Individual at High Down

Investigation into the death of a man whilst in the custody
of HMP High Down in June 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
September 2009
This is the report of the investigation into the death of a man, a remand prisoner who
was found hanging in his cell at HMP High Down in June 2008. He had been at High
Down for 11 months and was awaiting trial for murder. I offer my sympathies to his
family, friends and all those affected by his passing.
The investigation was conducted by my investigators. A clinical review was
undertaken by the local PCT and overseen by the Quality & Clinical Governance
Manager, from the PCT. The PCT commissioned a psychiatric report to assist their
review, written by the Consultant Forensic Psychiatrist. Although delayed, I am
grateful to both the Quality & Clinical Governance Manager and the Consultant
Forensic Psychiatrist for their reports. I am also grateful to the Governor of High
Down and his staff, in particular the Governor who made all the practical
arrangements for the investigators.
The man was a foreign national whose first language was Spanish. He enrolled in
an English language class soon after arriving at High Down to try to improve his
English. He was admitted to the healthcare inpatient unit for observation on his
arrival, due to his potential vulnerability arising from the alleged offence. Apart from
an isolated incident of self-harm just over a month after his arrival, no more concerns
were raised. Despite a number of reported incidents of problems with other
prisoners, his behaviour was considered by staff to be good. He made no mention to
staff that he was being bullied or threatened despite being asked.
During a routine roll check in the evening the man was discovered hanging in his
cell. He was resuscitated by staff and paramedics and taken by emergency
ambulance to the hospital where he later died.
I conclude that he was a young man who kept his feelings hidden from those around
him. It is clear from the investigation that separation from his family caused him
distress that was not evident to others and his actions could not have been predicted
by those responsible for his care. I commend staff for the speed of their intervention.
I also make nine recommendations, primarily covering provision for foreign national
prisoners, anti-bullying and three relating to healthcare procedures.
Of the twelve recommendations made the Prison Service accepted in full ten of
these and partially accepted one. A further recommendation was not accepted, but
this remains unchanged in the final report due to evidence available during the
investigation.
The version of my report, published on my website, has been amended to remove
the names of the woman/man who died and those of staff and prisoners involved in
my investigation.
Jane Webb
Deputy Prisons and Probation Ombudsman September 2009
2
CONTENTS
Summary
The investigation process
HMP High Down
Key findings
Issues
Conclusion
Recommendations
3
SUMMARY
The man arrived at HMP High Down in July 2007, having been extradited from Spain
to face charges of murder. He had never been in custody in England but had been
imprisoned in other countries.
On his reception at High Down, a health screen was completed by a nurse who
recorded that the man had no health concerns and so no referrals to other agencies
were made. He was placed in the healthcare centre for his first 48 hours in custody
due to the nature of the charges he faced. During this time no concerns were raised.
The man spoke little English and so enrolled in an education class. His tutors said
that he was a good student who made significant progress. He would talk to other
Spanish speaking prisoners during the lessons and would often help translate for
them as his English improved.
There was an isolated incident of self-harm in September 2007 when the man cut his
arms. When asked he told staff that he felt isolated by his language difficulties. He
was placed on Assessment, Care in Custody and Teamwork (ACCT) monitoring
which remained open for a week and was then closed following a case review.
There were no other incidents of self-harm and he raised no other concerns about
his vulnerability.
The man was found in possession of a mobile telephone in September 2007 and a
home made weapon in October 2007, following which he was moved to houseblock
2. He remained there for only a few days and asked to move to houseblock 1 where
there were other Spanish speaking prisoners. He was subsequently moved and
appeared to settle in well.
However, during the first few weeks on houseblock 1 he reported to an officer with
minor injuries to his face which he claimed were the result of a fall. The officer
considered the injuries to be consistent with an assault. The officer took him to be
seen by a nurse and his injuries were checked. Despite this incident, he continued
to go to education regularly and received favourable reports. There is little
documented information about him during the first part of 2008.
In June, he was approached in his cell by six other prisoners and a fight ensued.
Staff intervened and, along with one other prisoner, he was taken to the segregation
unit. A nurse assessed him and recorded that he had some superficial cuts to his
mouth. A senior officer from houseblock 1 asked him what had caused the fight to
which he responded that he had “just been angry”.
The man returned to the houseblock the following day. On his return, the senior
officer asked if he was content to be there despite the other prisoners remaining. He
said that he was alright and gave no indication that there would be any further
problems. Staff continued to investigate the cause of the incident and information
from another prisoner suggested that the man had been targeted by a gang of
bullies. Staff did not speak to the man about the information and he did not report
that he was being bullied. The other prisoners remained on the houseblock.
4
The man went to education as usual during the morning he was found hanging, but
kept to himself. His tutor, who had heard about the incident, asked if he was alright
and he said that he was. The tutor said he appeared reluctant to discuss what had
happened. He did not get involved in the lesson as much as he usually would, but
he did not appear as though anything was bothering him.
In the afternoon, the man was taken to the segregation unit for the adjudication
hearing about the incident two days earlier. The Governor, who held the
adjudication, said that the man pleaded guilty. When asked what had happened, he
said that he had punched the other prisoner, but provided no other explanation. The
Governor decided to postpone the adjudication so that the officer at the fight could
appear. The Governor said that during the adjudication she observed nothing to
suggest the man was at risk or vulnerable.
On his return to the houseblock, the man is said to have argued again with the group
of prisoners who entered his cell in June. However, this was not witnessed by staff.
All prisoners were locked in their cells at 4.30pm as there was no evening
association. At around 8.20pm the officer who was conducting a routine roll check
on the house block said when she initially checked him she thought that he was
sitting by the window. On a second, closer inspection a few moments later, it
became apparent that he was hanging. The officer immediately called her colleague
for assistance and went straight into the cell, cut the ligature and placed him on the
floor. Both officers, who had medical backgrounds, attempted to resuscitate him
until the arrival of healthcare staff. An ambulance arrived quickly and was followed
by other paramedics. They continued resuscitation and he was taken to hospital by
emergency ambulance.
Although the paramedics got a physical response from him, he never regained
consciousness. Tests carried out on his arrival at hospital confirmed that there was
no brain activity and the decision was taken to withdraw medical treatment. The
man was pronounced dead by medical staff at 1.45am.
After the man’s death, prisoners subject to ACCT monitoring were checked. His
family were notified via the Columbia Embassy and his body subsequently
repatriated to Columbia. Letters written in Spanish were found among his
possessions in his cell. They were translated by the police and indicate that he had
considered taking his own life. The report includes 12 recommendations.
5
THE INVESTIGATION PROCESS
1. My investigator opened the investigation in June 2008. She met the Deputy
Governor, a representative from the Independent Monitoring Board (IMB) and
the prison liaison officer.
2. Notices were published informing both staff and prisoners of the investigation
and inviting anyone with relevant information to contact the investigator. No
prisoners or staff contacted the investigator in response to the notices.
3. The local PCT were commissioned to undertake a clinical review to assess the
man’s medical care at High Down. This included a psychiatric review. I am
grateful to the psychiatrist, and the consultant forensic psychiatrist, for their
reports.
4. My investigator contacted the Metropolitan Police in June and spoke to
Detective Inspector (DI) who was dealing with the murder enquiry for which the
man had been charged. My investigator agreed with the DI that any relevant
information would be shared with police during the course of the investigation.
5. One of my Family Liaison Officers (FLOs) made contact with the legal advisor
in July. He is a legal advisor at the Columbian Consulate who was
representing the man’s family. My FLO explained the aim of the investigation
which would be independent of those conducted by the police and Coroner.
The legal advisor said that he had spoken with the man’s family and they were
keen to know as much as possible about what happened. Due to the family’s
first language being Spanish, the FLO explained to the legal advisor that she
would arrange for a copy of the information leaflet for families to be translated.
It was also agreed that a copy of the report would be translated.
6. Following the issue of the draft report the man’s family were given the
opportunity to respond to the report. No response was received.
7. During September and October 2008, my investigators went to High Down on a
number of occasions in order to interview staff and prisoners. Transcripts of
the interviews are annexed to the report.
6
The man
8. Little is known of the man’s life prior to his arrival at High Down. However, from
correspondence translated after his death, it is clear that his family meant a
great deal to him and keeping in contact with his partner and child was
important.
9. At High Down, he was described as a quiet person who generally kept to
himself. He had a small group of close friends who were mostly other prisoners
who spoke Spanish. He enrolled in the English for speakers of other languages
(ESOL) classes run by the prison education department. His tutors described
him as a very likeable individual who was a keen student. At no time during the
classes did he give any cause for concern. Although his English was limited he
was said to be able to make himself understood and equally understood what
was being asked of him.
7
HMP HIGH DOWN
10. Opened in 1982, HMP High Down was originally a local prison but in 2003 also
took on the role of a category B training prison. There are six houseblocks
each of which has three levels. The prison serves the Crown Courts of
Croydon and Guildford as well as the surrounding Magistrates Courts.
11. There is a wide range of activities available to prisoners as part of the regime,
which includes education, catering, workshops. There are also various courses
that enable prisoners to address their offending behaviour.
12. Healthcare at High Down is commissioned by the local PCT and provided by
Surrey Community Health Services. Sussex Forensic Medical Services
provides the GP cover. There is a healthcare wing with an inpatient capacity of
23 beds in single cell accommodation. In addition to this, a day care facility and
a wide range of primary care services are available.
13. Every prison in England and Wales has an Independent Monitoring Board
(IMB). The members are volunteers appointed by the Secretary of State for
Justice to independently monitor the day to day life in their local prison and
whether proper standards of care and decency are maintained. The IMB
published their most recent report in 2007. They wrote that they believe High
Down is well run, with “the vast majority of staff committed to providing a
secure, fair and decent regime for prisoners”. They also commented on the
Assessment, Care in Custody and Teamwork (ACCT) process, which was well
established at the prison, but described the quality of some observations of
prisoners on open ACCT documents as “variable.” (ACCT monitoring is put in
place for all prisoners who self-harm or where there is concern that they may
do so. It provides additional support and a higher level of observation and
interaction.)
14. HM Chief Inspector of Prisons conducted a full inspection of High Down in May
2006. She said in her report of this inspection:
“High Down, along with all local prisons, is under tremendous pressure
as a result of the growth in the prison population. Despite this, the
establishment had made considerable strides in a number of areas.
“There was a good suicide prevention policy in place. Monitoring
entries in ACCT’s were generally good, although case reviews were
poorly attended and the timing of some night entries was too
predictable.”
15. In relation to bullying and foreign national prisoners, HM Chief Inspector of
Prisons said the following:
“Prisoners complained of intimidation by staff both in our survey and in
focus groups. Allegations submitted confidentially referring to
intimidation and bullying by officers were not properly dealt with.
Prisoner-on-prisoner bullying did go on, and was under-reported. The
8
quality of investigations into alleged incidents of bullying was very poor.
Residential house blocks were not always effectively patrolled by staff,
leading to some perpetrators of assaults going undetected. There was
no intervention work for bullies, and little support offered to vulnerable
prisoners.
“While foreign nationals constituted a large proportion of the prison’s
population, there was no foreign nationals committee and no overall
strategic direction in the work being done. The foreign nationals’
coordinator had insufficient time to develop the work, and there was
little evidence of provision filtering down to the prisoners in most need.
There was no independent immigration advice, and there was an over-
reliance on the parole clerk.”
16. The Ombudsman took on responsibility for investigating all deaths in prison
custody in 2004. Since then there have been five apparently self inflicted
deaths at High Down. No issues raised in this report are relevant to any of the
previous deaths.
9
KEY FINDINGS
Initial reception at High Down
17. The man was charged with murder and remanded into custody in July 2007,
following his extradition from Spain. A Columbian national, he had spent
periods in custody abroad but this was his first time in prison in England. He
was taken to High Down where, on reception, a member of the healthcare staff
assessed him and a health screen was completed. He said that he had seen a
doctor within the last few months, but this had been for “nothing important”.
The nurse wrote on the health screen that,
”... He appears stable. Rather quiet in presentation, though does not have any
intention of harming himself ...”
18. The reception health screen instructs that a prisoner charged with murder or
manslaughter should be referred for a mental health assessment. No referral
to drug services or mental health was made for the man and it was not
considered necessary for him to be seen by the doctor. The initial health
screen provided little information which could have been due to his language
difficulties. Nevertheless, as he had been remanded on a charge of murder he
was located in the healthcare centre for observation. (It is normal procedure at
High Down for all prisoners that have been charged with such offences to be
located in the healthcare centre for the first 24 - 48 hours in custody. This is
partly for observational purposes as the prisoner could be vulnerable.)
19. As a Columbian national, his first language was Spanish. The Cell Sharing
Risk Assessment (CSRA) completed on his reception recorded that he spoke
little English but could communicate to a basic standard. No other issues were
recorded and he was considered to be “low risk” and suitable to share with any
other prisoner. (The CSRA is completed for all prisoners on their reception to
make sure that unsuitable prisoners do not share cells. An example of this
could be an openly racist prisoner and one from a visible ethnic minority. The
assessment involves the prisoner answering questions about their behaviour
and any previous custodial sentences.)
20. The man remained in the healthcare centre until July. He attended the Well
Man clinic where a further assessment of his medical history was undertaken.
The form was not signed and it remains unclear who completed it. During the
assessment, he said that he was a smoker and had no wish to take part in a
smoking cessation programme. He said that he would like to receive a
vaccination against Hepatitis B and a referral was made for him to attend the
clinic. No other medical concerns were identified. During the afternoon of 30
July, having completed his induction he was moved to houseblock 4. There is
no documentation to confirm whether he had been given a full induction or
provided with information that would assist him in settling into life at High Down.
21. Before leaving the healthcare centre, a discharge plan was completed by a
nurse. She recorded that he needed to “ventilate his feelings” and that he was
on an open ACCT. However, the ACCT document was not handed to the wing
10
and no further mention of it was made. The investigator interviewed the head
of healthcare at High Down. My investigator asked her if she could explain why
the ACCT was not available. She said that judging from the entries in the
medical record, she considered it unlikely that he would have been on an open
ACCT. She said that it was more likely that the nurse who completed the
discharge plan had completed the wrong section on the discharge document.
However, she said that she would need to look into the matter further to be sure
that an ACCT document had not been opened. (The head of healthcare
contacted my investigator on 6 November to confirm that she had spoken with
the nurse who did the, discharge plan who could not recall whether the man
had been subject to ACCT monitoring when she discharged him. The
document had not been traced and it was likely that it was a clerical error on
the discharge plan.)
22. In mid-August, the man began to go to an education class for ESOL. The tutor
in this class said that the man could speak a little English and was a quick
learner. She said that, although the man’s English was limited, he could
communicate and understood what other people were saying and what was
happening.
23. Another tutor in the ESOL class, told my investigator that when the man had
first come to the class he had almost no English. Despite this she said he was
a good communicator and could make himself understood with gestures. His
English improved a lot and he was able to make himself understood at a basic
level. My investigator asked her whether she thought that the man would have
been able to communicate easily with prison staff. She said that she did not
think that he would have found this easy. She found him to be a “proud person”
who would probably have been reluctant to be open about his problems, but he
seemed to get on well with staff. The tutor said that she did not think that the
man’s language skills were good enough to talk about his personal feelings.
She said that he spoke several times to a volunteer who helps in the classes
and speaks Spanish.
24. The volunteer said that she could not recall how she had first met the man.
She had been made aware that there was a Columbian prisoner who spoke
little English and she thought that he would benefit from a visit. My investigator
asked about her conversations with him and she said that they would discuss
his case and his family. She said that the man’s partner was expecting a baby
and they talked about his worries. My investigator asked whether the man ever
discussed problems he was having in the prison. She said that he would
sometimes be “very low” and she would ask him if he felt suicidal. However,
the man was a devout Catholic and told her that he would never commit suicide
under any circumstances. She said that she had never considered opening an
ACCT document as she did not think that he was at risk of self-harming during
the time that she was seeing him.
11
Incident of self-harm in September 2007
25. In September, the man moved from a shared cell to a single cell. There was no
particular reason for the move other than to give him the benefit of more
privacy. Later that day, he pressed his cell call bell and, when an officer went
to the cell, he noticed that he had several fresh cuts to his arms. He was taken
to a nurse to have the cuts treated. He told the officer that he wished to move
back to the shared cell, as he felt isolated alone in the single cell. The officer
opened an ACCT document and arrangements were made for him to return to
a shared cell.
26. A requirement of the ACCT process is that a trained assessor carries out an
assessment within 24 hours of it being opened. The man’s assessment was
completed by an officer in September. The officer recorded that translation was
difficult, but the man said that he had become depressed due to his inability to
communicate effectively. The man said that his self-harm had been a slow
build up and that he needed to release some pressure. However, he did not
want or expect to die.
27. When the officer asked him about any previous history of self-harm, he showed
a scar on his right arm that he said had been a result of a serious suicide
attempt eight years before. (It had not been mentioned or recorded during the
health screen completed on the man’s reception at High Down.) The officer
asked if he had any suicidal thoughts or intentions and he replied that he had
not. When discussing how he was coping, the man spoke about his children
and said he telephoned his family at least three times a week. The officer
recorded that, while this was a great comfort he became very emotional when
discussing his children. The officer believed that being away from his family
was at the core of the man’s problems. On concluding his assessment, the
officer recorded that, due to the language barrier, it was difficult to be sure that
the man fully understood the ACCT procedures. (There is no evidence to
suggest that using a translation service was considered.)
28. After the ACCT assessment, staff arranged for the man to speak with another
Spanish-speaking prisoner, who was also a Listener. (Listeners are prisoners
who volunteer to be trained by the Samaritans to provide confidential support to
other prisoners at times of crisis.) In addition, hourly observations were carried
out when the man was in his cell and staff recorded all their interactions with
him in the document during the core day. The ACCT remained open until 7
September when it was closed following a case review. The man went to the
review with two other prisoners who helped to translate. It was recorded during
the review that the man felt less isolated, was now settled and agreed to the
ACCT document being closed. A post closure review was carried out by a SO
in September, when he recorded that the man was “happy on A spur,
houseblock 4 and he would like to remain on there”. The SO told him about the
support that was available to him if he required it.
12
Discovery of mobile phone and bladed article
29. During a routine cell search in September, the man was found to possess a
mobile telephone. The wing history record indicates an entry by the officer who
had opened an ACCT document indicates that another officer had placed the
man on report. There is however no information as to whether an adjudication
took place and, if so, the outcome. (When a prisoner commits an offence
against prison rules such as possession of a banned article they are placed on
report by the officer who discovers the offence. An adjudication (hearing)
follows chaired by a governor. If found guilty, the prisoner will be awarded a
punishment ranging from forfeiture of privileges to cellular confinement. The
governor can also choose to suspend any award for a minor or first offence.)
30. The discovery of a banned item in any prison should be reported to the security
department via a security information report (SIR). (SIRs are used by any
person working in a prison to inform the security department of an incident that
might need monitoring such as friction between prisoners, the discovery of illicit
items or other relevant information) the man’s security file indicates that no
such report was received by the security department at High Down.
31. Information was however received by the security department, via an SIR that
the man was in possession of a bladed weapon. As a precaution, staff
searched the man and his cell and a sharpened toilet brush handle was
discovered. (It has been known that prisoners melt the ends of plastic toilet
brushes and fashion them into a point to make a rather crude but effective
weapon.) As a result he was placed in the segregation unit under Rule 53 of
the Prison Rules. (Rule 53 authorises the governor to segregate any prisoner
suspected of committing an offence pending adjudication.) He was seen by a
nurse who completed a Segregation Safety Screen. (The purpose of the
screen is to determine whether there are any healthcare reasons why a
prisoner cannot be held in segregation. It provides a “snapshot” of a prisoner’s
mental well-being while also taking account of their physical health.) No
medical objections were identified to him being segregated. He remained in the
segregation unit for a couple of hours before being moved to A spur on
houseblock 2.
32. An adjudication took place in October chaired by the Deputy Governor. The
man pleaded guilty and was awarded five days loss of association and loss of
access to television. (Association is the time that prisoners are out of their cells
and make telephone calls, take part in other wing based activities and talk to
each other.) It was also decided that the man should not return to houseblock
4. The same day, a wing officer recorded in the man’s wing history record
(page 16) that, he had “kept a very low profile over the last couple of days”.
Move to houseblock 1
33. The man asked to move to houseblock 1 where there were other Spanish
speaking prisoners. He was allocated to a shared cell in houseblock 1, A spur,
in October where he reportedly settled in well.
13
34. Ten days later, at 6.30pm in October, the man approached an officer with
scratch marks on his neck and bleeding from his upper lip. The officer
recorded on a form F213 that he considered the injuries to be consistent with
being assaulted. (F213 is the form used to record an injury to a prisoner.
Details are recorded of how the injury was sustained and what treatment staff
provided.) However, the man said that he had fallen over. The officer took
him to the treatment room where he was examined by a senior nurse. The
nurse wrote in the man’s medical record, “… Complaining of pain on nose, little
bleeding, no swelling. No other injuries except minor cut to inner and upper lip
...”
35. Nothing relating to this event was recorded in the man’s wing history file, but an
entry in his security file says that there was an altercation between him and
another prisoner at 6.30pm in October. There is also no evidence that either
prisoner was placed on report. The information in the security file came from
an SIR which could not be found and so was not available to the investigators.
It is likely that the altercation referred to is the one that resulted in the man’s
injuries on 22 October.
36. My investigator asked the wing manager on houseblock 1, if she could recall an
assault on the man in October. The wing manager said that she had spoken to
him about the incident but he refused to discuss it. She also told my
investigator that the prisoner who had assaulted the man was known to have a
very bad and violent attitude towards staff and prisoners. She added that he
was a strong man who was known to be a bully, and had been moved to the
prison due to his violent behaviour.
37. Although the SIR was received by the security department in October, it is likely
that it was sent there the previous evening. A Principal Officer explained to my
investigator that SIRs submitted after 3.00pm are collected the following day at
7.30am and processed by 11.00am. Those submitted before 3.00pm are
processed during the course of the day.
38. The man had limited contact with healthcare but did report sick again in
December 2007. It is recorded in his medical record:
“...For about 2 - 3 weeks pain around his right eye and also mucus and
pus in his right eye. Slight swelling below right eye but no visible
inflammation. To be given 400mg Ibuprofen 2 week course and eye
drops to be applied 6 times daily...”
39. There are very few entries in the man’s wing history file and, apart from one
entry in January 2008 that shows that he had not been approved for enhanced
status on the Incentive and Earned Privileges Scheme (IEP), there is a gap of
almost two months. (The IEP scheme rewards prisoners for good behaviour.
There are three levels, basic, standard and enhanced. Incentives include
access to in-cell television, more cash to spend, wearing their own clothes,
more time out of the cell and community visits. Each prison sets its own criteria
to obtain each level. Basic is the lowest level and is usually used for prisoners
14
who consistently fail to adhere to the prison regime, standard is the most
common and enhanced the highest.) There was no explanation as to why the
man was considered to be unsuitable for the enhanced level and he remained
on standard.
40. During the morning in March, a prisoner from another houseblock came into
houseblock 1 to collect cleaning equipment. On seeing the man, he began
making threats that he was going to “kill him”. The prisoner then reportedly
went to the gates onto the spur and shouted to other prisoners that he would
pay anyone who got the man £1,000. An SIR was submitted to the security
department but despite an instruction by the security manager, no entry was
made in his wing history file.
41. The SIR was processed by the security department and the security manager
wrote:
“... The prisoner’s employment status to be reviewed if he is in a
trusted position as this suggests he should be removed. He cannot be
allowed freedom of movement around the prison if he is going to
behave in a threatening manner. The man may have to be moved for
his own safety, a note is to be made in both wing history files and
observation books. Not to be located together ...”
42. The SIR was passed to the duty governor who commented, “... the man has
previously seriously assaulted the prisoner, which was his mitigation on
adjudication ...” It is not clear whether the comment refers to the adjudication
on the prisoner for the threats he made towards the man or for the previous
assault. My investigator attempted to gain further information but was unable to
do so. What is known is that there is no previous SIR information relating to the
man and the prisoner and no adjudication records for the man relating to an
assault on the prisoner.
43. In April, an officer made the following entry in the man’s wing history file:
“... Apart from taking his time when its time to go to his place of work
he has not been a problem on houseblock 1, B spur. Enjoys going to
the gym and recently given a single cell which he maintains. Limits
who he associates with ...”
44. The officer told my investigator, that she knew him very well. She described
him as a “loner” who associated with few other people. She said that his
English was not good but he was able to communicate with staff. The officer
said that the man did not like getting up in the mornings which had led to him
being late for education, and he was warned about this. Other than this, the
officer said that he was no problem and settled in well on the houseblock.
45. My investigator asked the officer whether she was able to recall the man having
any trouble with other prisoners. She said that she could not recall any
problems on houseblock 1. However, she said that he had asked to move to
another houseblock as he wanted to be with friends who spoke his language. It
15
was confirmed by the officer that he did move to another houseblock but
returned after a relatively short time and was located onto C spur, houseblock
46. The officer, who was working on B spur, said that she spoke to him after his
return to houseblock 1. She told him that she would move him back to B spur
as soon as a space was available. He subsequently moved to a single cell on
B spur.
47. There is no mention in the wing history file of the man being moved to another
houseblock or the reasons for his return to houseblock 1. My investigator
asked the officer whether she was aware of a reason why he had returned to
houseblock 1. The officer said that she recalled saying to the man, “You made
such a fuss that you wanted to go over there, how come you are back?” He
replied that he did not like it and was not getting on with people, but the officer
said that he did not mention any names.
48. However, during an interview with the wing manager, she told my investigator
that the man had asked to move to houseblock 5 (where there were a number
of other Columbian prisoners) as he felt isolated on houseblock 1. He moved
across but had problems relating to the incident with the prisoner who had
made threats towards him earlier, so returned to houseblock 1 the following
day.
49. The wing manager had made monthly entries in the man’s wing history file and
she was asked whether this was normal practice. The wing manager said that
she made monthly entries for all prisoners on the spur as this was a
requirement of the personal officer scheme. She said that she had been
trained at another prison and was used to doing so every month. (The personal
officer scheme is nationally operated but each prison has its own way of
delivering the scheme. A certain number of prisoners are allocated to a named
officer as a point of contact. The officer completes reports on prisoners for
which they are responsible, ensures entries are made in their wing history files
and offers general advice.)
50. The wing manager said that the scheme at High Down was different from what
she had been used to. Rather than allocating all prisoners a personal officer,
only those prisoners considered to be vulnerable were given a personal officer.
The officer who had accompanied the wing manager to the interview, said that
the purpose of the High Down scheme is to allow staff more time to focus on
those prisoners who need closer monitoring. He said that, due to the size of
the prison, if every prisoner had a personal officer then staff would spend
weeks writing in their history files. The wing manager told my investigator that
she did not believe the man had been highlighted as requiring a personal
officer, but she would normally write an entry on all prisoners who she worked
with.
51. An entry in the man’s history file in May shows that he was offered a space on
A spur as he had issues with unidentified prisoners. However, there is no
information to suggest that he had been having any problems previously. He
declined the opportunity to move to another houseblock but the entry gives no
16
reason for his refusal or names the officer he spoke to. My investigator
attempted to identify the officer who made the entry but was unable to do so.
Another entry made the following day says “received back onto houseblock 1”.
Again there is no other information to indicate that the man had spent the night
anywhere other than houseblock 1 and nobody could account for this or the
previous entry.
52. The volunteer helper told my investigator that she last spoke with the man in
May before she went on holiday. She said that he was nervous about his trial
and had been sent a suit by his partner. He had said that he was going to grow
his hair as he felt that this would look better in court. She said that, although he
was nervous, he told her that his solicitor thought that there was enough
evidence to clear him.
53. As mentioned earlier, very few entries were made in the man’s wing history file
between January - June 2008. My investigator interviewed, a prisoner who was
friends with the man. The prisoner explained that he had been a classroom
assistant in the English class attended by the man. He explained that High
Down has a system whereby prisoners who are fluent in a foreign language or
English assist the teachers.
54. He said that the man was a “cool guy” and was always friendly. He said that
the man had been in the class for sometime and had himself become almost
like a “mini-assistant” to the teachers. He would help by explaining things to
other Spanish speaking prisoners. My investigator asked the prisoner whether
he thought that the man had any problems communicating with staff. He said
that he felt that the man understood what was being said and equally could
express what he felt. In his view, his English was very “advanced”.
55. My investigator asked whether the man ever spoke about any concerns or
problems. The prisoner said that the man’s partner had given birth while he
was in custody. As he was a father they had this in common. They would talk
a lot about it and the man spoke of his desire to see his baby. He said that the
man never became emotional but it was clear that this was something that was
important to him.
56. Apart from his family, he said that the man also spoke about his impending trial.
He spoke about his prospects of being acquitted, but equally the possibility of
being found guilty. He told my investigator that he never said that if he was
found guilty what he would do and that he always looked at things in a positive
way.
Incident in June 2008
57. At 6.20pm in June while on association, six prisoners went into the man’s cell
and a fight ensued. The officer who responded to a general alarm on
houseblock 1 that indicated a problem. He was directed to the man’s cell
where he witnessed the man punch one of the prisoners. The officer, along
with other staff, restrained him who was taken to the segregation unit. The
prisoner that the man punched was also sent to the unit. (The purpose of
17
segregation is to maintain safety, order and discipline. A segregation unit
provides temporary accommodation for prisoners that have become violent or
disruptive, committed offences against prison rules or require protection if they
are under threat from other prisoners.)
58. The wing manager, who was on duty on houseblock 1, followed the man to the
segregation unit and spoke with a Principal Officer who was in charge. She
asked the Principal Officer if she could speak with the man as she had had a
number of dealings with him and he probably spoke with her more than any of
the other SOs. The wing manager told my investigator that she went to his cell,
sat on the bed with him and discussed what had happened. He told the wing
manager that the four prisoners had entered his cell and tried to use a mobile
telephone. He had refused and they began pushing one another. He
explained that this was when the officer had pressed the alarm. The man said
that he hit the other prisoner after staff had responded to the alarm. The wing
manager asked why he had done this in front of staff and whether it was so that
he would be moved off the houseblock. The man responded to this question by
saying that he had done it because “he was angry”.
59. When the man went to the segregation unit, he was seen by a nurse who
completed the routine segregation safety screen. The nurse also completed a
form F213. She recorded that he had a small cut inside his upper lip which
required no treatment and also had redness around his right eye for which he
was provided with an ice pack. She recorded no medical objections to the man
remaining in the segregation unit.
60. Once the healthcare section of the segregation safety screen has been
completed, the duty governor has to authorise it by signing the form. In June,
the duty governor. The segregation safety screen document does not specify a
requirement for the duty governor to physically see a prisoner located in the
segregation unit. However, a manager in the segregation unit, was asked by
my investigator whether it was normal for a duty governor to sign the form
without seeing the prisoner first. The manager in the segregation said that 90
per cent of the time the duty governor would see the prisoner first and the
exception to this would be if they were not available. He said that he felt it was
good practice for a duty governor to speak to a prisoner who had been brought
to the unit to explain why they had been segregated. He said that it was also a
way for the governor to satisfy himself that the segregation was justified and
acceptable. My investigator asked him if the duty governor would always be
aware that a prisoner had been segregated. He said that they would always
have to be made aware and provide approval. My investigator asked Governor
who had signed the form whether he had spoken to him before signing the
form. The Governor said that he did not see him. My investigator asked if he
was happy to sign without checking the prisoner and confirming that he was
located there for the proper reasons. The Governor said “I just assume that the
orderly officer would have his reasons for putting him there.”
18
The man’s return to houseblock 1
61. The man remained in the segregation unit and returned to houseblock 1 the
following day. The wing manager and an officer spoke with him on his return
before he went back to his cell. They asked if he felt safe on the houseblock
and whether there were likely to be any further problems. The prisoners
involved in June were also still on houseblock 1.
62. The wing manager said that the man was adamant that he would be fine. He
kept saying that there were no problems and everything was fine. He told my
investigator that she had the wing history files of prisoners involved the
previous evening. She showed their photographs to the man, asking if he had
any problems with them. She said that he just continued to say that everything
was fine. At no time did he mention that he was being bullied.
63. Another prisoner, a Listener and anti-bullying representative on houseblock 1,
told my investigator that he recalled speaking to the man when he returned
from the segregation unit in June. (The role of an anti-bullying representative is
to support anyone who is a victim of bullying and to report to the safer custody
team if they feel that a prisoner is being bullied. Their role is not to challenge
the bullies.) He said that he knew the man pretty well as he had been in the
opposite cell on houseblock 1 for about four months. The prisoner said that the
man’s English had not been very good but he was able to communicate easily
and make himself understood. He considered him to be a quiet individual, who
kept to himself. He had never gained the impression that the man felt
depressed or suicidal and did not consider him to be vulnerable. On the
contrary he said that he felt the man was “very much able to defend himself”.
64. My investigator asked the prisoner about his conversation with him when he
returned to houseblock 1. He said that the man had not asked to speak with
him but he spoke to him in his capacity as anti-bullying representative. The
prisoner asked if he was content to return to the houseblock after the incident
the previous evening. The man said that he was fine about coming back to the
houseblock. However, the prisoner told my investigator that he had got the
impression that the man felt isolated and he had informed him that there was
support if he required it.
65. My investigator asked him if he noticed any further trouble between the man
and the group of alleged bullies. He said that the group still targeted the man
and he knew that he was preparing to defend himself if the situation arose
again. He had seen a weapon the man had made and he felt he was capable
of retaliating if the group attempted to pressurise him again.
66. The prisoner continued by saying that he feared that the man might harm
individuals from the group rather than himself and he had therefore spoken to a
SO, who worked in safer custody. The prisoner said that he wanted staff to
keep an eye on the man as he feared that he might “lash out”.
67. The SO told my investigator that, as a member of the safer custody team she
was responsible for co-ordinating the Listeners and the anti-bullying
19
documents. This entailed collating how many were open and on which
houseblocks. (An anti-bullying document is opened on an individual when it is
believed that they are involved in the bullying of other prisoners.) The SO said
that the prisoner came to see her on the afternoon as he was concerned about
the man. His main concern was that the man could receive a long sentence if
convicted, so he believed that he would have nothing to lose by retaliating. The
SO completed an SIR and spoke with the houseblock PO in the presence of the
wing manager. The SO asked if they were aware of the prisoner named as
bullying the man. They replied that they were and it was being dealt with.
68. Following the interview with the SO, my investigator spoke again to the wing
manger and asked if she could recall the conversation with the SO. The wing
manager could not recall it but did speak with the SO quite often. However,
she said that she had received no information from the anti-bullying
representatives and, if she had, then different action would have been taken.
She said that the prisoners who had gone into the man’s cell in June were
being watched but, due to lack of information, none had been placed on anti-
bullying monitoring at that time.
69. The wing SO was off duty and returned the following day. My investigator
asked the wing SO if he had known the man prior to the incident. He said that
he had seen him every day as he would any other prisoner. The wing SO said
that the man was very quiet, polite and fairly amiable.
70. My investigator asked the wing SO what he did when he came on duty. He
explained that he was required to brief the staff and, before doing this, would
read the wing observation book to find out what had happened the previous
evening. He said that, as the wing SO, he had to investigate the incident to
establish the motivation behind it, such as bullying or racism. He said that he
made an entry in the observation book informing all the unit staff of the actions
that he wanted them to carry out, which included observing the prisoners.
71. The wing SO said that the information he gathered was later thought to be
inaccurate. It was initially thought that the prisoners had gone into the man’s
cell with the intention of using a mobile telephone, and if they had been caught
they would have blamed the man. (Mobile telephones are not allowed inside
prisons and cannot even be carried by those working there.) However, the
wing SO was told later that the man was himself in possession of a telephone
and the group had gone in with the intention of removing it. The wing SO said
that this information had not been substantiated. My investigator asked if the
prisoners involved had been placed on anti-bullying monitoring. He said that
this had been one of his actions. The prisoners had been considered to be
“potential bullies” and their movements were to be monitored. He said that it
was expected that at least one entry per day would be made in the documents.
72. My investigator asked the wing SO if he considered moving or separating the
prisoners. The SO said that he moved the prisoner he considered to be the
ringleader and thought that sufficient. He said that this prisoner had been on
anti-bullying monitoring at the time of the incident so there was enough
evidence to justify moving him. My investigator asked if the SO could be
20
certain that the prisoner had been moved as he was the one who was hit by the
man and taken to the segregation unit with him. The documents provided to
the investigators suggested that this prisoner had remained on the houseblock
until 14 June.
73. The wing SO told my investigator that he was sure that the prisoner moved
before this date as he recalled receiving a telephone call from an SO on the
houseblock that the prisoner had moved to. The SO had asked him to confirm
that the prisoner required a single cell. The investigators told the wing SO that
it was very difficult to ascertain whether the prisoner had moved or not as
events had been poorly documented.
Events of Friday
74. The SO, who had been on duty on houseblock 1 on the evening, submitted an
SIR following the incident. He wrote “... I suggest that all bar the man have out
stayed their welcome at High Down and should be transferred ASAP ...” He
also made a note in the wing observation book that, in his opinion, the group
should be separated. My investigator asked the SO if the individuals had been
separated and, if not, the reason why. The SO said that they had not been
separated and, when he returned to duty in June he was surprised to find them
still on the same wing. The SO said that he was told that a decision had been
taken to deal with it “in-house” but he did not know who had made that
decision. The SO went on to say that he was told that the man had been asked
whether he was happy to be back on the spur with the prisoners he had
problems with, and he had replied “yes, I have friends on the wing, I am happy
where I am”.
75. The man went to education on the Friday morning. The house block PO told
my investigator that she asked him if he was alright as she was aware of the
incident on the houseblock. He replied that he was alright, but he did not seem
to wish to talk about it. She told my investigator that it did not seem to bother
him, but he did not join in with the class as much as he usually would. He
spent time on his own working on the computer, which he had not done before,
and would have normally joined in the discussion.
76. The prisoner who was a classroom assistant was also in education that
morning. He told my investigator that he too was aware of the altercation
involving the man as he had not attended education the previous day. He said
that the man had told him that he had a mobile telephone and the prisoners
had gone to his cell with the intention of taking it from him. He said as a result
the man had lost the telephone and was upset by this. The man had told him
that one of the things that had kept him going was being able to contact his
partner. He said that he would talk to her a lot at night and she would tell him
about the baby. The prisoner said, although the man should not have had the
telephone, it was clear to him that this gave him considerable comfort.
77. My investigator asked him if he was worried about the man during their
conversation. He said that he was not. He could see that he was upset about
losing the phone as he had communicated with his partner every evening for
21
sometime. He likened it to the man coming home from work and talking to his
partner, telling her about his day and “offloading” to her. He said not having
any way of contacting his partner and speaking about the baby was upsetting
him the most. He said that the man did not seem to think that losing the phone,
was the end of the world, and he said that he would have to find a way of
getting another.
78. When asked whether he spoke with the man about anything else, he said that
they discussed meeting at the gymnasium over the weekend. He explained
that his houseblock went to the gymnasium on different days to the man so he
had told him that he was going to speak to his wing manager to see if they
would allow them to attend the same session. As there was no education on a
Friday afternoon, he did not expect to see him again until the Monday.
Adjudication for the fight in June
79. During the afternoon of Friday in June, the man was taken to the segregation
unit for his adjudication hearing at around 3.00pm.
80. The Governor who did the adjudication explained to my investigator that she
had no knowledge of the incident before the adjudication as she would
otherwise have been ineligible to hear the case. The first information she had
about the incident was when the report was read out at the hearing. The
Governor asked the man whether he understood the evidence. He replied that
he did and that he had no questions. The Governor asked him to explain what
had happened in his cell. He told her that he had an argument with another
prisoner and then punched him in the face. He said that he had hit the other
prisoner first and the other prisoner had not hit him back. The Governor
recorded on the adjudication document and told the man her impression that he
was not telling her everything and that someone had told him what to say.
81. There was another officer who was present in the adjudication as an escorting
officer. He showed the man the word “bully” in a Spanish phrase book to
ascertain if he was under pressure from anyone. It is recorded in the
adjudication papers that the man confirmed “yes” when he was shown this.
The adjudication was postponed to allow the officer who had reported the
incident to attend and the man was taken back to his cell.
82. My investigator asked the Governor whether she was able to communicate with
the man easily. The Governor said that she could but he had “quite an attitude”
and been “quite flippant” and did not want to say very much. The governor said
that when the man was shown the word “bully” it was not clear whether he was
indicating that he understood the word or if he was being bullied. My
investigator asked the Governor whether she would have done anything
differently if she had felt that the man was being bullied. The Governor that he
did not appear to her to be vulnerable, and appeared quite a confident man.
Events during the evening in June
22
83. There is little documented about the man’s movements following his return to
the houseblock after the adjudication. The second prisoner told my investigator
that he had seen the same group of prisoners, “baiting” him during the
afternoon. He overheard the man say to one of the prisoners “let’s go into the
showers to sort this out then”. The man then went into the shower area with
the prisoner, followed by the rest of the group, before then walking out again.
The prisoner told my investigator that the group then shouted to the man “if you
are going to threaten us then we will threaten you” but he returned to his cell.
This is the last account of anyone seeing the man that afternoon. The prisoner
said that this would have been around 4.00pm.
84. My investigator asked the prisoner whether staff would have seen this
exchange taking place. He said that he did not think so. He said that staff are
generally aware of bullying on the houseblocks and do take action against
known bullies. The prisoner told my investigator that this particular group of
prisoners were known for stealing and there had been some tension on the
wing for a few weeks. When asked how effective he felt the anti-bullying
representative was, the prisoner told my investigator that he did not think it was
as effective as that of a Listener, and prisoners rarely approached him to say
they were being bullied. He added that he had not spoken to him as a Listener
and he had not said that he felt vulnerable or unhappy.
85. On Friday afternoons prisoners are locked up earlier and there is no evening
association. They are locked in their cells after collecting their evening meal
and not unlocked again until the following morning, unless there is an
emergency. There is no record of any problems on the houseblock during the
early evening or anything to suggest that staff had to go to the man’s cell for
any reason. He was seen sitting on his bed at 7.15pm by an officer while he
was conducting a roll check.
86. The first officer on the scene who was on duty on houseblock 1 during the
evening and was due to leave at 9.00pm. The night officer, Operational
Support Grade (OSG) had arrived on the wing and begun to do the roll check.
(At various times of the day a count of prisoners takes place, usually at shift
handovers.) The first officer on the scene said that it was getting close to
9.00pm and she had been told that she could go off duty as soon as the roll
had been reported. To help the OSG, she began counting on the third landing,
and started on C spur before moving across to B spur where the man’s cell was
located. She explained that in order to check that each prisoner was in their
cell, it was necessary to open the observation panel and look inside.
87. The first officer on the scene said that when she looked into the man’s cell, she
saw him sitting by the window with the lights off. She said that from the way he
was sitting, it looked as though he was “hanging a line” out of the window.
(Prisoners use lengths of torn bed sheet or other material to make a “line”
which they then use to pass items from their windows to other prisoners.) She
thought that this was unlike the man and she continued to count along the
landing. When she got to the end of the landing, she thought that she should to
go back to check what he was doing and so she returned to his cell. She
opened the observation panel slowly to see if she could catch him doing
23
something. She realised that he was still in the same position. She told my
investigator that the man was a “bizarre” colour and she called for assistance
from her colleague who was also on the houseblock.
88. The first officer on the scene told my investigator that, after calling to the
second officer, she pushed the alarm button on the landing. She decided to
open the door and go in without waiting for the second officer. (Prison staff are
advised to wait for assistance from a colleague before entering a cell if they are
unsure.) She used her anti-ligature knife to cut the ligature, which was
attached to the window bars, and lowered him to the floor. (The knife is a tool
for cutting ligatures and is carried by all prison staff for use in an emergency.)
By the time that she had lowered the man to the floor, the second officer on the
scene arrived and they began to administer cardio pulmonary resuscitation
(CPR.) She said that, as a trained nurse, she was very familiar with performing
CPR. She had checked for a pulse and ascertained that there was not one and
the man was not breathing.
89. The second officer on the scene told my investigators that he was on duty with
the first officer on the scene on the evening of June. He had completed the
earlier roll check at around 7.15pm and recalled seeing the man sitting on his
bed. He said he thought it was about an hour later at 8.15pm when he heard
the officer’s alert and went to assist her. My investigator asked him if he or the
officer used their radios to request medical assistance. He told my investigator
that the SO who was the duty senior officer and he asked him to contact the
control room to call an ambulance and medical assistance. My investigator
asked the second officer on the scene how long it would have been from him
arriving at the cell to the SO requesting medical assistance. He said that it was
“within seconds.”
90. The SO who was the duty senior officer told my investigator that he was about
to leave the houseblock when he heard the first officer on the scene shout. He
was unsure whether she was calling him and then heard her call the second
officer. The SO said that there was something in her voice that made him think
that there was a problem, so he went back to the houseblock. He told my
investigator that he saw the first officer on the scene on the third landing and
the second officer making his way up the stairs. The SO called up to first
officer on the scene and asked what the problem was and she replied that a
prisoner was hanging. The SO said that he could not recall if it was himself or
the second officer who made the radio call to alert the control room of the
situation, but it was made straight away. The call was recorded by the control
room at 8.40pm. The ambulance was contacted at 8.42pm. The SO went to
the office to collect an intervention kit and an emergency first aid kit before
making his way to the cell. (An intervention kit is located on each wing and
contains basic first aid equipment.)
91. The SO and the second officer on the scene were unable to get the airway aid
to work and none of the staff had been issued with face masks. Instead, the
second officer on the scene used a piece of J cloth as a face mask and
continued giving breaths to the man. The SO told my investigator that he
thought to himself that the man could not have been found by two better staff,
24
as the first officer on the scene was an ex nurse and the second officer on the
scene was an ex healthcare officer. The two officers continued CPR until
healthcare staff arrived.
92. The nurse, who arrived for night duty, had just taken the radio call sign Hotel 2
(which is the emergency response) when he heard the call for medical
assistance. My investigator asked Hotel 2 to explain the coding system at High
Down for medical emergencies. Hotel 2 said that there are three codes. Red
indicates a prisoner with severe chest pain, collapsed, not breathing or
hanging, essentially a life threatening condition. Amber indicates a prisoner
who may have cut themselves and green is for a minor ailment such as a
headache. Hotel 2 confirmed that the call that came over the radio was “red”
and he quickly made his way along with other nursing staff to houseblock 1.
93. The SO who had also arrived for duty and taken over as the night orderly
officer. (The night orderly officer is in charge of the entire prison during the
night state.) He was with the duty governor, when they heard the alarm sound
on houseblock 1. The SO told my investigator that, within 30 seconds of
hearing the alarm, a code red was called over the radio and he told the
Governor that he would go to the houseblock. When he got there he was
directed by staff up to the man’s cell. The SO told my investigator that the two
officers were administering CPR when he arrived. He immediately used his
radio to contact the control room and ensure that an ambulance had been
called and staff were available to escort it straight to the houseblock. The SO
then contacted the Governor and asked him to make his way straight to the
houseblock.
94. The Governor arrived at the cell at the same time as the healthcare staff who
then took over from the officers administering CPR. Hotel 2 said that they
continued to try and get a response from the man but failed to establish any
signs of life.
95. The ambulance arrived at the prison at 8.45pm and was taken directly to
houseblock 1. Paramedics took over and continued to treat the man. The first
ambulance crew were assisted by paramedics from the Helicopter Emergency
Medical Services (HEMS). This is operated form the Royal London Hospital
and provides a service to the Greater London area and often consists of a
trauma doctor and paramedic. The HEMS team arrived by car at the prison at
9.10pm. The medical team continued to treat him and eventually obtained a
pulse. He was transferred by emergency ambulance to the hospital, at 9.57pm.
96. The SO arranged for two members of staff to accompany the man in the
ambulance. Due to his condition, no restraints (handcuffs) were used. He said
that initially there was a disagreement with one of the HEMS doctors who said
that there was not enough room for prison staff to go in the ambulance, but it
was quickly agreed that one member of staff would travel in the front of the
HEMS car and the other in the ambulance.
97. The man was taken into the trauma room at the hospital. The SO told my
investigator that the escort staff rang and told him that he had suspected brain
25
damage and medical staff were carrying out further tests and more should be
known within the hour.
98. Medical treatment continued but, at approximately 1.40am, medical staff took
the decision to withdraw treatment as tests confirmed that the man had no brain
activity. He was pronounced dead at 1.45am.
26
Actions following the man’s death
99. The SO told my investigator that, after hearing that the man had died, he asked
his staff to ensure that all prisoners on open ACCT documents were checked.
He explained that this is a requirement following a death in custody.
100. A member of the IMB at High Down, was on call in June and was contacted at
home when the man was discovered. She told investigator that the ambulance
was outside when she arrived at the prison. The member of the IMB attended
the “hot debrief” (this is an opportunity for staff involved in an incident to share
their observations and for managers to ensure that they are alright). She said
that she was next to the first officer on the scene who was upset. She then
went to houseblock 1 where she met the OSG who she described as being “in
a bit of a tizz”. She told my investigator that she stayed with the OSG for a
while and then the IMB chairperson arrived. She said that IMB chairperson
also stayed on the houseblock for a short time and then went to the detail office
where the debrief had been taking place. The member of the IMB decided to
remain with OSG and accompanied her as she walk around the houseblock
checking those prisoners on ACCT monitoring.
101. As the member of the IMB walked around the houseblock she spoke to a
number of prisoners who indicated that, in their opinion, the man should not
have been left there. One prisoner said that he had spoken to safer custody
about prisoners being bullied. However, she was not able to provide the names
of the prisoners who had spoken to her.
102. The second officer on scene told my investigator that when he arrived for duty
on the morning of 14 June, the mood on the houseblock was quite subdued.
As the SO had reported sick, and he was put in charge. During the course of
the morning there were various rumours that something was going to happen
during the exercise period. My investigator asked him to explain what this
meant. He told her that the rumours were around the man having been bullied
by the group of prisoners and other prisoners were speculating that this was
why he had taken his life. The officer said that as a precaution to ensure that
all prisoners were kept safe, he cancelled the exercise.
103. The Governor who was also the duty governor gave instructions for the
prisoners identified as involved in the bullying to be removed from the
houseblock to the segregation unit.
104. The prison liaison officer and the SO came into the prison and took over
notifying the man’s next of kin. This was proving difficult as he was a foreign
national. The prison contacted the Foreign Office, Columbian Embassy, UK
Immigration Services and the Metropolitan Police murder squad, (who had
been dealing with the man’s case) in the hope of gaining further details about
his next of kin.
105. The Columbian Embassy contacted the prison at 2.30pm that day and said that
they had already been notified of the man’s death. Similarly, his solicitors had
27
also been told. The prison was told that the man’s solicitor would not be
available until the Monday when details of the next of kin would be provided
and that they were based in Columbia.
106. My investigator, visited High Down to open the investigation, the Governor
explained that another prisoner who was the man’s friend had telephoned his
wife. He asked her to contact the Columbian Embassy so that they could tell
the man’s partner about his death. Fortunately, the prison was able to contact
the Embassy to ask them to pass the news on before it reached the man’s
family by this unofficial route.
107. My investigator also spoke with the SO who informed her that the appointed
prison family liaison officer (FLO). The SO explained that the prison had
initially contacted the Foreign Office as they were unable to contact the
Columbian Embassy. The legal Advisor at the Columbian Consulate in
London, contacted the man’s family in Columbia on the afternoon of 14 June.
108. The legal advisor visited High Down on 16 June. He said that the man’s family
had asked for help to have his body flown back to Columbia and they wanted
his correspondence from the family to be retrieved from his cell. The legal
advisor added that a cousin of the man might travel from Columbia to sort out
the arrangements.
109. The prison arranged for the man’s body to be repatriated and met the costs.
110. My investigator spoke with the legal advisor on 28 November and asked how
he first came into contact with the man. He was contacted initially by the man’s
legal team as he wanted to give the power of attorney to his partner in
Columbia and so a lawyer was required. The legal advisor visited him at High
Down, with his solicitor, in May 2008.
111. My investigator asked the legal advisor whether the man had mentioned any
problems in the prison or concerns about his family. He replied that the man
mentioned having trouble with some prisoners who tried to take property from
him. He confirmed that this would have been prior to the events.
112. The legal advisor was asked by my investigator whether the man appeared
distressed but he said that he appeared quite calm and very relaxed. He said
that the man spoke very calmly and appeared to be a gentle person and he did
not notice any depression or anger. The man was mostly concerned with his
family in Columbia, especially his baby daughter, whom he had not seen and
which he was sad about.
113. My investigator asked the legal advisor about a conversation that he had with a
police officer in Columbia. (This was in relation to the man receiving a
telephone call a few days before his death from someone in Columbia making
claims about his partner’s personal life.) He said that he spoke to the man’s
partner after his death about the rumour. She told him that it did not make
sense as she kept in touch with him all the time. She spoke to him two nights
before he died when he was very happy because his court case was going well.
28
Liaison with the Metropolitan Police
114. Following the man’s death, one of his tutors, was sorting through his course
work. She discovered two exercise books that contained what appeared to be
letters written in Spanish. It was apparent that the books could contain
significant information and, when my investigator was notified of their existence,
she informed the prison that they should be passed to the police.
115. The exercise books were subsequently passed to Detective Inspector (DI),
Metropolitan Police, who arranged for them to be translated. The police also
found an undated letter written in Spanish amongst other correspondence in
the cell and it was also translated.
116. After the documents were translated, the police shared the findings with my
investigator. The letter found in the cell appeared to be a suicide note although
it had not been placed in a prominent place to be found by staff. In the letter,
the man wrote that he was unable to continue. He thanked his partner for the
time that they spent together and that he wished he could change things to see
his daughter grow up. The man ended the letter by saying “this is my good-
bye”.
29
ISSUES
Provision for foreign national prisoners
117. The most recent report by HM Chief Inspector of Prisons, is critical of the
provision of services for foreign national prisoners at High Down. The man was
located in the healthcare centre on his reception at High Down where he spent
his first 48 hours in custody and his induction took place.
118. The induction policy at High Down says that it will take place over two days with
various subjects being discussed with new prisoners by peer advisors (who
have volunteered to be a point of contact for fellow prisoners). Information for
foreign national prisoners is scheduled to be provided on the second day.
Prisoners like him who are not located directly onto a houseblock are seen
individually by a peer advisor the day after their arrival. There is no record in
his wing history file of the content of his induction and is nothing signed by him
to confirm that he had one.
When a prisoner is not immediately located onto a houseblock following
their reception into custody, the Governor must ensure that they are
provided with the same opportunities for induction and that this process
is clearly recorded in their wing history files.
119. Staff at High Down use the “The Big Word” telephone translating service. The
local operating procedure states “... High Down aims to support prisoners
whose first language is not English and do not have sufficient knowledge of the
language to participate in the regime or make use of the support services ...”
120. Some staff recorded that the man was able to communicate and make himself
understood. Equally, others said that his lack of English was a frustration for
him. He attended ESOL classes to try and improve his English. His tutors
considered that, although he made significant progress, when he first entered
custody his English was poor.
121. The Big Word translation service might have proved useful following the man’s
self-harm in September 2007 when the officer conducting the assessment was
unsure whether he had fully understood the process. It would have been
equally useful to use their services to ensure that the man fully understood the
adjudication process and to clarify that he had no concerns with being located
on the houseblock.
I recommend that the services of the ‘Big Word’ are clearly displayed on
residential units for both staff and prisoners and that staff are
encouraged to use them.
122. The induction documents and information provided to prisoners were not filed in
the man’s wing history. Therefore I am unable to say whether or not this was
given to him in English or Spanish. It is essential that information for prisoners
whose first language is not English is available in a wide selection of
languages.
30
The Governor should ensure that information for prisoners is available in
as many languages as possible.
123. During the investigation the investigators asked to see a copy of the Foreign
National Policy but were informed that it was being re-written and was not
currently available.
I recommend that the Governor ensures that an up to date Foreign
National Policy is published and available to all staff.
124. The man was found in possession of a mobile telephone on more than one
occasion. It is known from his conversations with others that he missed his
partner and child. It seems that his reasons for having the telephone were to
enable him to maintain regular contact with his family rather than for any
nefarious reason.
125. Contact with their family is something that is likely to be important to all
prisoners and must be more so for a foreign national prisoner whose family live
abroad. Although arrangements are in place at High Down for foreign national
prisoners to be able to purchase extra telephone credit, it is likely that the high
price of international calls makes obtaining a mobile telephone attractive.
126. There is also the issue of time differences as some foreign national prisoners
are unable to call abroad. I understand that this is a national problem across
the Prison Service, but the Governor may wish to look at ways this can be
addressed within the policy at High Down.
127. The Consultant Forensic Psychiatrist, who completed the clinical review, also
makes the following comment in relation to foreign national prisoners:
“...when a foreign national with limited English language abilities is
remanded in custody, it is essential that the health needs should be
identified with the use of interpreting services to at least provide a
baseline health assessment. It is difficult to know now whether the
man understood the questions asked of him on the reception screening
and Well Man screen or could convey information about his
background health history...”
Assessment, Care in Custody and Teamwork (ACCT) procedures
128. The man was placed on ACCT monitoring in September 2007 following an
isolated act of self-harm. The procedures when opening the document were
correctly followed and it was appropriately closed following a multi-agency case
review. There was no indication that an ACCT needed to be opened at any
other time. Even after the incident on 11 June I am satisfied that there was no
evidence to suggest that he was at any greater risk of self-harm.
31
Security Information Reports (SIRs) and adjudications
129. During the man’s time in custody, several SIRs were submitted in relation to
him having weapons and possible problems with other prisoners. One SIR
referred to another prisoner, threatening him on houseblock 1 and offering to
pay £1000 to any prisoner who harmed him. The duty governor recorded on
the SIR that the man had previously “seriously” assaulted that prisoner, but
there is no SIR or adjudication information to support this.
130. It was recorded in his wing history file that the man was found in possession of
a mobile telephone on 25 September for which he was placed on report.
However, there are no records to indicate whether an adjudication took place
and no SIR relating to this incident was recorded as having been received by
the security department. I make the following recommendation:
The Governor should remind all staff of the importance of recording and
sharing information. Sharing information, no matter how minor, could
add to a bigger picture and identify a person who might be at risk or a risk
to others.
Incident on 11 June
131. Following the incident on houseblock 1, the man was moved to the segregation
unit with one other prisoner. I believe that this was appropriate given the nature
of the offence. He was seen by a member of the healthcare staff who
confirmed that he was fit to be held in segregation and completed the
segregation safety algorithm as required. The algorithm does not state that it is
necessary for the duty governor to see a prisoner before signing the record.
However, it was established during the course of the investigation from staff
working regularly in the unit considered it good practice for duty governors to
satisfy themselves of a prisoner’s well being by seeing them before signing the
document. The investigator was told that this happened on the majority of
occasions.
The Governor should make it a requirement for the duty governor to see a
prisoner before signing a segregation safety screen.
132. On his return to houseblock 1 the following day, the wing manager asked him
whether he was alright to return to his cell. The man confirmed that he was.
However, during this investigation, it became clear that other information had
been available to staff during the course of that day. It indicated that he had
been targeted by a gang of bullies. This information does not seem to have
been shared with all the staff on the houseblock and he was not asked about
the new information.
133. The prisoner who was taken to the segregation unit with the man also returned
to the houseblock. Given that this prisoner was already subject to anti-bullying
procedures prior to the incident, I question whether it was appropriate for him
to return to the same houseblock.
32
134. The five other prisoners involved in the incident were placed on stage 1 of the
anti-bullying measures. At High Down, stage 1 should be used where there is
not enough evidence to prove that the prisoner is bullying. The prisoner is
monitored for a period of 28 days and should be interviewed beforehand.
135. It appeared during the investigation that staff were confused as to the
requirements of the anti-bullying procedures. Some officers believed Stage 1
was ”covert” and that prisoners were not told they were being monitored.
Others said that it was necessary to inform the prisoner as stated in the
guidance.
The Governor should publish a notice to staff reminding them of the
correct procedures to be followed in respect of anti-bullying
documentation.
The Governor should ensure that managers are completing daily checks
on all anti-bullying documents and that these are recorded.
136. The guidance also requires a minimum of one quality entry to be made daily in
the document. The investigator found that this was not happening. In one
document there was a gap of five weeks without an entry. When the
investigator asked, she was told that the prisoner had been moved to a different
houseblock and they were unaware that he was subject to anti-bullying
procedures. The procedures at High Down clearly state that managers must
check anti-bullying documents daily to ensure that entries are being made.
137. In addition to monitoring alleged bullies, there are also procedures for
supporting the victim. They indicate that an AB4 Support for Victim form should
be completed at the same time as the anti-bullying monitoring form, in
consultation with the victim. Following this, regular entries should be made in
the prisoner’s wing history file relating to his welfare.
138. There is no evidence that the man was consulted or that an AB4 was
completed. There are no entries in his wing history file after the event to his
welfare.
The Governor should ensure that victims of bullying are supported in line
with the published guidance and that this forms part of the management
checks.
Response to the man’s hanging
139. When the first officer on the scene realised that there was a problem with the
man in June she immediately called the second officer for assistance. At the
time of the incident, the first officer on the scene was a relatively new member
of staff. Realising that the man required immediate help, she made a decision
to enter the cell on her own. I am aware that staff entering cells on their own is
often the subject of some debate. By assessing the seriousness of the
situation, noting that the man was in a single cell and making the decision to go
into the cell I consider that the first officer on the scene exercised good
33
judgement and her actions are commendable. I have been made aware that
the Governor has already recognised the actions of the officer and I would be
grateful if my comments could also be shared with her.
140. The second officer on the scene responded quickly and as both the officers had
a medical background, they ensured that first aid was administered
appropriately until the arrival of the medical staff. In particular, the quick
thinking of the second officer on scene when he realised that there were no
face masks deserves mention. Again, I would be grateful if my comments
could be passed on to him. I make the following recommendation.
The Governor and Head of Healthcare should ensure that all emergency
response boxes contain the necessary equipment including face masks
and that they are checked on a regular basis.
Other clinical findings
141. The clinical reviewer, has covered a number of areas in her report which I
summarise here:
”... Within the man’s notes the Well Man screening was both undated
and unsigned. An in possession medication assessment was not
completed, although he was subsequently prescribed medication to
hold in possession. (All prisoners who require medication should be
assessed as to their suitability to hold their own medication. They are
then required to sign a compact that states that they agree to abide by
the rules relating to this.) There is also a suggestion that a care plan
was to be put in place on his discharge from the healthcare centre.
The Consultant Forensic Psychiatrist was not provided with any
information relating to any care plans. The guidelines for completing
notes have not been followed in respect of the Well Man screening
which was neither signed nor dated and in places illegible.
The Head of Healthcare should ensure that a regular audit takes place of
the quality and accuracy of the notes in prisoner’s medical records.
“The reception health screen indicates that a prisoner charged with
murder or manslaughter should be referred for a Mental Health
Assessment, this does not appear to have happened for the man and
there appears to have been no mental health interaction during his time
in custody. It is important that the reception health screen is followed.
Although he appears to have been a very settled prisoner he does not
appear to have had the opportunity to discuss his situation, and ability
to cope with the prison environment in the face of serious charges ...”.
The Head of Healthcare should ensure that a clear pathway for referrals to
mental health Inreach is published and, where a referral is made, the
follow up needs of a patient are explicit.
34
CONCLUSION
142. The man seems to have been a very private person. He had a tough exterior,
evident in the way he dealt with the problems he encountered with other
prisoners, and chose not to share his feelings. The information that came to
light after the man’s death would indicate that he was a vulnerable man despite
the impression he portrayed to his group of friends and staff who knew him
well.
143. The letter discovered in his cell was clearly written as a suicide note and would
indicate that he was ending his life. It is unclear why the man chose to take his
life, but it is evident that he thought the world of his partner and daughter, and
found it difficult to cope with being separated. It is possible that, facing the
possibility of a life sentence, he found this separation too much to bear.
35
RECOMMENDATIONS
For the Governor
1. I recommend that the Governor ensure that an up to date Foreign National
Policy is published and available to all staff.
The Prison Service accepted this recommendation and said:
The latest Foreign National Local Operating Policy was published in March
2009. This is a live document and is reviewed regularly.
2. I recommend that the services of the ‘Big Word’ are clearly displayed on
residential units for both staff and prisoners and that staff are
encouraged to use them.
The Prison Service accepted this recommendation and said:
The Diversity department will ensure that the posters/information regarding ‘the
big word’ translation company are clearly displayed on all residential units. A
Governors Notice will be re-issued regarding the translation services available
for staff. Foreign National posters are displayed in all areas. Staff are aware
that they can use the big word. Regular reminders are published in the bulletin
and will be displayed at the gate on the information screen.
3. The Governor should ensure that information for prisoners is available in
as many languages as possible.
The Prison Service accepted this recommendation and said:
Laptop computer and translation software has recently been purchased. All
relevant paperwork is being translated into 12 languages. Target date
December 2009.
4. When a prisoner is not immediately located onto a houseblock following
their reception into custody, the Governor must ensure that they are
provided with the same opportunities for induction and that this process
is clearly recorded in their wing history files.
The Prison Service partially accepted this recommendation and said:
It is not possible for prisoners located in other areas of the prison to receive the
full induction process on HB3 after arrival and initial allocation. This is due to
prisoners being vulnerable/security risk/discipline issues etc and therefore not
suitable to locate/mix with the main population. However, prisoners are seen
on the Saturday by the induction officer and peer worker. The induction officer
can record in the prisoners case notes that they have visited and inducted the
prisoner. However if there are staff shortages the induction officer may not be
available and the peer worker should then inform staff of his attendance for
36
them to record this in the case notes. This work should be revisited in the
review exercise of the current profiles. Target date January 2010.
5. The Governor should remind all staff of the importance of recording and
sharing information. Sharing information, no matter how minor, could
add to a bigger picture and identify a person who might be at risk or a risk
to others.
The Prison Service accepted this recommendation and said:
This will be addressed by a Governors Order being published. Also, this will be
addressed through new case management procedures that are being
implemented. One person will be responsible for managing and receiving all
the information in relation to an individual prisoner. This is hoped to be in place
by September and will be fully established by the target date of January 2010.
6. The Governor should make it a requirement for the duty governor to see a
prisoner before signing a segregation safety screen.
The Prison Service accepted this recommendation and said:
Governors Orders will be issued, however this will not be met if a prisoner is
segregated during the evening. The Governor’s Orders should therefore state
that the Governor will visit the prisoner at the earliest opportunity when
commencing duty the following day and must satisfy themselves that the
Orderly Officer has seen the prisoner and reported back to the Duty Governor
in full. Target date January 2010.
7. The Governor should publish a notice to staff reminding them of the
correct procedures to be followed in respect of anti-bullying
documentation.
The Prison Service accepted this recommendation and said:
Governors Notice to be issued to all staff. Target date January 2010.
8. The Governor should ensure that managers are completing daily checks
on all anti-bullying documents and that these are recorded.
The Prison Service did not accept this recommendation and said:
There are no national procedures to be followed in relation to Anti-Bullying
measures. PSO 2750 states that depending on the impact and resources
available, each establishment must devise their own local approach. Unit
Senior Officers should carry out management checks of the Anti Bullying
documents.
I accept that Highdown have a local protocol for managing open Anti Bullying
documents. However, during the course of my investigation I did not find any
37
managers including Unit Senior Officers carrying out regular quality checks.
The recommendation remains unchanged.
9. The Governor should ensure that victims of bullying are supported in line
with the published guidance and that this forms part of the management
checks.
The Prison Service accepted this recommendation and said:
There is a local procedure for monitoring and prevention of bullying and the
anti-bullying book procedures should be followed by staff and the unit
managers should be checking these procedures are being adhered to. Target
date January 2010.
For Governor and Head of Healthcare
10. The Governor and Head of Healthcare should ensure that all emergency
response boxes contain the necessary equipment including facemasks
and that they are checked on a regular basis.
This recommendation was accepted and actions have been completed. In
response, the Head of Healthcare said:
Each house block and reception, inpatients and outpatients have ambu bags,
airways and defibrillation machines. There is a bag, which has additional
resuscitation equipment in it. Nurses are trained In CPR and defibrillation and
also receive regular updates. There is also a full resuscitation trolley within the
inpatient unit.
11. The Head of Healthcare should ensure that a regular audit takes place of
the quality and accuracy of the notes in prisoner’s medical records.
This recommendation was accepted and actions have been completed and are
ongoing. In response, the Head of Healthcare said:
Regular audits do take place on medical records. Surrey Community Health
has an audit template for medical records, this is used within the prison, and
the findings are reported through our governance structures.
12. The Head of Healthcare should ensure that a clear pathway for referrals to
mental health Inreach is published and, where a referral is made, the
follow up needs of a patient are explicit.
This recommendation was accepted and actions have been completed. In
response, the Head of Healthcare said:
Clear referral pathway in place. There is a weekly multidisciplinary allocation
meeting for new referrals. All referrals are scrutinised on a daily basis. Once a
patient has been assessed, they are allocated a key worker if appropriate.
38
There is a care plan and regular reviews by the key worker. If there is no
identified mental health need the in reach team will refer to appropriate
agencies when necessary and will clearly state that the referral has been
assessed and case closed.
39