.
(cid:127) The man had little documented contact with the medical and healthcare
nursing staff and they were not directly involved in his drug therapy
regimens.
(cid:127) There is no obvious clinical explanation for the man’s hanging, with no
evidence of mental disturbance, depression or ideation of self-harm prior to
the act.
(cid:127) Comment has been made about the delay in resuscitation equipment
arriving at the man’s cell. This is unlikely to have contributed to the
unsuccessful resuscitation attempt.
The reviewer makes two recommendations, which I endorse:
Prisoners who elect to undergo detoxification should have the reasons for this
decision fully documented and reviewed during the detoxification process.
There should be readily available psychological support for prisoners who
elect to undergo detoxification, particularly if the process is rapid as in the
man’s case. Regular review should be undertaken and documented.
Was the decision to transfer the man from Nottingham to Lincoln appropriate?
115. At consultation stage, the man’s family expressed their concern that he may
not have been treated fairly by being transferred from HMP Nottingham to
HMP Lincoln. They thought his transfer had an adverse effect on him.
116. The investigation found that the decision to transfer the man was based
entirely on a claim made by his female CARATs worker that he had behaved
improperly by making advances towards her. The man was initially warned
about this but he continued to exploit every opportunity to see her despite
being assigned a male CARATs worker, being sacked from his job as a
cleaner and being placed on the ‘risk to females’ register. On 25 September,
an attempt was made to move the man to a different wing. However, he
became aggressive and was moved to the segregation unit. Two days later he
was transferred to HMP Lincoln as this was the only prison that could offer him
a drug misuse programme.
117. The man’s family made available to my investigator extracts from a diary the
man had kept whilst in prison. In it were some graphic descriptions of alleged
lewd activities between him and the woman concerned. The man’s family
believed these suggested that both were equally guilty of improper behaviour.
118. The investigation conducted by the Governor found no direct evidence of any
improper behaviour on the part of the woman. She had acted appropriately in
immediately reporting the man for making advances towards her. Although it
is not clear to what extent the man was given an opportunity to explain himself,
there was plenty of evidence that after initially being warned to stay away from
the woman, he continued in his efforts to see her. In my view, it was not
possible for anyone at HMP Nottingham to prove that the claims of lewd
behaviour between them as recorded in the man’s diary were true.
119. In these circumstances, I am satisfied that the Governor of Nottingham
managed this episode appropriately and that his decision to transfer the man
was reasonable.
Was the man appropriately managed in the segregation unit at Lincoln?
120. Policy guidelines for the management of prisoners in conditions of segregation
are contained in Prison Service Order (PSO)1700. The principal components
of that policy are as follows:
(cid:127) Within two hours of being segregated, an initial segregation safety screen
should be completed by a registered nurse or a doctor.
(cid:127) The Governor must authorise initial segregation for up to 72 hours.
(cid:127) Prisoners who are held in segregation must be visited by prison
management and by others who work in the prison.
(cid:127) All prisoners who are segregated should have a Segregation History sheet
opened for them.
(cid:127) At least the following people must visit and speak to all staff and prisoners
in the segregation unit:
a. operational manager
b. the person in charge of the prison (at least once per week)
c. members of the Independent Monitoring Board
d. a member of the chaplaincy team
Segregation safety screen
121. The man’s ability to cope with the effects of segregation was assessed on
three occasions: once on 24 October when his segregation was initiated, again
on the morning of 25 October and finally on the morning of 26 October. On
each occasion, the assessor was required to note whether the man was
showing any signs of being unwell because of withdrawal from drugs or for
other reasons. Each time the assessor judged that the man was showing no
such signs. None of the members of staff involved in the assessments was
given any reason to doubt the man’s ability to cope with segregation or with
the punishment of cellular confinement. I am satisfied that staff complied
appropriately with PSO 1700 in this regard. I am also satisfied that, in the
circumstances, the punishment of cellular confinement was not unduly harsh.
The man had been rebuked by an officer for being out of his cell when already
under a punishment of loss of association. His response was to make implied
threats to her safety.
Authorisation of segregation
122. As the man was initially placed in the segregation unit because he had
offended against Prison Rules, no formal authorisation for his segregation was
necessary other than through the adjudication process. However, verbal
authorisation was given by the duty governor. I am satisfied that the
procedures at the two adjudications held on 25 and 26 October respectively
were correctly followed and the decisions as to the man’s retention in the
segregation unit were appropriate.
Segregation reviews
123. PSO 1700 sets out the following policy for segregation reviews:
“The period of initial segregation under Prison Rule 45
(i.e. for the good order of the prison) without a review
board is for a maximum of 72 hours.”
My investigator was told that had the man not died, a review board
would have met on 27 October - the day his period of punishment
would have expired - in order to consider whether he should remain in
the unit. I consider this to be appropriate in the man’s case.
Access to regime facilities
124. The man’s status in the segregation unit was that of a prisoner subject to
cellular confinement and awaiting a hearing by an independent adjudicator for
an alleged offence of assault against a member of staff. PSO 1700 sets out
the following requirements for those prisoners subject to cellular confinement:
“The regime to which a prisoner will have access if he is
serving a period of cellular confinement as part /all of a
disciplinary award under Prison Rule 55(e) will be as laid
down in the Prison Discipline Manual (Chapter 7):
“(para 7.21) Prisoners serving a punishment of cellular
confinement will be located in an ordinary cell set aside for
the purpose. A bed, bedding, a table and a stool or chair
must be provided in the cell and there must be access to
sanitary facilities at all times. Other furnishing and fittings
may be provided at the governor’s discretion.
“(para 7.22) Prisoners serving a punishment of cellular
confinement will be allowed all normal facilities except those
which are incompatible with cellular confinement unless a
punishment of forfeiture of those facilities has also been
imposed. Facilities which should normally be compatible are
a reasonable number of personal possessions, cell hobbies
and activities, entering public competitions and own clothes
and footwear where these have already been allowed.
Facilities which will normally be incompatible are use of
canteen, use of private cash (although exceptions might be
needed, for example to send money home or to purchase
replacement radio batteries, phone cards or postage stamps)
and association.
“(para 7.23) Prisoners entitlements to correspond, to
exercise, and to make applications to the governor, seconded
probation officer, chaplain and Independent Monitoring
Board, are unaffected by cellular confinement. Prisoners will
be allowed to attend the main service of their religion unless
prevented under Standing Order 7A. Prisoners will be
allowed to have books within the limits set out in Standing
Orders. Visits and access to a telephone should be allowed
unless the prisoner’s behaviour and attitude make removal
from cellular confinement impracticable or undesirable. Visits
should take place at a time or place away from other
prisoners.”
125. As the man was awaiting a hearing by an independent adjudicator, it would
have been both impractical and inappropriate to allow him to serve his three
day period of cellular confinement in any location other than the segregation
unit. My investigator was told that as the man was held in the segregation unit
under punishment rather than for the good order of the prison, and as he was
only held there for less than 72 hours, no formal history sheet was opened.
126. Scant documentary evidence was available to show what facilities and
activities the man could access during that period. The punishment of cellular
confinement included the withdrawal of his television. However, it is not clear
whether he was given any books to read or whether he had anything in his cell
to distract his attention away from his plight. I consider this to be a crucial
factor in the management of prisoners undergoing periods of cellular
confinement, especially since the absence of such materials can have an
adverse effect on their mental health.
The Governor should ensure that in the case of any prisoner located in
the segregation unit, proper records are kept to show the full range of
activities and facilities afforded.
Visits by officials
127. Paragraph 7. 24 of the Prison Discipline Manual sets out the following further
requirement:
“A prisoner serving a punishment of cellular confinement must be
observed by an officer at least once an hour and must be visited
by the chaplain. The governor or an operational manager above
the grade of principal officer must visit all prisoners in cellular
confinement daily. Where there are concerns about the potential
deterioration of a prisoner’s mental health, they should be drawn to
the attention of healthcare staff. A doctor must visit each prisoner
as often as their individual needs dictate. Visits must be made to
such prisoners on all other days by a healthcare professional (e.g.
qualified nurse). At each visit, the doctor or nurse must assess the
prisoner’s physical, emotional and mental well being and whether
he or she is sufficiently fit for the punishment to continue. A note
of each visit must be made in the patient’s medical record. If there
are concerns about the prisoner’s state of health, the issues must
be discussed with the rest of the healthcare team. Where the
healthcare team considers that there are clinical reasons why the
punishment should not continue, they must inform the duty
governor/in-charge governor, who must fully consider and act on
the advice of the healthcare team.”
128. On 24, 25 and 26 October the man was visited, as required, by the duty
governor, chaplain, and the doctor or a nurse. No concerns were noted.
Although the doctor made comments about the man in the segregation safety
algorithms, there is no evidence that he wrote anything in the man’s medical
record.
The PCT should ensure that contemporaneous entries are made in the
medical record of any prisoner subject to cellular confinement following
visits by qualified medical practitioners.
129. The investigation found no evidence that the man was observed at least once
an hour by an officer, as required by PSO 1700. It is known that on the last
day of his life, the man was seen at 11.30am, after his adjudication, by the
second segregation unit officer. On that occasion, the second segregation unit
officer said the man was not cheerful but was accepting of his situation. The
second Senior Officer told my investigator that the man took his lunch that day.
A member of staff in the segregation unit confirmed that the meal was served
at 11.30am. It is possible that the man was not observed again before he was
found hanging at 1.40pm.
The Governor must ensure that, in keeping with the provisions of PSO
1700, all prisoners subject to cellular confinement are observed by an
officer at least once an hour and that a record of each observation made
is entered into the appropriate history sheet and segregation unit diary.
130. That said, it is clear that the man was seen by different disciplines during his
brief time in the segregation unit. I am satisfied that the provisions of PSO
1700 were adequately met and that the management decisions made in
respect of the man were appropriate.
Effects of detoxification
131. In her clinical review the clinical reviewer reports as follows:
“During his periods of imprisonment the man’s drug addiction
was managed by the Substance Misuse Team with methadone
maintenance. Two weeks before his death the man requested
conversion from maintenance therapy to methadone to
detoxification using subutex (buprenorphine). The reason
given by the man for a change from maintenance therapy to a
detoxification programme was his stated desire to work with a
person whom he described as his partner, who was already
involved in work with drug abusers and addicts. He underwent
a rapid detoxification programme, shortened to 8 days at his
request. During this period, there appears to have been a
marked deterioration in the man’s behaviour, with two reported
incidents of aggression towards Prison Officers. There were
no reported physical signs of drug withdrawal during this
period. The man was seen daily by a member of the
Substance Misuse Team and reported no problems with his
rapid detoxification. The key worker from the team confirmed
that the man was happy that he had managed to detoxify and
there was no evidence of mental disturbance.”
132. The clinical reviewer acknowledges the existence of published evidence that
rapid detoxification from methadone can result in both physical withdrawal
symptoms and the precipitation of psychosis with abnormal behaviour
patterns. However, she found no reported evidence of physical withdrawal
during the man’s detoxification period and nothing to suggest the development
of a mood disorder or psychosis.
133. Although I concur with the reviewer’s conclusions and therefore make no
formal recommendation on this subject, I cannot overstate the importance of
ensuring that prisoners who may be detoxifying are carefully assessed before
being placed in the segregation unit and are closely monitored once there. My
investigations into the deaths of other prisoners in segregation units have often
highlighted a link between the fact of their detoxification and their mental
health.
Was the man’s risk of suicide properly assessed at Nottingham and at Lincoln?
134. Prior to his imprisonment on 29 June 2007, the man swallowed a large number
of heroin “wraps”. There is some doubt as to his motives for doing so. The
medical forms completed while he was in police custody carry the comment
that he did so as a deliberate act of self harm. Consequently, a Prisoner
Custody Officer raised a self harm warning form to alert prison staff to the
possibility that the man was at risk. The decision to raise this form was, in my
view, entirely appropriate. However, the man later told a member of prison
staff that he swallowed the heroin to avoid detection by police. I am
persuaded that this, rather than an attempt to kill himself, was likely to have
been his intention.
135. An assessment of his risk of self-harm was carried out when he arrived at
Nottingham. No current risk was identified. As a result, there was no need to
invoke self-harm monitoring procedures. The man showed no suicidal
tendencies during the two week period he spent there prior to his release on 5
July. This was also the case during his second period at Nottingham between
23 July and 27 September.
136. A brief entry made in his medical record when the man arrived at Lincoln
shows that there were no concerns about any risk of self-harm or suicide at
that stage. On the contrary, he was described as being in good humour,
despite having been removed from Nottingham because of his behaviour
towards a female member of staff.
137. During the initial stages of his period at Lincoln, the man behaved well and
gave no indication that anything was troubling him. However, his behaviour
deteriorated significantly two days before he died. He became disrespectful
towards a female officer and allegedly assaulted a male senior officer. This
led to his transfer to the segregation unit. On the day of his death, he
mentioned that he wanted to a move to another prison. His only explanation
was that he had “messed up” at Lincoln. However, it is clear that even at this
stage, the man showed no obvious signs that he was contemplating suicide.
138. I believe the man’s risk of suicide was satisfactorily assessed both at
Nottingham and Lincoln. I conclude that there were no grounds upon which
staff could reasonably have been expected to initiate formal self-harm
monitoring procedures.
Was the response to the discovery of the man hanging prompt and effective?
139. The man was found hanging at approximately 1.40pm on 26 October by a
Senior Officer. She entered the cell in the company of a prison officer without
hesitation and called for assistance at the same time. Together they
supported his body and cut the ligature without delay. Once this had been
done, CPR was administered. An ambulance was requested within four
minutes and a paramedic crew arrived at the cell within 17 minutes. The
Senior Officer, the officer, prison nurses and the prison doctor made
determined and sustained efforts to save the man’s life but, sadly, without
success. Death was pronounced at 2.07pm.
140. I am satisfied that staff acted promptly once the man was discovered hanging.
There was no undue delay in removing the ligature or in administering CPR.
An ambulance was called within four minutes of the discovery and the
response time achieved by the paramedic crew was in keeping with normal
expectations.
I believe the discipline staff, healthcare staff and the paramedic crew did
everything possible to try to save the man’s life, in harrowing
circumstances. I commend them.
141. My investigator was told that no defibrillator was taken to the cell with the rest
of the emergency first aid equipment after the initial alarm had been raised.
The prison doctor said he thought the absence of this piece of equipment
would not have affected the outcome as there were signs of clinical death on
his arrival at the cell.
142. Although I am satisfied with the prison doctor’s judgement, I take the view that
the failure to make a defibrillator available at the outset in any future
emergency might jeopardise the chances of saving a life.
The Governor should ensure that the full range of emergency equipment,
including a defibrillator, is taken to a life threatening emergency as a
matter of course. Contingency plans should make this clear and key
staff should receive appropriate training.
Were appropriate courtesies extended to the man’s family in the aftermath of
his death?
Informing his next of kin of his death
143. No details of the man’s next of kin were recorded in his prison record at
Lincoln because he had refused to disclose them when he was first received in
prison. This caused immense difficulties when it became necessary to inform
the man’s family of his death. However, it was achieved three and a half hours
after his death was pronounced. The man’s family were most appreciative of
this.
I congratulate the Governor’s secretary, who acted as Family Liaison Officer,
for this achievement.
I nevertheless recommend that the Governor should ensure every effort
is made to encourage prisoners to disclose details of their next of kin as
part of the reception and induction procedures.
Funeral arrangements
144. The man was cremated at Mansfield Crematorium in November 2007. With
the agreement of the man’s family, representatives from the prison attended
the service. Flowers were sent from prisoners and staff. The full costs of the
funeral were offered by the Governor.
RECOMMENDATIONS
At consultation stage, the Prison Service rejected none of the following
recommendations:
Management of prisoners in the segregation unit
1. The Governor should ensure that in the case of any prisoner located in
the segregation unit, proper records are kept to show the full range of
regime activities and facilities afforded.
2. The Governor, in conjunction with the PCT, should ensure that
contemporaneous entries are made in the medical record of any prisoner
subject to cellular confinement following visits by qualified medical
practitioners.
3. The Governor must ensure that, in keeping with the provisions of PSO
1700, all prisoners subject to cellular confinement are observed by an
officer at least once an hour and that a record of each observation made
is entered into the appropriate history sheet and segregation unit diary.
Emergency first aid equipment
4. The Governor should ensure that the full range of emergency equipment,
including a defibrillator, is taken to a life threatening emergency as a
matter of course. Contingency plans should make this clear and key
staff should receive appropriate training.
Next of kin details
5. The Governor should ensure every effort is made to encourage prisoners
to disclose details of their next of kin as part of the reception and
induction procedures.
Congratulatory
6. I congratulate the Governor’s secretary, who acted as Family Liaison
Officer, for tracing and breaking the news of the man’s death, within
three and a half hours of death being pronounced despite the immense
difficulties she encountered.
Commendation
7. I believe the discipline staff, healthcare staff and the paramedic crew did
everything possible to try to save the man’s life, in harrowing
circumstances. I commend them.
Good practice
8. The policy adopted at Lincoln requiring a representative of the
healthcare staff to attend from the outset any incident involving the
restraint of prisoners is in my view an example of good practice.