Individual at Birmingham

Investigation into the circumstances surrounding the
death of a prisoner
at HMP Birmingham in August 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2009
This is the report of an investigation into the death of a man who was found hanging
in his cell in K wing at HMP Birmingham on 18 August 2007. He was 30 years old.
I extend my sincere condolences to the man’s family and friends for their loss.
The investigation was carried out by one of my colleagues. Heart of Birmingham
Teaching Primary Care Trust appointed a panel to carry out a review of the man’s
clinical care and treatment. I would like to thank the staff at Birmingham for their
help.
The man had Irish nationality. He was serving a comparatively short sentence with a
conditional release date in early December 2007. On completion of the sentence, he
faced probable extradition back to Ireland where he would have been charged with
certain other offences.
The man arrived in Birmingham less than 72 hours before his death, having been
transferred there from HMP Wandsworth. His transfer arose from the currently
endemic problem of overcrowding in the London prisons. He had already moved
prisons on several occasions. After his arrival the man told a mental health nurse
that he was felt depressed and he asked for sleeping tablets. The nurse did not
consider that the man was displaying any symptoms of depression. Even so, he
completed a referral for a follow-up consultation with a doctor.
Neither the nurse nor any other members of staff at Birmingham saw any signs to
suggest that the man might have been at risk of self-harm. One officer described
him as a ‘larger than life’ character which accorded with how the man described
himself in a letter found after his death. The letter was among a number found at
Wandsworth in which the man spoke of himself as a person who always laughed and
joked, but only to mask his true feelings. The man also referred to taking his life.
The man’s mother has said though, that putting pen to paper was her son’s way of
dealing with problems so they should not be assumed to be suicide letters. She also
pointed out that the letters were written some days before her son’s death and he left
behind no such letters at Birmingham.
Whether or not the enforced relocation from a prison in London to one in Birmingham
played a part in the man’s death cannot be known. However, transfer is an
acknowledged risk factor, and my report shows that the man was uncertain why he
moved and concerned that his family would be unable to visit him. I make five
recommendations: two concerning arrangements for dealing with prisoners’ property,
the others to procedures in healthcare.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2009
2
CONTENTS
Summary 4
The Investigation Process 6
HMP Birmingham 8
Key Findings 9
Issues 14
Recommendations 20
3
SUMMARY
On 18 August 2007, the man was found hanging in his single cell in HMP
Birmingham. He was 30 years of age and had previously been living in London with
his partner and three young children.
The man had been arrested on 8 January 2007 in connection with two counts of
burglary. He was initially remanded into HMP Blakenhurst (a prison in Redditch, to
the south of Birmingham) before being transferred to HMP Pentonville. He was later
transferred to HMP Wandsworth.
On 5 June, the man was convicted of burglary and theft and sentenced to one year
and nine months imprisonment. His conditional release date was 3 December 2007.
The man was an Irish national wanted by the Irish authorities in connection with
offences that occurred while he was living there. Consequently, extradition
proceedings commenced and he attended Westminster Magistrates’ Court on 14
August in connection with those measures. By the time the man’s case was dealt
with, all the London prisons were full and he spent that night in a police cell before
being transferred to HMP Birmingham the following afternoon.
On arrival at Birmingham on 15 August the man was taken through the standard
prison reception processes which included seeing a reception nurse. The man told
the reception nurse that he had family problems and was also worried about his
sentence. He asked her for sleeping tablets. The reception nurse noticed no signs
that the man might be at risk of self-harm but she referred him to the mental health
team because of the worries he reported about his family and his sentence.
Following the referral by the reception nurse, the man was seen that evening by a
Registered Mental Nurse (RMN). The man told the RMN that he was ‘severely
depressed’ because he had lost his partner and children and was having trouble
sleeping. The RMN recorded what the man said, but he did not observe any signs of
true clinical depression. In fact, he did not even think that the man was low in mood.
The RMN was content, however, that the man should be prescribed tablets to help
him sleep and he asked a doctor to write a prescription. The RMN also referred the
man for a non-urgent follow-up consultation with a doctor.
The man was initially located into D wing, which is Birmingham’s first night centre.
Whilst there, he received a first night induction assessment during which he was
given general information about prison life and about the prison. The man was
asked about self-harm and he said that he had no such thoughts. He asked why he
had been transferred to Birmingham and was told that it was probably because the
London prisons were full.
The man received the second stage of his induction the following day and was again
asked about self-harm. He again said that he had no such thoughts.
The man telephoned his partner later in the day. He told her that he was now in
Birmingham and asked her to send him some money.
4
At about 2.00pm on 17 August, the man was transferred to K wing and he
telephoned his solicitor’s office just after his arrival. His solicitor was out of her office
at the time but he spoke to one of her colleagues. The man said that one of his
reasons for telephoning was about being transferred to Birmingham which meant
that, having three young children, his partner would be unable to visit him.
The man was allocated a cell on the fourth landing on K wing. The cell had been left
in a mess by the previous occupant and the man asked one of the landing officers if
he could clean it. The officer noticed the man’s Irish accent and told him that she
was of Irish decent. They chatted about where their respective families came from
and the man began singing the song ‘It’s a Long Way to Tipperary’. The officer told
my investigator that the man seemed a jovial, larger than life, character.
Two other officers from K wing also recalled having contact with the man on 17
August including the officer who locked his cell door for the night. Both officers
thought that the man seemed in a stable mood.
At just after 3.00am on 18 August, officers discovered that a prisoner in A wing had
hanged himself. In response to that sad event, all the other cells in Birmingham
were checked. Officers reached the man’s cell at about 4.00am when they found
him hanging from a ligature that had been wedged into the top of the cupboard door.
Staff went into the cell but the man was already dead and so no attempts were made
to resuscitate him.
When the man was transferred to Birmingham he went without his belongings which
remained for the time being in Wandsworth. When the belongings were collected
after the man’s death they were found to include a number of unsent and undated
letters to his mother and partner. In these letters the man spoke about his feelings.
He indicated that he had nothing to live for and that he intended to end his life. The
man’s mother has said that it was her son’s habit to put his thoughts on paper when
he was feeling low. She has also emphasised that the letters were written some
time before her son’s death.
5
THE INVESTIGATION PROCESS
1. The investigation was opened on 22 August 2007 when my colleague visited
HMP Birmingham. My investigator met Birmingham’s Head of Safer Custody,
and a trade union representative. My investigator informed them of the nature
and scope of the investigation. Notices were issued informing staff and
prisoners about the investigation. No members of the Independent Monitoring
Board (IMB) were available that day. My investigator subsequently interviewed
a number of the staff who had dealings with the man. No prisoners came
forward in response to the notices.
2. A clinical review of the man’s care and treatment was carried out by a panel
appointed by the Heart of Birmingham Teaching Primary Care Trust.
3. One of my Family Liaison Officers telephoned the man’s partner to explain the
purpose of the investigation and to give her the opportunity to raise any
concerns or questions she would like explored or addressed. The man’s partner
felt strongly that it was inappropriate to have transferred him to Birmingham
given that it would be difficult for her to visit as she had three young children.
She said that he had telephoned her several days before his death and had not
sounded low in mood. She could not believe that he would take his life,
especially without leaving a letter of explanation. The man’s partner also
questioned why he was located in a single cell given that he had previously
harmed himself while in prison.
4. My family liaison officer also telephoned the man’s mother. She said that her
son was initially very concerned about being extradited back to Ireland.
However, he had written to her towards the end of July to say that he had come
to terms with the prospect. She said that his children were very important to him
and she found it hard to believe that he would choose to leave them. The man’s
mother spoke about the letters that were subsequently found at Wandsworth in
which her son spoke about ending his life. She said that it was his practice,
when low, to put his thoughts on paper. She did not therefore consider the
letters to be suicide letters.
5. The man’s partner and mother both spoke about difficulties in contacting prison
staff after the man’s death when trying to determine who was the next-of-kin and
in obtaining his belongings and making funeral arrangements. The man’s
partner said that she was never contacted directly by Birmingham, all contact
was initiated by her. She was also told that she would be able to visit her
partner’s cell but this was not in fact arranged.
6. The solicitors acting for the man’s partner subsequently wrote to my office
raising some additional issues. They said that the man’s partner understood that
when the man went to court on 15 August he was told that his cell at
Wandsworth was reserved for him and he would be able to return after his court
appearance. She also said that the man had written to her complaining that he
was being singled out by some of the staff at Wandsworth, in particular for being
Irish. He wrote that he would be left until last to collect his food, by which time
there would only be salads to eat.
6
7. When this report was issued in draft form to all interested parties, I received
substantial responses both from the man’s partner (through her legal advisers)
and, directly, from the man’s mother. The issues raised by each have been
addressed either within this report, or within letters to the respective family
members which have accompanied this final report.
7
HMP BIRMINGHAM
8. HMP Birmingham is a local prison built in 1849 for adult male prisoners. The
prison can hold around 1,450 prisoners.
9. In his brief time at Birmingham, the man was initially located in D wing, which is
the first night centre. He then moved to K wing, which is for second stage
induction and where prisoners remain for around a week before transfer to one
of the main residential wings.
10. In February 2007, Birmingham received an announced inspection from Her
Majesty’s Chief Inspector of Prisons. In the introduction to her report the Chief
Inspector wrote:
“This inspection took place at a time of renewed and acute population
pressure … During the inspection Birmingham was receiving overcrowding
drafts (of prisoners) from London, and displacing the same number of its
own prisoners to Liverpool …”
11. In its annual report for the period 1 July 2006 to 30 June 2007, Birmingham’s
Independent Monitoring Board (IMB) commended the work carried out by each
of the three units with which the man had contact – reception, the first night
centre (D wing) and the second stage induction centre (K wing). The IMB spoke
about how busy each unit had been, but said new receptions to the prison were
being dealt with quickly, sensitively and with respect. The IMB also noted that
there had been a great improvement in the caring and conscientious treatment
of prisoners on induction during the past year.
12. The man’s death was the 12th apparently self-inflicted death in Birmingham since
I took on responsibility for the investigation of deaths in custody in April 2004.
8
KEY FINDINGS
13. On 8 January 2007, the man was arrested at his home in London and charged
with two offences of burglary that had occurred the previous November. He
spent two days in police custody before being remanded into HMP Blakenhurst
in Redditch, south of Birmingham on 10 January. The most likely reason for the
man being taken to Blakenhurst is that all the London prisons were full. On 17
January, the man was transferred to HMP Pentonville.
14. The man was convicted of burglary and theft on 5 June 2007 for which he was
sentenced to one year and nine months imprisonment. His conditional release
date, taking account of time served on remand, was 3 December 2007.
15. At this time, the man was still wanted by the Irish authorities in connection with
certain offences in which he was allegedly involved while living in Ireland. As a
result, the man attended extradition proceedings at court on a number of
occasions. Due to crowding in the London prisons, the man did not always
return to a London prison following a court appearance. In the period 18 June to
19 July the man spent time in the following prisons: Pentonville, Edmunds Hill (in
Suffolk), Wandsworth, Edmunds Hill again, and Wandsworth again.
16. The man had been continuously at Wandsworth for almost a month when he
attended Westminster Magistrates’ Court on 14 August. By the time his case
was heard that day, all the London prisons were again full and he spent that
night in a police cell. The following day he was transferred to HMP Birmingham.
17. On arrival at Birmingham on 15 August, the man was seen by a reception nurse
for a standard prison reception health assessment. The nurse made the
following entry in the man’s electronic medical record:
“… not on any medication but requesting [sleeping tablets] due to family
problems. No medical conditions … refer to mental health. Worried about
sentence. Self harmed once, four years ago1 but hasn’t done anything
since. Doesn’t feel that he will self-harm here. States doesn’t want to share
a cell.”
18. At interview, the reception nurse said that she had some recollection of the man
and recalled him having some worries about his family and his sentence.
However, she could not recall him elaborating on those problems. Nor did he
elaborate about why he did not want to share a cell. He simply said that it was
due to a previous experience that he did not wish to talk about. The reception
nurse said that the man seemed a little down, but there was no sign of any
mental health problems and no indication to her that he might have been at risk
of self-harm. The nurse said that she would not have referred the man to the
mental health team if he only requested sleeping tablets. She referred him
because of all the problems he mentioned such as family worries and concern
1The man reported at a previous prison that it was the news of his father’s death that caused him to
harm himself.
9
about his sentence. She added that prisoners referred to the mental health team
on first reception are seen by the team the same day.
19. A Registered Mental Nurse (RMN) saw the man on the evening of 15 August
following the referral from the reception nurse. In assessing the man, the RMN
used a tick chart headed ‘Brief Mental State Examination’. The majority of the
RMN’s assessments indicated that the man was mentally stable. For instance,
he recorded that the man was well groomed, he was calm, his speech was
normal and there was nothing to indicate that he had any thoughts of self-harm.
However, the RMN also noted: “Says severely depressed. Lost house, children
and wife/partner.”
20. The RMN told my investigator that the expression ‘severely depressed’ came
from the man. The RMN did not himself consider there was any evidence that
the man was clinically depressed. In fact he did not even seem low in mood.
However, for further investigations the RMN made a non-urgent referral for
follow-up by a doctor (a non-urgent referral meant that the man would be seen
several days later). The man also said that he had not slept well for several
days and asked for sleeping tablets. The RMN was satisfied that this was a
reasonable request, so spoke to the reception doctor who wrote a prescription.
21. The first night officer on D wing said that prisoners usually spend their first one
or two nights on D wing where they receive an induction into prison life in
general and information about Birmingham in particular. Prisoners are spoken to
both individually and in groups. The first night officer saw the man on 15 August
for a first night induction assessment. The officer told my investigator that the
man said he did not understand why he had been transferred to Birmingham.
The first night officer told him that he was not the only prisoner who had arrived
from London that day so it seemed the London prisons were full. In answer to
questions about self-harm, the man said that he had never attempted to harm
himself and had no current thoughts of doing so. The officer said that the first
night induction assessment usually takes between ten to 15 minutes to complete
and the question about the reason for the transfer to Birmingham was the only
significant matter they discussed. The officer said that the man was calm and
polite throughout the interview. He thought that this was his only contact with
the man.
22. On the morning of 16 August, the man had a brief telephone conversation with
his partner. He told her that he was now in Birmingham and he gave her the
address. He also asked her to send him some money.
23. An officer who works on D wing conducts second day interviews with prisoners.
He saw the man on 16 August. This officer told my investigator that he had only
a vague recollection of the man as he was one out of about six or seven
prisoners transferred from London that week. The officer said that prisoners
transferred from London usually ask why they have been transferred and how
they can be transferred back again. The officer thought that the man asked
these questions, but there was nothing unusual about him and he seemed
resigned to what had happened. The man was again asked whether he felt at
risk of self-harm and again replied that he had no such thoughts.
10
24. At just before 2.00pm that afternoon the man attempted to telephone his partner.
She did not answer and the man began to leave a voicemail message. However
the message ended after only a few words: “… this is …”
25. At about 2.00pm on 17 August, the man was moved to K wing. K wing deals
with the second stage of the induction process such as an introduction to the
gym and information about education.
26. A Senior Officer (SO) told my investigator that just after arriving on K wing the
man asked for a welfare telephone call2. He told the senior officer that he had
been transferred from Wandsworth, had no money, and wanted to telephone his
solicitor. The senior officer authorised the call. The senior officer said that their
contact had been brief, but they shared a brief joke about regional accents and
the man seemed fine.
27. My investigator obtained a copy of the telephone conversation that the man had
with his solicitor’s office on the early afternoon of 17 August. The man’s solicitor
was not in the office but a colleague offered to take a message. The man said
that he was telephoning for two reasons. First, he was phoning about his appeal
against his conviction. Second, he was phoning to report that he had been
transferred to Birmingham. He said that with three young children it would not
be possible for his partner to visit him.
28. An officer who works on the fourth landing on K wing where the man had been
allocated a single cell. This officer told my investigator that the previous
occupant had left the cell in a mess and the man asked her if he could clean it.
He also asked her several questions about the wing. The officer noticed the
man’s Irish accent and told him that her family were from Ireland. She asked
him where he was from. They chatted about their backgrounds. She thought
that the man seemed quite jovial and he sang the song ‘It’s a Long Way to
Tipperary’. The officer told my investigator that the man seemed a ‘larger than
life’ character. The man asked the officer if he could telephone his partner, but
when he dialled the number he got no reply. The man continued cleaning his
cell, which he finished in about half-an-hour. The officer asked the man if he
wanted to try again to contact his partner. He telephoned once more but again
got no reply.
29. The man told this officer that he had three young children and asked about
obtaining a transfer back to Wandsworth. She told him about the application
process. The officer left the wing at about 6.00pm and the man remained in a
good mood throughout the afternoon. She noticed him talking to the landing
cleaners about general arrangements on the wing. That was the last time that
she saw him.
30. The second officer on K wing’s fourth landing told my investigator that her
practice is always to introduce herself to prisoners when unlocking them in the
morning. Despite the high throughput of prisoners on K wing, she remembered
2Awelfare telephone call is one made at the prison’s expense.
11
meeting the man on 17 August because of his Irish accent. The second officer
said that the man was very polite and seemed not to have any concerns or
problems. The second officer recalled checking the man when carrying out a roll
check at around 8.00pm that evening. She said that she looked into the cell and
saw the man lying on his back on his bed, watching television. His feet were
crossed and his hands were behind his head. The second officer said that the
man seemed fine.
The discovery of the man’s death
31. At just after 3.00am on 18 August, a prisoner was found dead in his cell in A
wing. As a result, the night patrol officers checked all the other cells. At just
before 4.00am, a fourth officer began checking the cells on the fourth landing on
K wing. When the officer looked into the man’s cell he saw him suspended from
a ligature made from a bed sheet that was wedged into the cupboard door. The
officer called for assistance. Several staff responded without delay and entered
the cell. Staff supported the man’s body and cut the ligature. One of the staff
responding was a nurse. She noted in the man’s clinical records that his body
was cold to the touch and cyanosed3. As it was obvious to staff that the man
was dead, cardio pulmonary resuscitation was not attempted. Ambulance
paramedics arrived at the prison at 4.08am and the man was officially
pronounced dead at 4.13am.
After the man’s death
32. The man’s partner lives in London. Birmingham contacted the prison closest to
her home, HMP Wormwood Scrubs, and asked staff from that prison to visit to
break the news in person. One of the prison’s governors, together with a
chaplain, visited that afternoon to tell his partner of the man’s death.
33. The man’s mother lives in Ireland. Birmingham contacted the police authorities
in Ireland and an officer from a local station told her of her son’s death. The
man’s body was subsequently returned to Ireland for his funeral. Birmingham
arranged for the funeral directors to send their bill direct to the prison for
settlement.
34. Birmingham’s deputy governor was contacted at home shortly after the man’s
death and he attended the prison before 5.30am. He held a debriefing meeting
before the night staff went off duty. Staff were offered support by the prison care
team. An additional care team member was also placed on duty for the following
night. Prison staff spoke to prisoners in the cells adjoining the man’s to inform
them about what had happened.
35. As the man’s transfer from Wandsworth to Birmingham was unplanned, he had
travelled direct from court to Birmingham without his belongings. Following the
man’s death his belongings at Wandsworth were collected together and sent to
Birmingham. The belongings were found to contain a number of letters to his
mother and his partner. Among other sentiments expressed, the man wrote that,
3Cyanosis is when the body’s extremities turn blue due to absence of oxygen.
12
although he always laughed and joked, he did so to prevent people seeing how
much he was damaged. He explained that he felt he had nothing to live for and
that it was his intention to kill himself. He also wrote that it was his decision and
no one else was to blame.
13
ISSUES
The man’s transfer to Birmingham
36. Before his arrest in January 2007, the man was living in London with his partner
and three young children. Having been convicted and sentenced, and having
moved prisons several times, the man was by 15 August in HMP Wandsworth.
On that day he went to Westminster Magistrates’ Court for a hearing on
proceedings for his extradition to Ireland in connection with past offences there.
By the time the man’s case had been dealt with, the London prisons were full
and so he was transferred to Birmingham. The man was confused about the
reason for his transfer. He asked staff at Birmingham for an explanation and he
also asked about obtaining a transfer back to London.
37. In her most recent inspection report on Birmingham, Her Majesty’s Chief
Inspector of Prisons referred to the acute prisoner population pressure. The
effects have included the transfer of prisoners from London to Birmingham. The
consequences for prisoners’ family ties need no elucidation. The man’s partner
might well have been eligible for assistance with travelling expenses, but even
so a visit would have been tiresome for her and the children.
38. The Chief Inspector issued her report in February 2007. By the time of the
man’s transfer to Birmingham, just six months later, the national prison
population had risen by 1,000, and one year on from the man’s death the
population has risen by a further 3,000. The impact on individual prisoners is
manifest in terms of disruption, uncertainty and continuity of care.
39. The man’s partner had understood that his cell at Wandsworth had been
reserved for him so he could return there after his court case. Prison Service
Instruction 30/20064 includes direction on discharge to court. It sets out
categories of prisoners who should always return from court to the discharging
prison. Such prisoners include juveniles, category A (high risk) prisoners,
vulnerable prisoners, those with mobility problems etc. The man did not fall into
any of the listed categories. If anyone did tell the man that he would be returning
to Wandsworth after his court appearance, they were incautious (and, as things
turned out) incorrect to do so.
Should staff have realised that the man was at risk?
40. The paperwork supplied to my investigator by Birmingham included nothing from
the man’s last period in Wandsworth (although papers from earlier periods of this
particular sentence were included and must have reached Birmingham via
Wandsworth). Because of the missing paperwork, it has not been possible to
consider how the man was coping in Wandsworth in the weeks leading up to his
unplanned transfer into Birmingham on 15 August. From information held
centrally, however, Wandsworth have been able to confirm that the man was not
subject to the special monitoring and support arrangements that are put in place
4Advice, guidance and instruction to staff are contained in documents known as Prison Service
Orders (PSOs) and Prison Service Instructions (PSIs).
14
for prisoners deemed to be at risk of self-harm. This investigation has therefore
focussed on the man’s time in Birmingham.
41. Upon his arrival in Birmingham the man was seen by the reception nurse for an
initial healthcare assessment. She noted that the man reported harming himself
once in the past, four years previously, but that he had no present thoughts of
self-harm. The reception nurse noted that the man wanted sleeping tablets,
which he said he needed due to family problems. She also recorded the man
saying that he was worried about his sentence. (As he had only a few months
remaining of his current sentence, his worry presumably related to his potential
extradition.) The reception nurse told my investigator that she had no concerns
that the man might be at risk of self-harm, but she referred him to the mental
health team due to his request for sleeping tablets.
42. The Registered Mental Nurse (RMN) saw the man later that day. He noted the
man as saying that he was severely depressed due to losing his partner and
children. At interview, the RMN said that the words ‘severely depressed’ were
the man’s. As far as the RMN was concerned, the man was not displaying any
signs of depression and did not even seem low in spirits. The RMN asked the
reception doctor to prescribe sleeping tablets. He also wrote a referral for a non-
urgent follow-up by a doctor for further investigations.
43. Even though the man had no more than brief contact with several staff at
Birmingham, most of those who encountered him were able to recall him to
mind. One officer described the man as a ‘larger than life’ character which
seems to accord with the way in which he described himself in a letter to his
mother. More specifically, this officer talked about the man chatting about
Ireland and singing ‘It’s a Long Way to Tipperary’ when she told him of her Irish
roots.
44. Other staff who recalled the man from their brief contact with him were three
other officers as well as the Senior Officer. None recognised any signs that the
man might have been at risk, and he denied having any thoughts of self-harm
when asked during the induction process at Birmingham.
45. We know that the man was confused about his transfer to Birmingham. He
asked several staff about the reason for this and about transferring back to
London. However, there is nothing to suggest that the man expressed concerns
about being in Birmingham that should have alerted staff to the possibility he
would harm himself. It should be borne in mind too, that during this fairly brief
time in custody, the man had already been transferred between prisons on a
number of occasions.
46. I conclude on this matter that there were no grounds for staff to have suspected
that the man was at risk.
15
Should the man have been in a single cell?
47. The man’s partner has questioned the decision to place him in a single cell,
given that he had previously harmed himself in prison. This investigation has
shown that he was allocated a single cell after expressly requesting one when
he arrived in Birmingham. He told the nurse on reception that his reason for
making the request was a previous experience about which he did not wish to
elaborate.
48. In deciding whether or not to place a prisoner in a single or a shared cell staff
need to consider a variety of factors. They need to consider whether the
prisoner might pose a risk to others, or indeed whether the prisoner might be at
risk from others. In managing prisoners at risk of self-harm, it is recognised that
cell sharing can be an important element of the support provided for the at-risk
prisoner. However, responsibility for the care of an at-risk prisoner lies with
management and staff, not with the at-risk prisoner’s cell-mate.
49. As already mentioned, the man’s one declared act of self-harm had been four
years previously. On arrival in Birmingham he denied having any present
thoughts of self-harm, and there seems to have been nothing about his
demeanour to cause staff to think otherwise. Had staff considered the man to
be at risk, they would have put in place an action plan to minimise the risk. That
plan might have included putting him in a shared cell. But with no apparent
reason to believe there was any risk, the decision to place the man in a single
cell was reasonable.
50. I should add that the man’s records include two other cell-sharing risk
assessments indicating his reluctance to share a cell. One was from Edmunds
Hill dated 18 June when the man said that he had concerns about sharing. He
did, however, agree to give sharing a try. The second assessment was
completed at Wandsworth on 5 July when the man declared that he would not
share. The man’s request for a single cell at Birmingham was not, therefore, an
unusual or suspicious request for him to have made.
Missing paperwork from Wandsworth
51. My investigator has made concerted efforts to try to locate the probable missing
papers for the man’s last period in Wandsworth. He was assured by
Wandsworth that the documents would have been sent with the man when he
went to Westminster Magistrates’ Court on 14 August. He was told that this
would be standard practice because of the possibility of the prisoner being
transferred to a different prison following the hearing. However, despite
repeated enquiries of Birmingham, no further papers for the man have been
located.
52. It is not possible for me to say definitively where the missing papers might be but
I am inclined to believe that they remain somewhere in Wandsworth. The only
other explanation is that Birmingham received all of the papers, managed to
secure most of them, but also managed to lose all those for the man’s time at
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Wandsworth from 19 July to 14 August. I think the former explanation is the
more likely.
53. Without knowing what was recorded in the missing papers it is not possible to
say whether their disappearance might have compromised the man’s care in any
way after his arrival in Birmingham. Most importantly, however, we at least know
that the man had not been judged at risk of self-harm while at Wandsworth.
54. The man’s partner has said that he wrote to her complaining about maltreatment
by some of the staff at Wandsworth. Again, the lack of paperwork for the man’s
last spell in Wandsworth makes it difficult for me to comment conclusively on this
matter. My investigator has been informed, however, that the man submitted no
formal complaints at Wandsworth about his treatment during that period.
The man’s referral for follow-up by a doctor
55. On 20 August, two days after the man’s death, the form completed by the RMN
referring the man for a medical follow-up was found in a uniform jacket that was
hanging on a chair. Birmingham investigated the circumstances that resulted in
the form being misplaced. The investigation discovered that that an Operational
Support Grade officer collected the referral form and put it in his jacket pocket.
His intention was to deliver the form to the primary care team but he forgot to do
so.
56. This referral had been for a non-urgent follow-up, meaning that the man would
probably not have been seen until after that weekend. As a consequence, the
fact that the referral form went missing for a short period of time would have had
no impact on the man’s care.
The response when the man was found
57. The man was discovered at 4.00am when it was decided that all cells should be
checked following the discovery of the death of another prisoner earlier that
night. Under normal circumstances, a full roll check would not have been started
until around 5.30am. When the man was discovered, staff responded quickly to
cut away the ligature and to check for signs of life. Examinations carried out by
a nurse clearly indicate that the man was already deceased. I consider that the
decision not to attempt resuscitation was reasonable.
Contact with the man’s family
58. The man had named his partner as his next-of-kin and had named his mother as
another person who should be notified in the event of an emergency. I was
pleased to learn that Birmingham arranged for both family members to be
notified promptly and in person of the man’s death. Birmingham also liaised
appropriately with regard to the man’s funeral arrangements.
59. Much less well handled have been the arrangements for other contact with the
man’s family. When I issued my report in draft form, I commented on two
aspects of the family liaison arrangements. The first aspect related to the man’s
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property. My understanding at that time was that some of the property was still
held at the prison despite several requests for its return from the man’s partner’s
solicitors. I referred then to the guidance supplementary to chapter four of
Prison Service Order (PSO) 2710 which contains advice on deciding who is
legally entitled to the property, and on what to do in the case of a dispute within
the family as to this entitlement. I expressed the opinion that this was a matter
that should have been resolved long before. I then went on to recommend that
the prison should arrange for the man’s property to be returned to his family
without further delay. The Prison Service’s response was to accept my
recommendation and to say that:
“The man’s partner’s solicitors have requested that the prison keep the
man’s property for the time being whilst they try to ascertain how the man’s
partner would like to receive it (whether she will collect it in person or would
prefer to have it sent by post).”
60. In preparing this final version of the report, my investigator asked Birmingham
whether the property had at last been returned to the man’s partner. My
investigator was told that the property had not been returned to the man’s
partner but had instead been posted to his mother in Ireland5. I was dismayed to
hear of this. Having indicated in response to the draft report that the property
would be returned, correctly in my view, to the man’s partner (and the mother of
his children), I can see no logic to a reversal of that decision. I fear that this
news may only serve to add further to the man’s partner’s distress.
61. In my draft report I made a second recommendation relating to property:
I also recommend that the Governor ensures that staff dealing with
families following deaths in custody are reminded of the guidance set out
in PSO 2710 concerning prisoner property.
62. The Prison Service’s response to that recommendation was to say (rather
complacently) that:
“Staff dealing with deaths in custody are aware of the guidance set out in
PSO 2710 concerning prisoner property.”
63. The circumstances concerning the handling of the man’s property, as I have just
related, suggest most strongly that staff awareness may need reinforcement
through training. I draw this to the Governor’s attention.
64. In my draft report, I also referred to the man’s partner’s complaint about on-going
contact with Birmingham. She had said that she was not contacted directly by
Birmingham, and that all contact was initiated by her. Nor were arrangements
made for her to view the man’s cell. In its response, the Prison Service said that
arrangements had been made on two occasions for the man’s partner to visit the
prison to view the cell but she did not attend on either occasion.
5Please refer to the Annex to this report.
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The letters found at Wandsworth
65. After the man’s death, letters were found among his belongings at Wandsworth
which could be considered as suicide letters. They were undated and the man’s
mother told my Family Liaison Officer that she did not think they should be
assumed to be suicide letters. She said the letters were written at Wandsworth
so were obviously completed some time before her son’s death. She said that it
was her son’s practice to put his thoughts and feelings down on paper when he
was feeling low. The man’s mother also said that, if her son intended the letters
to be suicide letters, he would have written them in Birmingham.
66. Whether or not the man intended to take his life will be a matter for consideration
at the Coroner’s Inquest.
Main findings from the clinical review
67. The clinical review found that the man received care comparable to that he could
have expected to have received in the community. However, the reviewers
comment that the man’s frequent moves between different prisons would
suggest that none of the staff were able to get to know him. (I agree.) The
reviewers found some deficiencies in record keeping and have made three
recommendations which relate to communication and record keeping. I endorse
their recommendations.
Independence of the clinical review
68. In the case of public sector prisons such as Birmingham, I am required to
approach the commissioning Primary Care Trust to obtain a clinical review of the
prisoner’s care and treatment. In order to achieve independence, I would expect
the review to be undertaken by individuals with no direct contractual links to the
prison. However, recent practice following deaths in Birmingham has been for
the clinical review to be conducted by senior healthcare staff employed in the
prison. That is what has happened in the man’s case. I expressed my concern
in a recent investigation report about the potential conflict of interest and
apparent lack of independence that results from with this practice. In that report,
I urged the Heart of Birmingham Teaching PCT to consider my concerns when
appointing reviewers in future investigations.
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RECOMMENDATIONS
The following recommendations were made in the draft version of this report. The
Prison Service’s responses appear in italics following each recommendation.
Despite the Prison Service’s acceptance of the first recommendation, the man’s
property was subsequently returned to his mother rather than his partner (this is
discussed in paragraphs 59 and 60). The Prison Service’s response to the second
recommendation is discussed in paragraphs 62 to 63.
1. The Governor should arrange for the man’s property to be returned to his family
without further delay.
Recommendation accepted: The man’s partner’s solicitors have requested that the
prison keep the man’s property for the time being whilst they try to ascertain how the
man’s partner would like to receive it (whether she will collect it in person or would
prefer to have it sent by post).
2. I also recommend that the Governor ensures that staff dealing with families
following deaths in custody are reminded of the guidance set out in PSO 2710
concerning prisoner property.
Recommendation accepted: Staff dealing with deaths in custody are aware of the
guidance set out in PSO 2710 concerning prisoner property.
I also endorse the following three recommendations made by the clinical review
panel:
3. All consultations should be recorded contemporaneously in the electronic
medical record.
Recommendation accepted: Consultations are being recorded contemporaneously in
the prisoners’ electronic medical records.
4. A clear protocol should be written for onward referral and communicated to all
staff.
Recommendation accepted: Pathway is in place. This will be re-issued and audited.
Target for completion is end November 2008
5. All prescribed medication should be entered into the electronic medical record.
Recommendation accepted: In place and audited by head of pharmacy.
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ANNEX
Following the issue of the final report of this investigation, Birmingham confirmed that
the man’s property had not in fact been posted to his mother in Ireland but was still
held at the prison. The property was then, correctly, sent to the man’s partner.
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