Individual at Edmunds Hill

Investigation into the circumstances surrounding the
death of a man at HMP Edmunds Hill
in August 2008
Report by the Prisons and Probation Ombudsman
for England and Wales
April 2009
Final report
This is the report of an investigation into the apparently self-inflicted death of a man
at HMP Edmunds Hill in August 2008. The man was found hanging in his cell at
7.30am during a routine check. He was pronounced dead by paramedics at 8.06am.
The man was 27 years old.
I offer my sincere sympathies to his family for their loss.
I appointed an investigator from my team to investigate the circumstances
surrounding his death on my behalf. She was assisted by another of my
investigators. I would like to thank the Governor and his staff for their support during
the investigation. My lead investigator also received excellent assistance from the
appointed liaison officer at Edmunds Hill. I am also grateful to the clinical reviewer
who was appointed by Suffolk Primary Care Trust to conduct a clinical review of the
care provided to the man.
The man had been recalled to prison two months before his death, having breached
the conditions of his licence. In my experience, recalled prisoners often feel
confused by the reasons for their return to prison, and may be uncertain about when
they will again be released. I also sense that the prisons that receive them are not
always sufficiently prepared for the task. However, I do not believe that his recall to
prison was a critical factor in his death. Concerns about his relationship with his wife
and access to his son appear to have been pivotal.
The man did not often share his thoughts or worries with friends or staff at Edmunds
Hill. He had some history of depression and other mental health problems, but gave
staff at the prison no indication that he was struggling to cope. However, my
investigation has revealed a failure to pass on and record some information relevant
to risk on the night before his death.
The death of the man was the first to have occurred at Edmunds Hill since I took
over responsibility for investigating all deaths in prison custody in 2004, and the first
since the prison became a male establishment. Clearly, the prison has little
experience of deaths in custody and most of my recommendations focus on the gaps
in their procedures after his death. I have made six recommendations and note one
area of good practice.
This version of my report, published on my website, has been amended to remove
the names of the man who died and those of staff and prisoners involved in my
investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2009
Final Report 2
CONTENTS
Summary 4
The Investigation Process 5
HMP Edmunds Hill 7
Key Events 9
Issues 21
Conclusion 27
Recommendations 28
Final Report 3
SUMMARY
The man who is the subject of this report was initially sentenced to 16 months
imprisonment for driving offences in March 2007. He was released on licence in
September of that year. He breached the conditions of his licence and was recalled
to prison on 4 July 2008. Having been arrested by the police, the man was taken to
HMP Pentonville. He was transferred to HMP Edmunds Hill on 18 July and had
been there almost six weeks when he died. The man had been in prison several
times before.
The man had a history of depression and paranoia, and had been diagnosed with a
personality disorder with explosive outbursts. He had received treatment in the
community, but had not complained of any symptoms for a couple of years.
Healthcare staff at Edmunds Hill were aware of the man’s previous mental health
problems but, during assessments, found that he was no longer suffering from them.
He denied feeling depressed and said that he had no thoughts of harming himself or
committing suicide. He appeared to be positive and motivated and was in the
process of appealing against his recall to prison. Staff on the unit where he lived
described him as someone who was “getting on with his sentence”. He gave them
no cause to worry and seemed to have adjusted well to life at the prison.
The man’s friends on his unit said that he was sometimes worried about his
relationship with his wife and losing contact with his young child. About two weeks
before he died he told one friend that he felt like killing himself. His friend did not tell
anyone else about their conversation, but spent time trying to reassure and comfort
him.
On 27 August 2008 the man repeatedly tried to telephone his wife and finally spoke
to her at about 6.30pm. During the telephone call, he was upset and anxious. When
the call finished, his friends became worried about him because his mood seemed
low and he was not himself.
Prisoners were locked in their cells at 6.45pm. A fellow prisoner was concerned
about the man’s welfare and asked a member of staff on the unit to keep an eye on
him. Staff discussed the matter and checked his file for any reports that he was at
risk of harming himself. They found no such indication and decided that staff should
check on his welfare the next day. Staff coming on duty that evening were not told
about the prisoner’s concerns. No entry was made in the staff observation book or in
the man’s prison file. Staff were not required to make any checks on him overnight.
At 7.30am on 28 August, staff carrying out a routine check on the unit discovered the
man hanging from the window of his cell. They quickly went inside and cut the
ligature. Healthcare staff arrived very soon afterwards, but it was clear that he had
been dead for some time and that nothing could be done to help him. The
paramedics pronounced him dead at 8.06am.
Final Report 4
THE INVESTIGATION PROCESS
1. My office was notified of the man’s death on 28 August 2008 and the
investigation was allocated to one of my investigators later that day. My
investigator and her colleague visited HMP Edmunds Hill to open their inquiries
on 1 September.
2. My investigator issued notices inviting staff and prisoners to contact her with any
information they felt might be relevant to the investigation. Three prisoners wrote
to my office about the man’s death. They were all interviewed as part of the
investigation. My investigator and another colleague carried out interviews with
staff and other prisoners at the prison during October 2008.
3. Suffolk Primary Care Trust (PCT) appointed a clinical reviewer to undertake a
clinical review. My investigator and the clinical reviewer conducted several joint
interviews with members of the prison’s healthcare department. I am also
grateful for the co-operation of Suffolk Constabulary who shared information with
my investigator.
4. My investigator was provided with relevant documentation covering the man’s
time in prison, including a copy of his core prison record, his Inmate Medical
Record (IMR), and the staff incident reports written after his death. She was also
able to listen to a recording of his final telephone conversation on 27 August.
There is no Closed Circuit Television (CCTV) in place on unit 5/6 at Edmunds
Hill.
5. During the investigation my investigator met the chair of the prison’s Independent
Monitoring Board and a representative of the local branch of the Prison Officers’
Association. She also spoke to the man’s probation officer and criminal defence
solicitor.
6. One of my family liaison officers contacted the man’s family to invite them to be
involved in the investigation process. The family liaison officer spoke to the
man’s mother and wife who felt that he had showed no signs of being suicidal.
They had a number of concerns about his death. In particular, these were as
follows:
(cid:127) Whether Edmunds Hill had been aware of the man’s history of depression,
and, if so, what they had done about this.
(cid:127) If staff on his unit had known that he was vulnerable on 27 August, as
suggested in a letter sent to his mother by another prisoner. My investigator
subsequently identified that this letter had been written by the prisoner who
had raised concerns on 27 August and who was interviewed during the
investigation.
(cid:127) Whether prisoners were checked on overnight.
(cid:127) Why the man had not been found until 7.30am.
(cid:127) Why two inhalers had been found in his cell.
(cid:127) If the man was receiving any healthcare treatment, and whether he had any
health problems that meant he should have been checked on during the night.
(cid:127) If the man had a cell bell which he could use to call staff during the night.
Final Report 5
(cid:127) If the man’s unit was covered by CCTV.
In conversation with the family liaison officer, it became clear that the family had
not been offered funeral expenses by the prison as required by the relevant
Prison Service Order. My investigator agreed to look into this matter, and also
consider the level of liaison and support the family had received from the prison
following the man’s death.
I hope that this report answers all the family’s questions.
Final Report 6
HMP EDMUNDS HILL
7. HMP Edmunds Hill is a category C training prison near Bury St Edmunds,
Suffolk, holding up to 366 prisoners. It became an adult male prison in 2005,
having previously been a female establishment. It accommodates sentenced
prisoners serving less than three years or having less than nine months of their
sentence left to serve. Accommodation in the prison is arranged across eight
units and prisoners may be placed in single or double cells.
8. Her Majesty’s Chief Inspector of Prisons, made a full announced inspection of the
prison in October 2006. At that time, the Chief Inspector noted that the prison
had come a long way since its role change but that there were a number of
shortcomings to be addressed. She found that whilst the prison was generally
“calm, controlled and safe”, suicide and self harm procedures were “weak”.
Relationships between staff and prisoners were commended, and staff were
found to interact with prisoners in a thoughtful and caring way. However, Dame
Anne reported that the prison’s personal officer scheme needed some
improvement.
9. Each penal establishment in England and Wales is monitored by an Independent
Monitoring Board (IMB). The Board consists of members of the local community
who have full access to every prisoner and each part of the prison. The IMB
produces an annual report, with the last available report for Edmunds Hill
covering the period January to December 2007. The IMB reported that, in
general, the prison was well managed and run. However, they agreed with the
Chief Inspector that the personal officer scheme was still underdeveloped.
Recalled prisoners
10. In 2005, the Chief Inspector conducted a short review of recalled adult male
prisoners because of the growing numbers being recalled to prison after
breaching the conditions of their licence. The review concluded that neither
recalled prisoners, nor the prisons that received them, were adequately prepared.
Recalled prisoners often did not have enough information or understanding of
their situation, and receiving prisons were not always given enough warning of
recalled prisoners’ arrival. Few prisons were found to have appropriately trained
staff in place to help recalled prisoners understand the process.
11. The Chief Inspector found that recalled prisoners sometimes remained outside
normal prison routines, either because they chose to or because staff were not
sure of their status. This meant that:
“… risks and needs were not picked up in the way that should happen with
newly-received prisoners. Vulnerabilities, for example, to suicide and self-
harm … could go unnoticed and prisoner frustration and anger at their
situation might not be promptly identified and managed.”
12. The review concluded that prisons should provide the following to recalled
prisoners:
Final Report 7
(cid:127) “Safe reception and induction and effective safer custody support
(cid:127) Effective legal advice
(cid:127) Proper access to regimes
(cid:127) Preparation for re-release …“
Privacy keys
13. All prisoners with single cells at Edmunds Hill have privacy keys for their cells.
The keys can be used during periods of the day when the cells have been
unlocked by staff. Each prisoner’s privacy key is individual and only allows them
to lock and unlock the door to their own cell. The privacy locks mean that
prisoners cannot enter other cells during periods of unlock, although keys held by
staff override the privacy locks and allow access to cells at all times. At night,
when prisoners are locked in their cells, only keys held by staff will unlock the cell
doors.
Cell bells
14. Each cell at Edmunds Hill is fitted with a cell bell. On the man’s unit, the cell bell
is located on the wall by the cell door. The cell bell enables prisoners to summon
staff assistance when they are locked in their cells, or when the prison is in patrol
state. (Patrol state is when staffing is at a minimum and prisoners are locked in
their cells, for example, overnight.) On pressing the cell bell, an alarm panel in
the unit office lights up, showing staff exactly which cell requires assistance. The
cell bell can only be switched off by staff pressing the reset button on the wall
immediately outside the cell in question. Cell bells are only intended for
emergency use.
Radio call signs
15. Staff at Edmunds Hill use specific call signs when alerting healthcare staff to
incidents in the prison. ‘Code Blue’ is used to indicate a medical emergency
where someone is not breathing or is having difficulty breathing. ‘Code Red’ is
used to indicate a medical emergency where someone is bleeding. The use of
such a code system informs healthcare staff which medical supplies and
equipment may be needed.
Final Report 8
KEY EVENTS
16. The man appeared at Harrow Crown Court in March 2007. He was sentenced to
16 months in custody for dangerous driving and served his sentence at HMP
Wormwood Scrubs. His prison records from Wormwood Scrubs indicate that it
was an uneventful period. There are no documented concerns about the man’s
mental health or vulnerability.
17. In September 2007 he was released on licence until May 2008 when his
sentence would expire. One of the conditions of his licence was that he had to
live at an address specified by probation. He was found a place in approved
premises (hostel accommodation provided and managed by the Probation
Service) in North London. However, in November 2007 the man left the
approved premises. He told probation staff that he did so after a fight with
another resident. The police were notified that he had breached his licence and
should be returned to prison to serve the remainder of his sentence.
18. The man, his wife and baby, travelled to Ireland for several months. He was
considered to be unlawfully at large. He was finally arrested by the police and
taken to HMP Pentonville on 4 July 2008. On arrival, he underwent a first
reception healthscreen with a nurse. (The purpose of the healthscreen is to
identify any immediate physical or mental health concerns and whether any
referrals need to be made to the doctor or other specialist service. At Pentonville,
the healthscreen is recorded on a computer and a printout is made for the
prisoner’s file.) The man’s healthscreen recorded that he suffered from asthma
but otherwise was physically healthy. The doctor prescribed two inhalers for his
asthma. The nurse recorded that he was of “normal mental state” with no current
thoughts of suicide or self harm. She noted that he had previously suffered with
an “unspecified depressive disorder”.
19. In reception at Pentonville the man also underwent a Cell Sharing Risk
Assessment (CSRA). This is to assess the level of risk a prisoner poses to other
prisoners and, therefore, whether he is suitable to share a cell. The first part of
the CSRA is completed by a member of prison staff and the second by a member
of healthcare staff. The CSRA also provides staff with another opportunity to
assess whether the prisoner has a history, or any current risk, of self harm or
suicidal thoughts. The man was assessed as being of low risk to others, with no
concerns noted.
20. During his short time at Pentonville he gave staff no cause for concern. On 18
July, he was transferred from Pentonville to Edmunds Hill to serve the remainder
of his sentence. His Prisoner Escort Record (PER) noted that he could be violent
and might be an escape risk. (The PER provides information about the risks
posed by a prisoner being transferred either from police custody, court, or
between prisons. It is based on known information such as the prisoner’s
offences or medical history and their risk of escape or self harm or suicide.)
There was no indication that the man was likely to harm himself or attempt
suicide.
Final Report 9
21. Whilst in reception at Edmunds Hill the man underwent another CSRA. Once
again, no risks or concerns were identified and he was assessed as low risk. He
was placed in a double cell whilst he went through the prison’s induction process.
During his induction interview on 21 July he was asked if he had ever harmed
himself or if he had attempted suicide in the last two years – he said he had not.
He also denied having used drugs or alcohol in the past.
22. A nurse carried out the man’s first reception healthscreen on 18 July. In
interview, she said she had read the healthscreen carried out at Pentonville. The
nurse recorded that, when asked, the man reported no history of depression, self
harm or drug use. However, she noted that he said he had had contact with
mental health services at his local hospital two years previously because he had
suffered with paranoia. The nurse told my investigator that, because of his
previous contact with mental health services, she referred him to the mental
health in-reach team for assessment as a matter of course. She also recorded
that he suffered with asthma and had a heart murmur. She knew that he had
been given two inhalers for his asthma at Pentonville and that he still had them
with him on arrival at Edmunds Hill.
23. On 24 July, the man was discussed at a multi-disciplinary team meeting,
attended by staff from the prison mental health in-reach team. His history of
depression was noted but it was concluded that he was not currently showing any
signs of mental ill health. Nonetheless, it was decided that he should be seen by
the doctor for a review.
24. The man’s mother, wife and son visited him on 27 July. Two days later he was
visited by his criminal defence solicitor. In interview, his solicitor said the man
was upbeat and positive. She said that at no time did he mention feeling
depressed. She explained that he had fully understood the reasons for his recall
to prison and, whilst keen to appeal against the decision (the appeal to the Parole
Board was ongoing at the time of his death), he appeared to be coping well.
25. The solicitor told my investigator that the man had made it clear to her and to
prison staff that he wanted a single cell. His solicitors wrote to the prison on 30
July to ask that his applications for a single cell be dealt with as a matter of
urgency due to his history of mental health problems and previous attempts to
harm himself. In the letter, the solicitors also mentioned that the man had asked
to see someone from the mental health team but had not yet been seen. The
residential manager at Edmunds Hill replied on 1 August. He explained that the
man had completed the induction process and had, that day, been allocated a
single cell on unit 5/6. The residential manager also explained that, after
assessment by healthcare staff, no current mental health problems had been
identified but that the man had been referred to the doctor.
26. Following the multi-disciplinary team meeting on 24 July, the man was seen by a
prison doctor on 6 August. The doctor noted in the man’s records that he had a
history of depression and had been diagnosed with a “personality disorder
(explosive type)”. The doctor recorded, however, that the man had not received
any treatment for these conditions for over a year. The man told the doctor that
he had misused alcohol in the past but did not do so any longer. He also said he
Final Report 10
had never misused drugs. He denied having any thoughts of harming himself or
suffering from anxiety or aggression. The doctor concluded that he should be
referred back to the mental health team for assessment because of his
personality disorder.
27. A mental health nurse met the man on 8 August and completed a primary mental
health screen. There appears to be some confusion amongst healthcare staff
about whether the man had referred himself, been referred by the nurse at his
initial healthscreen, or by the doctor on 6 August, or a combination of the three.
Certainly the man’s records indicate that he had requested a referral to the
mental health team.
28. During the primary mental health screen (which is designed to gather some basic
information about the mental health of the patient and identify if they need further
intervention from the mental health in-reach team), the man denied any thoughts
of self harm or that he was low in mood. He told the mental health nurse that he
had been seen by the psychiatric team at his local hospital and had been
diagnosed with a personality disorder. He told her that he had used cannabis as
a teenager but did not admit to any other drug use. Under the section ‘Past
deliberate self harm and suicide attempts’ the mental health nurse wrote, “Yes he
has, but he didn’t tell me this.” In interview, she explained that, whilst the man
had not admitted to this, she had read his file later which mentioned that he had
harmed himself in the past.
29. The mental health nurse said that the man had seemed positive and told her that
things were going well in his life. He said he had a good relationship with his wife
and that they had a young child. She felt he was well motivated to “get his life on
track”. The nurse asked him to rate his mood on a scale of one to ten, with ten
being good. He said his mood was currently at eight.
30. The man was asked why he wanted to see the mental health team and he replied
that he wanted help to challenge his licence recall. The mental health nurse
explained that it was quite common for prisoners to think that they could
challenge their recall for health reasons, and that she could assist them with this.
She told him that she could not help him with his recall and he became angry with
her, which she saw as a sign of his motivation.
31. After meeting him the mental health nurse was satisfied that, despite his history,
he currently showed no signs of depression and had no thoughts of harming
himself. She knew he had been seen by the doctor who could have prescribed
anti-depressants for him if that had been necessary. The mental health nurse
explained that she too could have prescribed anti-depressants, had she thought it
necessary, but she was satisfied that he did not currently need them. She
decided that he did not need any further mental health intervention at that time,
but told him how he could access help if he needed it at any point in the future.
32. Two days later, on 10 August the man was visited again by his mother, wife and
child. They did not mention to staff that they had any specific concerns about him
following the visit.
Final Report 11
33. The man’s time at Edmunds Hill was uneventful. Staff interviewed as part of this
investigation said that they did not know him well but that he was no trouble on
the unit. The staff observation book for unit 5/6 and the man’s personal prison
file show that staff thought him to be settling in well to life at Edmunds Hill, giving
them no cause to worry. He was keen to work whilst in prison and staff on his
unit were helping to arrange this. In the meantime, he was attending education
every day.
34. Two officers were allocated as the man’s personal officers. Members of staff at
Edmunds Hill may be personal officers for up to 20 prisoners on their unit. In
interview one of the personal officers explained that a personal officer is expected
to be the prisoner’s “first port of call” if they have a problem or question. Personal
officers also meet their prisoners once a week and must make entries in the
prisoner’s file so that other staff are kept informed of any concerns. Weekly
entries were made in the man’s prison file by both officers.
35. The officer said that he had not got to know the man very well during his time at
Edmunds Hill because he was a quiet man who seemed to take being in prison
“in his stride”. He was aware that the man had a few friends on the unit, some of
whom he had known from previous sentences or from the community.
36. As part of the investigation the investigator and a colleague interviewed a friend
and fellow prisoner of the man, at HMP Blundeston. Before his transfer to
Blundseton the friend had a cell on the same corridor as the man on unit 5/6 at
Edmunds Hill. They also had mutual friends on the outside. The friend said that
he and the man often spent their association time together. (Association is the
period when prisoners are free to mix with each other, make telephone calls, and
spend some time outside. At Edmunds Hill, association takes place between
4.45pm and 6.45pm on weekdays.) He remembered that, about two weeks
before he died, he had talked to the man about his relationship with his wife. The
man explained that he was feeling “stressed” about the relationship and was
worried that his wife was planning to return to Ireland with their child. The friend
told my investigators that, during this conversation, the man said that he felt like
killing himself. The friend said that he told him not to be silly and to keep focused
and think of his child.
37. My investigators asked the friend if he had told anyone else about this
conversation and, in particular, about the man mentioning killing himself. He
explained that he had not because he had spent time reassuring the man and
“talking that silliness out of him”. My investigators asked the friend if he had
taken the man’s words seriously. He described the man as “very stressed” but
said that he thought he was “a strong minded bloke”.
38. A second prisoner who was also a friend of the man told my investigators that the
man had talked to him about his relationship with his wife, and his fears that he
would lose contact with his son. This prisoner said that the man had never
mentioned feeling suicidal.
39. While in prison, prisoners are given an individual Pin number to make telephone
calls. This allows the prison to record and monitor calls being made by each
Final Report 12
prisoner, if necessary. The records relating to the man’s Pin number show that
on 27 August, during association he telephoned his wife 19 times and his mother
four times. The second prisoner said that the man had become agitated and
anxious when he tried several times to call his wife and there was no answer.
His records indicate that on 17 occasions when the man tried to speak to his wife
that afternoon there was no reply. At 6.26pm he spoke to his wife. My
investigator has listened to a recording of that conversation, and it appears that
he found it difficult and became very anxious. The call lasted for about five
minutes and ended when his wife put down the phone.
40. The friend remembered speaking to the man in the exercise area shortly after
that telephone call. He said that the man was clearly upset by the call and was
particularly worried about his relationship with his son. In interview, the friend
said:
“… [the man] has explained to me that … if he can’t be with her and have his
child, there was never going to be an in between, he was never going to be a
part time dad, he was never going to have someone else there [looking after
his child].”
41. Shortly after the man made this telephone call, prisoners on units 5/6 were told to
return to their cells for the night. A third prisoner and friend of the man who had a
cell directly opposite him, was also interviewed by my investigators. He said that
each night before they were locked in their cell he would always check that the
man and other prisoners with cells nearby had everything they needed for the
night. As usual, he asked the man if he wanted any tobacco or anything else.
He replied “… I don’t need nothing because I can’t take nothing down tonight …
me and my wife are finished.” The third prisoner said he asked again if there was
anything the man wanted, to which he replied, “No I can’t take nothing tonight, it
is time for me to go home.” The prisoner was very worried by his reply but he did
not speak to any member of staff about his concerns. He knew, however, that
the man’s friend was also concerned about the man’s mood.
42. The friend said he was worried about the man because he seemed very down
after his telephone conversation and was “not his usual self”. The friend said that
he wanted to speak to a member of unit staff about the man and so, at about
6.40pm, he went to find the senior officer who was in charge of the unit that day.
The friend said that, when he got the unit office, another prisoner was also
waiting to see the senior officer who told them both that it was time for lock up
and that they should return to their cells.
43. The senior officer was also interviewed as part of this investigation. He
confirmed that the man’s friend had come to his office on the evening of 27
August, just as lock up had been announced. He could not remember what the
friend had said to him but recalled that he told him and another prisoner, who
also wanted to see him, that they should return to their cells. The senior officer
told my investigators that it was quite common for prisoners to come to the unit
office as lock up was being called to make applications, and that there was a set
time for doing this. He said that there was nothing in the friend’s behaviour or
manner to suggest that he urgently needed to speak to staff and, when told to
Final Report 13
return to his cell, he did so. The senior officer told my investigators that if the
friend had said that it was urgent, or if he had been more persistent, he would
have made time to talk to him before he was locked in his cell. The friend
confirmed that he had not told the senior officer why he wanted to see him.
44. At about 6.45pm, staff on unit 5/6 began locking prisoners in their cells for the
night. A prison officer was responsible for locking up prisoners on the man’s
corridor. In interview, she said she remembered locking the man in his cell that
evening. He was lying on his bed, with his arms behind his head. As she locked
his door she said, “Goodnight” and he replied, “Goodnight, Miss.” The officer
said she had been over the events of that night many times since the man had
died, but thought that he had seemed his usual self and had given her no cause
for concern.
45. The man’s friend was not in his cell when the officer initially came to lock his
door, so she continued locking the rest of the cells on the corridor and returned to
his cell last. When she returned, he was standing at the doorway waiting for her.
The friend said that when the officer came to his cell, he pulled her by the arm
into his cell. He said that he was worried about the man and asked her to “keep
an eye on him”. He said that she nodded and locked his door. In interview the
friend explained that he had not told the officer and she had not asked, why he
was worried about the man.
46. The officer said that after she had locked the friend’s door she returned to the unit
office and spoke to the senior officer about what the prisoner had said to her.
She explained to him that she had just seen the man when locking his door and
that he had seemed fine. In interview the officer said that if she had felt
concerned about the man she would have returned to his cell to talk to him. She
said she would have done this even though her shift was nearing the end and it
was time for lock up. She felt that she would have been supported by her
colleagues if she had wanted to spend extra time making sure he was okay.
47. As a result of their conversation the senior officer checked the man’s file to see if
there were any concerns or issues noted. There was nothing in the file to
suggest that staff should be unduly concerned about him. He decided that one of
the man’s personal officers should speak to him the following day and check that
he was okay. The officer who had locked the cells said that one of the man’s
personal officers was in the office while she and the senior officer were
discussing the man and she made sure he was aware of her conversation with
the man’s friend. The man’s personal officer was responsible for handing over to
the evening staff and, according to the officer who locked the cells, said he would
tell them about the man. The man’s personal officer told my investigators he had
no recollection of such a conversation and did not remember hearing any
concerns about the man.
48. Another officer was on duty on unit 5/6 between 6.45pm and 9.00pm on 27
August. He told my investigator that day staff normally went off duty at about
7.00pm, and that a handover of information from day staff to evening staff was
carried out at about 6.45pm. He explained that the handover normally included
information on those prisoners on an ACCT document (Assessment, Care in
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Custody and Teamwork – the process by which prisoners at risk of suicide or self
harm are supported and monitored) and those on the basic level of the Incentives
and Earned Privileges (IEP) scheme. (The IEP scheme is designed to
encourage and reward good behaviour whilst in prison. There are three levels –
basic, standard and enhanced. Prisoners on basic level have the lowest number
of privileges.) The handover should also include those being monitored or
supported for other reasons. The officer explained that this was also the point at
which more general concerns about specific prisoners could be discussed. He
told my investigator that he could not recall being told that there were any
concerns about the man that night. The handover sheet (which should be signed
by the officer handing over information and the officer receiving the information)
was not signed to indicate that the 6.45pm handover had taken place. The officer
cannot recall who was responsible for handing over to him that night.
49. The officer was also asked about the purpose of the Staff Observation Book, one
of which can be found on each unit within the prison. He explained that it
provides a written record of any information that might be useful to other staff
working on the unit. He said that, if staff are worried about a particular prisoner,
they can use the Staff Observation Book to inform all staff about this. No entries
were made in the Staff Observation Book for unit 5/6 on 27 August reflecting the
man’s friend’s concerns, or indicating that staff should speak to the man the
following day.
50. An officer support grade (OSG), who had 19 years experience at the prison, was
on duty on unit 5/6 on 27 August. The night shift formally begins at 9.00pm, but
the OSG and the officer working from 6.45pm until 9.00pm confirmed that night
staff usually arrive on the units by 8.40pm so they can receive a handover before
the evening staff go off duty. The OSG was asked what sort of information is
usually passed on in the handover and he explained:
“[If] they have had problems with someone during the day and they say he
may play up during the evening or at night, once they know that there is just
one [member of staff] on. There may be concerns that somebody has been
upset about something, they may have had a bad visit or something like this,
it may have been all sorts of problems really.”
51. That night, the officer working from 6.45pm until 9.00pm was responsible for the
handover to the OSG. He was not aware of any concerns about the man and so
did not mention him during the handover. The OSG told my investigators that
night staff “sometimes got a whisper off the other prisoners” if they had concerns
about someone, and that they might ask staff to check on them during the night.
No prisoners spoke to the OSG about the man that night.
52. Unit 5/6, which houses 80 prisoners in single cells, is staffed by a single OSG
overnight. The OSG’s responsibilities include ensuring all the cell doors are
locked, monitoring prisoners on ACCT documents and other intervention plans,
answering cell bells during the night, checking fire equipment and patrolling the
unit. On 27 August 2008, Edmunds Hill had no prisoners on ACCT documents.
Final Report 15
53. In interview, the OSG was asked whether all prisoners were checked on during
the night. He explained that day staff carry out the last roll check of the day
(when all the prisoners are counted to make sure all have been accounted for) at
7.30pm. Night staff are not required to perform a count or physical check of all
prisoners on the unit themselves. The OSG confirmed that night staff do not
check on individual prisoners unless they are on an ACCT document or specific
concerns have been raised about them. He said that prisoners were only
checked if there was a reason to do so. However the OSG added that, if prison
staff had concerns about particular prisoners and had asked night staff to keep
an eye on them, they would:
“… try to do a sort of unofficial look in on them. If I know he has been passed
over to me, normally when we go round checking the doors, if a flap [has]
been left open on a window we will close it, but in his … case we would look
in just to see what he is doing at the time or whatever, might speak to him and
say are you alright, he will nod, wave or swear at you or whatever he wants to
do, but that sort of thing.”
54. As the OSG had not been informed of any concerns about the man and he did
not press his cell bell during the night, he was not checked on between 6.45pm
on 27 August and roll check at 7.30am the next morning.
55. My investigators also asked the OSG and prisoners on unit 5/6 about the use of
cell bells during the night. The OSG said that, whilst the cell bells were intended
for emergency use, prisoners use them for a variety of non-urgent reasons. He
thought that prisoners were very comfortable about using the cell bells. This was
confirmed by two prisoners who were interviewed during the investigation and
who said that prisoners were confident in using their cell bells if necessary.
56. Prisoners on the man’s corridor explained how they would often talk to each other
after being locked up by shouting through their doors. The man’s friend told my
investigators about his efforts to speak to the man after lock up that night. He
explained that at about 9.40pm he called out to him, as he often did, to talk about
the television programme, Big Brother, which they both used to watch. He called
several times but got no response. At this point a prisoner in the cell next to the
man told the man’s friend that he had been trying to speak to him since about
8.00pm and that he must already be asleep. The man’s friend said that he fell
asleep shortly after that and heard nothing unusual during the night.
57. The OSG recalled the night of 27 August as being one of the quietest he had
ever experienced at Edmunds Hill, with only two cell bell calls all night. He
explained that he walked around the whole of the unit several times during the
night shift, at intervals of not less than 40 minutes and not more than one hour
and 20 minutes.
58. Overnight, Edmunds Hill is managed by the Night Orderly Officer (NOO) and
three other officers who visit each unit of the prison several times during the night
to supervise and support the OSGs on the units. The Night Orderly Officer in
charge of the prison that night was interviewed. She explained that as part of
her responsibilities, she made rounds of the prison and arrived on unit 5/6 at
Final Report 16
12.05am. She told my investigators that she spoke with the OSG whilst on the
unit and he had nothing to report.
28 August 2008
59. Three officers (including the man’s personal officer) had all arrived at the prison
ready to begin work at 7.30am. The OSG went off duty and left the prison. The
man’s personal officer began the roll check on the unit and asked one of the
other officers to carry out the count on the top landing (where the man’s cell was
located). The officer reached the man’s cell (number 6:21) and opened the
observation flap in the door. He saw him standing by the window, facing the cell
door, with something tied around his neck. He described the man as “slumped
with his chin on his chest, his arms dangling next to him”. On seeing him, the
officer said he was quite sure that he was dead.
60. Edmunds Hill Local Instruction 2.100, dated 3 March 2008, sets out the protocol
for entering cells during the patrol state. According to the instruction, under
normal circumstances at least two members of staff should be present when a
cell is opened. Where there is, or appears to be, immediate danger to life, cells
may be opened by one member of staff and without the authority of the Orderly
Officer, although the control room must be contacted before such action is taken.
61. The officer conducting the roll check on the top landing used his radio to put out a
‘Code Blue’ call, which alerts healthcare staff that assistance is needed for
someone who is not breathing. He radioed for permission from the Orderly
Officer to enter the cell. He had not yet received a response from the Orderly
Officer when the other two officers arrived on the landing and they went into the
cell together.
62. The man’s personal officer explained that he had continued the roll check on the
ground level of unit 5/6 and had reached the cell directly under the man’s. When
he heard the Code Blue call for the cell on the upper landing, he quickly ran up
the stairs. The personal officer heard the officer conducting the roll check on the
top landing calling for permission to enter the cell and knew it must be a serious
situation. On arriving at cell 6:21, he looked through the flap and saw the man
hanging from the top right hand corner of his window. He had used a piece of his
bed sheet to make a ligature.
63. Within seconds a third officer also arrived on the corridor and shouted to the two
officers to enter the cell. The officer who had been conducting the roll check on
the top landing opened the man’s cell with his keys while the man’s personal
officer took out his anti-ligature knife (a knife specially designed to cut ligatures
safely which is carried by all operational staff at the prison). All three officers
then went into the cell. The man’s personal officer took hold of the man’s body
and cut the ligature from around his neck. He explained to my investigators that
the man’s body was “cold and rigid” and it was clear that he had been dead for
some time. Staff could see that rigor mortis had set in and so they did not lay his
body on the floor.
Final Report 17
64. In interview the third officer said that he made the decision that there was nothing
that could be done to revive the man and that they should leave the cell. He was
asked whether anyone checked him for a pulse at this point, and he explained
that they had not as they believed that he had been dead for some time.
65. Both this officer and the man’s personal officer said that they would have felt
confident beginning cardio-pulmonary resuscitation (CPR) if they had needed to.
The man’s personal officer had received up to date first aid training, whilst the
other two had received some training in the past although this was now out of
date.
66. On leaving the man’s cell, the officer who had been conducting the roll check on
the top landing went to the unit office and the third officer went to speak to the
prisoner in the cell opposite. The prisoner had heard the Code Blue call and was
very upset. The man’s personal officer remained outside the man’s cell and
healthcare staff arrived.
67. Two nurses (including the one who had carried out the first reception
healthscreen) had arrived at the prison at about 7.20am and were in the
healthcare centre when they heard the Code Blue call over their radios.
Accompanied by an agency staff nurse, they grabbed the emergency equipment
and made their way to unit 5/6. One of the nurses told my investigators that she
took the emergency resuscitation bag, which contains all the equipment
necessary to begin resuscitation. The other two brought the defibrillator and
oxygen. The nurse who took the emergency equipment also told my
investigators that she always carries resuscitation equipment in a small pouch
attached to her belt so she can begin working on a patient even if she does not
have the emergency bag from healthcare.
68. Unit 5/6 is some distance from the healthcare centre at the prison and the nurse
who carried out the first reception healthscreen estimated that it had taken them
about five minutes to reach the unit. Healthcare staff carry keys, so they were
able to head to the unit immediately on hearing the Code Blue. The nurse
carrying the emergency equipment arrived on the corridor first and followed other
staff who were running towards the man’s cell.
69. The nurse with the emergency equipment went into the cell and saw the man
standing by the window. She noticed his arms and legs were blotchy, and when
she touched his body he was cold. She recognised that rigor mortis had set in
and was sure that he had been dead for some time. Nevertheless the nurse
checked for a pulse and any sign of life. She found none. The nurse who had
conducted the first reception healthscreen also entered the man’s cell and agreed
that there was nothing they could do.
70. The incident log, compiled by a member of staff in the communications
department, indicates that an ambulance was called by the staff there at 7.38am,
following the Code Blue radio call. The paramedics pronounced the man dead at
8.05am.
Final Report 18
Prisoner support
71. The man had a number of friends with cells near to his, several of whom had
heard the officer make the Code Blue call. Those interviewed by my
investigators said that they knew the man had died without being told so by a
member of staff. However, they said that staff had come to them in person and
told them the news of his death.
72. Prisoners living on the man’s corridor were ‘buddied up’ (put in cells together or
with other friends and family in the prison) later that morning, so they could
comfort and support each other. Members of the prison chaplaincy team visited
the unit and prisoners were offered the chance to speak with them, or with
Listeners (prisoners trained by the Samaritans to offer a confidential support
service to other prisoners), or with members of staff. One of his friends was
placed on an ACCT document that day.
73. Prisoners on unit 5/6 and across the prison organised a collection and wreath for
the family. They were also invited to write down prayers and thoughts in the
chapel, which were sent on to the man’s mother.
Contact with the man’s family
74. The man’s mother was informed of her son’s death by local police on the morning
of 28 August. Edmunds Hill did not have any trained family liaison officers in post
on 28 August but a governor was appointed to liaise with the family. This was his
first experience of family liaison. He maintained regular contact with the man’s
mother. Members of the man’s family were given the opportunity to see his cell
when they came to the prison to collect his belongings.
75. The man’s mother told my family liaison officer that the prison had not offered her
any financial assistance with the man’s funeral expenses. She also said that she
had not been sent a letter of condolence from the Governor. It appears that the
Governor and the family liaison officer thought that an offer of financial assistance
had been made, albeit not explicitly, in a letter sent to the man’s mother shortly
after his death. This issue was raised by our investigator with the Deputy
Governor, who ensured that a clear offer of financial assistance was made to the
mother. The prison provided my investigator with a copy of the letter of
condolence they had sent to the mother of the man shortly after his death.
Staff support
76. The Governor did not hold a hot debrief on the day of the man’s death but instead
thought it more appropriate to talk to members of staff involved individually. (A
hot debrief is a meeting of staff involved in a traumatic incident to establish the
events, identify any immediate learning points, and allow those involved to share
their thoughts and feelings. It is a requirement of Prison Service Order 2710.)
He then called a full staff meeting at lunchtime to tell staff about the man’s death.
Several members of staff who had been involved in responding to the Code Blue
call decided not to attend the full staff meeting, fearing that they would be subject
to too much attention from their colleagues.
Final Report 19
77. Generally, prison staff involved said that they felt well supported by the prison.
The majority said that members of the prison’s care team made contact with them
immediately following the man’s death. However the nurse who had brought the
emergency equipment and a senior officer (who responded to the Code Blue call)
told my investigators that they had felt “forgotten” in the aftermath of the death.
Neither had been asked to make an incident statement, nor had spoken to the
Governor on the day of the man’s death, nor been offered support from the care
team. They were not invited to attend the Critical Incident Debrief, which took
place several weeks later.
78. As noted above a governor had acted as the prison’s family liaison officer. He
told my investigators that he had been well supported by senior management at
the prison, but had not been contacted by the prison’s care team. He felt that this
extra support would have been useful to him.
Final Report 20
ISSUES CONSIDERED DURING THE INVESTIGATION
The man’s recall to prison
79. The man had been released from prison in 2007 on licence and was recalled,
having breached his licence conditions, in July 2008. His criminal defence
solicitor told my investigator that at the time of his death they were in the process
of appealing against the recall decision. She explained that he fully understood
why he had been recalled and when he would be released. I am pleased that
this was the case and that both Pentonville and Edmunds Hill, most likely helped
by the input of the man’s solicitor, appear to have provided him with clear
information about his recall.
80. Whilst at Edmunds Hill, it seems that the man fully engaged in the regime. He
was attending education and steps were being taken to find him a job in the
prison. I believe that, whilst his recall was undoubtedly a source of frustration for
him and the reason he was separated from his family, there is no evidence to
suggest that it directly contributed to his death.
Clinical care
81. Suffolk PCT commissioned a clinical review of the care given to the man whilst
he was at Edmunds Hill. The reviewer had access to the man’s clinical records
and statements from staff, and undertook joint interviews with my investigator.
82. The clinical review found that there were gaps in record keeping with some
signatures and various entries missing from his clinical record. Such gaps might
be partially resolved by the introduction of a clinical computer system at the
prison. The clinical reviewer has made the following recommendation which I
endorse:
The Head of Healthcare should offer additional training in record
keeping to staff.
83. Various documents contained within the man’s prison file make mention of his
past history of depression, paranoia and personality disorder. A report written by
his probation officer in November 2007 recorded that he had attempted to self
harm in the past. Healthcare staff at Pentonville, who assessed him on his recall
to prison, noted his history of depression but found that he was of “normal mental
state” and had no current thoughts of harming himself. Whilst at Edmunds Hill he
was assessed first by a nurse in reception, then by a prison doctor, and then by
the mental health nurse who carried out a mental health screen.
84. The man told healthcare staff at the prison that he had no current thoughts of self
harm or suicide and denied feeling depressed. The mental health nurse found
him to be positive and motivated.
85. The clinical reviewer considered whether healthcare staff had reasonably
assessed the man’s risk to himself and concluded that:
Final Report 21
“From his Clinical Records and interviewing staff it is clear that at no time did
he give any cause for concern, either verbally or through his behaviour.”
86. The clinical reviewer is satisfied that staff at Edmunds Hill properly assessed the
man’s mental health whilst he was at the prison. While he had a history of
depression and there were indications that he had tried to harm himself in the
past, staff reasonably concluded that there was no current evidence to suggest
that he was thinking of harming himself or taking his life.
Response to prisoners’ concerns about the man
87. Following the man’s telephone conversation with his wife shortly before lock up
on 27 August, some of his friends on unit 5/6 were concerned about him. The
man’s friend asked the officer locking the unit that night to “keep an eye” on him.
The officer discussed this with the senior officer, who looked through the man’s
file for any areas of concern. On finding none, he decided that staff should speak
to the man the next day to check his welfare.
88. I have considered whether the staff’s response to the man’s friend’s concerns
was reasonable and appropriate, given the available evidence. The friend said
that he did not explain the nature of his concerns about the man to either the
officer or the SO. He had not told anyone about the man mentioning suicide in a
previous conversation. Staff did not feel they knew the man well. But there were
no indications that he was vulnerable or at risk of harming himself. The officer
locking the prisoners up that night appropriately discussed the issue with SO,
who correctly checked the man’s file for indications of concern. Their interviews
with my investigators indicated that they had given proper consideration to what
action should be taken in response.
89. However, my investigators identified that the process for passing on concerns
about prisoners between staff is not sufficiently rigorous. Although the SO and
the officer were satisfied there was no immediate cause to worry about the man,
the information should have been passed on to staff coming on duty that evening
and night. An entry should have been made in the Staff Observation Book
reflecting the concerns raised about the man and the need for staff to check on
him the following day. Similarly, an entry should have been made in his wing
history record. The daily handover sheet should have been signed by staff giving
and receiving the handover information.
The Governor should remind staff of the importance of making quality
entries in the Staff Observation Book and in prisoners’ files, and of the
importance of properly handing over information at the end of each shift
and signing the daily handover sheet.
Final Report 22
Checking prisoners overnight
90. At Edmunds Hill, the last roll check of the day takes place at 6.45pm. Staff
working on the units in the evening and overnight do not carry out a roll check of
their own, and the next one takes place at 7.45am. Night OSGs, who staff the
units overnight, are expected to check that all the cell doors are locked when they
come on duty. They must check on prisoners on ACCT documents and those
who need to be checked for any other reason, as directed. However, prisoners
who are not being supervised under any intervention plan will not be checked
during the night. The man’s family were concerned that he was not visibly
checked by staff for over 12 hours.
91. During the course of this investigation, Prison Service Headquarters was
approached for information regarding the timing of roll checks. The National
Security Framework requires that four roll checks are made during any 24 hour
period. The exact timing is at the discretion of the Governor of each
establishment, although there is an expectation that one roll check will be
undertaken in the morning and one in the evening.
92. The timing of roll checks at Edmunds Hill complies with these directions. Given
that the man was not on an ACCT or requiring supervision for any other reason,
there was no requirement for staff to check him overnight. I appreciate that this
will be of little comfort to the man’s family, but I do not think there are any grounds
for criticising the prison. It would not be proper for prisoners to be checked
throughout the night unless there is good reason for doing so.
93. The man’s mother had sight of the draft report. She remains concerned that her
son was not checked for over 12 hours and considers that the processes for
checking on prisoners overnight are not sufficient.
94. I was concerned to learn, however, that the OSG who was on duty on unit 5/6
overnight on 27 August, left the prison before the roll check was carried out and
found correct on 28 August. The establishment’s Night Orders for OSG Night
Patrols direct that they:
“… Must not leave the unit until the member of staff coming on duty has
satisfied themselves that the unit roll is correct, all gates/doors are secure and
any prisoners on ACCT have been checked.”
95. Staff have confirmed that it is not uncommon practice at Edmunds Hill for OSGs
to leave the establishment before such checks are done. On this basis the OSG
cannot be individually criticised. However, if he had not already left the prison he
would have been there when the man was found. This reinforces my earlier
recommendation about the importance of properly handing over between shifts.
My investigator has been assured that the practice is currently being looked at by
senior management at the prison, and a procedure is to be introduced to ensure
that night staff remain on their unit until the roll has been found to be correct.
Final Report 23
The prison’s response to the man’s death
96. The death of the man was the first to have occurred at Edmunds Hill since it
became a male establishment. Staff at the prison have little previous experience
of dealing with deaths in custody. I am pleased to find, therefore, that the staff
response to finding the man hanging was prompt and efficient. The prison’s local
instructions allow for a single member of staff to enter the cell in life threatening
situations without the permission of the Orderly Officer. The officer undertaking
the roll check on the top landing initially radioed for permission to enter the cell.
However, when two other officers arrived on the landing, they instructed the
officer to go into the cell. I am satisfied that staff acted quickly but safely.
97. All staff who went into the man’s cell and saw his body agreed that it was clear
that he had been dead for some time. I agree that under such circumstances it
was not appropriate for CPR to be attempted. However, during the course of the
investigation, it became clear that there is currently no rolling programme of first
aid refresher training for staff at Edmunds Hill. This means that there may be
times when none of the operational staff on duty has in-date first aid training.
Given that the prison does not have 24-hour healthcare cover, this is likely to be
of particular concern overnight and could have very serious consequences. I am
aware that there are plans to ensure that all Senior Officers are given first aid
refresher training, although there is no timescale for their implementation. With
this in mind, I make the following recommendation:
The Governor should put in place a rolling programme of first aid
refresher training for all Senior Officers in the prison within a specified
timescale.
98. The nurse who carried the emergency equipment told my investigators that she
routinely carries a small pack, attached to her belt, which contains all the
equipment she would need to begin CPR in an emergency when the medical bag
has not yet arrived. I am pleased to highlight this example of good practice.
It is good practice for healthcare staff to carry emergency resuscitation
equipment at all times.
99. The man’s friends on unit 5/6 were treated with proper consideration. They were
told of the man’s death and quickly offered the support of the chaplaincy team,
Listeners and prison staff. They were then moved into cells with other friends or
family. Shortly after his death, prisoners organised a collection for a wreath and
were able to attend a memorial service in the prison chapel.
Compliance with Prison Service Order 2710
100. The prison’s death in custody contingency plans were activated promptly and
carried out efficiently. Generally, staff who knew the man or who had responded
to the Code Blue call on the morning of 28 August felt well supported by senior
management at the prison. Although no hot debrief was held, the Governor
spoke with most staff individually in the hours following his death because he felt
Final Report 24
this to be more appropriate. A full staff meeting was then held at lunchtime on 28
August to inform the remaining staff present of his death.
101. Prison Service Order (PSO) 2710 (Follow up to deaths in custody) instructs that
“[t]here must always be a hot debrief immediately after the incident”. Italicised
sections of PSOs are mandatory. However, in this instance I am satisfied that the
decision not to hold a hot debrief was a considered one, and speaking to staff
individually provided an opportunity to reassure and support them. However, the
purpose of a hot debrief is also to identify learning points that might prevent
another death occurring. This learning may be best identified in a group setting
and through discussion.
102. Having seen the draft report, the Governor provided the following information:
“The Silver command suite was shut at 12:00hrs and I arranged a hot debrief
in the visits hall for 12:45hrs. I met with the individual members of staff who
were first on the scene between 12:00 and 12:45 and some of them asked if
they could be excused debrief. I felt this was appropriate. I extended the
debrief to all staff as there were many departments involved in passing
messages to prisoners or moving prisoners to the chapel and this may be why
the PPO describes a “full staff meeting”. The debrief did more than inform
staff of what had occurred. Staff were given an opportunity to share their
thoughts, we discussed learning points and staff highlighted colleagues who
had been particularly involved or who had done a particularly good job that
morning. I also informed staff of the support that would be on offer for them
and the prisoners.”
103. The majority of staff involved were contacted by the prison’s care team
immediately following the man’s death. However, two members of staff who were
not identified as having responded to the Code Blue felt they had not received
support from the prison. They did not speak to the Governor on the day of the
man’s death, did not speak to anyone from the care team, and were not invited to
attend the Critical Incident Debrief held several weeks later.
The Governor should ensure that procedures are in place to identify all
staff involved with a serious incident.
104. Prior to the man’s death, Edmunds Hill did not have any trained Family Liaison
Officers in place. The supplementary guidance to PSO 2710 dealing with liaison
with bereaved families states that either a trained FLO or a senior member of staff
should be appointed. A governor was appointed to undertake the role late in the
morning on 28 August, but had never done so before and had not had any formal
training. He received some limited instructions from the trained FLO at HMP
Highpoint, which is just across the road from Edmunds Hill.
The Governor should identify suitable staff to undergo the Prison
Service family liaison training as a matter of urgency.
105. News of the man’s death was broken to his mother by police officers local to her
home. PSO 2710 indicates that it is preferable for prison staff to visit family
Final Report 25
members rather than police. However, the Governor explained to my
investigators that he was concerned that news of the man’s death would spread
quickly around the prison and a friend or acquaintance of him might contact the
family first. On this basis, and given that the man’s family did not live locally, he
decided that it was most appropriate for the police to visit the family. Under PSO
2710, prisons are encouraged to identify local prison staff who can break the
news to the family. Use of the police should be a last resort. The Governor will
wish to bear this in mind in the event of any future death in the prison.
106. The prison provided my investigator with a copy of the letter of condolence sent
by the Governor to the man’s mother. The prison FLO said they had also sent
some written information for bereaved families. However the man’s mother said
she had not received a letter of condolence and was not clear that she was
entitled to financial assistance towards the cost of her son’s funeral. It appears
that an offer of assistance was made, but it was not sufficiently explicit to be clear
to the man’s family. Once told of the confusion, the prison arranged for the
payment towards the funeral costs. However, no one from the prison offered to
attend the funeral, which is recommended in the supplementary guidance to PSO
2710.
107. The family liaison officer told my investigators that he had received good support
from senior management at the prison but was not contacted by members of the
care team. Given the nature of the role of the FLO, it is important that they are
offered support from the care team and that this is on an ongoing basis.
108. In view of the rarity of deaths at Edmunds Hill, I suggest that the Governor
arranges for Contingency Planning Exercises to be held.
The Governor should ensure that the prison complies with the requirements
of PSO 2710, Follow up to a death in custody, particularly regarding:
(cid:127) Holding a hot debrief for all the staff involved.
(cid:127) Making a clear offer of financial assistance for the funeral costs.
(cid:127) Appointing trained family liaison officers who are supported whilst
they carry out their duties.
(cid:127) The supplementary guidance regarding liaison with the bereaved
family.
Final Report 26
CONCLUSION
109. The man appeared to have settled in well to the routine at Edmunds Hill and he
gave no cause for concern throughout his six weeks there until the night before his
death. Although staff were told that there were some concerns about him, this
information was not included in any record. There were no indications on his wing
record that he might try to harm himself so no additional safeguards were put in
place to support him on the night he died.
110. My investigation has identified a number of ways in which Edmunds Hill can
improve its response to indications of concern, not least by improving the record
keeping and transfer of information between staff. However, I do not believe that
the man’s actions could reasonably have been foreseen. Nor do I think that any of
the recommendations I have made would have prevented the man from taking the
actions he did.
Final Report 27
RECOMMENDATIONS
1. The Head of Healthcare should offer additional training in record keeping to staff.
The Prison Service accepted this recommendation.
2. The Governor should remind staff of the importance of making quality entries in
the Staff Observation Book and in prisoners’ files, and of the importance of
properly handing over information at the end of each shift and signing the daily
handover sheet.
The Prison Service accepted this recommendation. A notice to staff has been
issued.
3. The Governor should put in place a rolling programme of first aid refresher
training for all Senior Officers in the prison within a specified timescale.
The Prison Service accepted this recommendation. The response was:
“Edmunds Hill has since developed its own training department and a new
programme has been developed, first aid as a priority.”
4. The Governor should ensure that procedures are in place to identify all staff
involved with a serious incident.
The Prison Service accepted this recommendation. A new set of contingency
plans have been written to ensure this occurs.
5. The Governor should identify suitable staff to undergo the Prison Service family
liaison training as a matter of urgency.
The Prison Service accepted this recommendation. A Family Liaison Officer has
been appointed and trained.
6. The Governor should ensure that the prison complies with the requirements of
PSO 2710, Follow up to a death in custody, particularly regarding:
(cid:127) Holding a hot debrief for all the staff involved.
(cid:127) Making a clear offer of financial assistance for the funeral costs.
(cid:127) Appointing trained family liaison officers who are supported whilst they
carry out their duties.
(cid:127) The supplementary guidance regarding liaison with the bereaved family.
The Prison Service accepted this recommendation.
GOOD PRACTICE
It is good practice for healthcare staff to carry emergency resuscitation equipment at
all times.
Final Report 28