Individual at Canterbury

Investigation into the circumstances surrounding the
death of a man whilst in the custody of HMP Canterbury in
November 2007
Report by the Prisons and Probation Ombudsman
for England and Wales
March 2008
This is the report of an investigation into the death of a man who was found hanging
in his cell at HMP Canterbury in November 2007. He had used a head prayer
covering as a ligature tied around his neck and attached to his cell window bars. His
cellmate and staff responded immediately and attempted to resuscitate him. Sadly,
despite their best efforts, he did not regain consciousness and was pronounced dead
in his cell at 8.40am. The man was a foreign national prisoner from India. He was
39 years of age.
I would like to add my sincere condolences to those already expressed by the
Governor, staff and prisoners at Canterbury to the man’s family and friends for their
loss. I hope that this report answers their questions, but recognise that it may not
alleviate their pain or lessen their grief. A key objective of my investigation has been
to give the man’s family and friends every opportunity to raise any concerns about
his death. One of my Family Liaison Officers and the lead investigator have spoken
to a representative of the family, and we have done all we can to answer their
questions.
Three investigators from my office conducted the investigation. I also commissioned
a clinical review into the man’s care and treatment that was undertaken by the East
Kent Coastal Primary Care Trust. I must thank the Governor of Canterbury, and his
staff for their help and active cooperation during this investigation. I am also grateful
to the Kent Police for their ready assistance.
In September 2007, the man who is the subject of this report had been arrested at
Stansted Airport seeking re-admission to this country using a Portuguese passport.
He was charged with possession of a false instrument (the passport), and sentenced
to 15 months imprisonment with a recommendation for deportation. Following
sentence, it is clear that the man became increasingly frustrated with his
predicament. He was unable to work to support his family, and was uncertain about
his future. At the time of his death he was being monitored and supported under the
Prison Service’s special procedures for those believed to be at risk of self-harm.
The man’s death was the first apparently self-inflicted death to have occurred at
HMP Canterbury since 1 April 2004 when I became responsible for investigating all
deaths in prisons. His death was one of 23 amongst foreign national prisoners
during 2007. I have made six recommendations in this report.
This report has been anonymised for publication on the website of the Prisons and
Probation Ombudsman.
Stephen Shaw CBE
Prisons and Probation Ombudsman March 2008
2
CONTENTS
Summary 4
Investigation process 5
Background 6
HMP Canterbury
Independent Monitoring Board
Suicide and self-harm monitoring
Samaritans
Listeners
Consultative committees
Violence reduction
Counselling, Assessment, Referral, Advice, and Throughcare (CARAT)
Chaplaincy
Race equality
Immigration casework
Early Release Scheme (ERS)
Facilitated Return Scheme (FRS)
Interpreting services at Canterbury
HM Chief Inspector of Prisons’ inspection report
Foreign National Prisoners
Key findings 13
Issues considered in the investigation 21
Conclusions 24
Recommendations 25
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SUMMARY
The man who is the subject of this report was an Indian national. He had paid an
agent £10,000 to arrange his passage to the United Kingdom. It is unclear exactly
when he first entered the UK, but he arrived in London a few years before his death
using false travel documents. He worked as a building labourer to support his family
who remained in India, and was paying off his debt to his agent.
The man’s mother was diagnosed with cancer in 2007 and, through his agent, he
arranged to acquire false travel documents to allow him to return to India. He was
arrested in September 2007 at Stansted Airport seeking admission back into the UK
as a European Economic Area (EEA) national. It was noted that he was in
possession of a forged passport. He made a claim for asylum, but was prosecuted
and convicted for the possession and use of a false instrument (a Portuguese
passport).
At the Crown Court in September 2007, the man was sentenced to 15 months
imprisonment and recommended for deportation. He was initially held at HMP
Chelmsford before being moved to HMP Wormwood Scrubs. He transferred to HMP
Canterbury on 1 October 2007.
Upon reception into Canterbury, the man denied having any self-harm thoughts but
said he missed his family. He was assessed as having good physical and mental
health. He had access to reading and writing materials, made telephone calls and
received visits. He also attended Sikh prayers, education classes and workshop.
Whilst at Canterbury he was seen by immigration officials and his deportation
options were discussed.
The man was placed on an open ACCT (Assessment, Care in Custody and
Teamwork) document – the Prison Service’s system for monitoring and supporting
prisoners thought to be at risk of self-harm –after his cellmate raised concerns over
his odd behaviour and demeanour. The procedures were comprehensively
recorded. The man attended his self-harm reviews with a prisoner acting as an
interpreter. It is apparent that the man was uncertain about the future that awaited
him in India, and felt he could no longer control events.
Concerns were raised by his cellmate on 7 November 2007 when the man was
found with his prayer head covering tied around his neck. Six days later, he was
discovered hanging in his cell by his cellmate. This time the prayer head covering
had been attached to the cell bars.
Staff acted promptly and efficiently in cutting the man down, laying him on the floor
and commencing resuscitation. An ambulance was summoned and attended
quickly. Sadly, the man was pronounced dead in his cell. A post mortem
examination found he had died as a result of suspension. There was no evidence to
suggest third party involvement.
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THE INVESTIGATION PROCESS
1. The investigation was formally opened at HMP Canterbury on 14 November
2007 by my investigators. The Governor and his staff produced the man’s
core record and a number of other documents for examination. My
investigators met with members of the chaplaincy, and arrangements were
made for them to meet with members of the Prison Officers’ Association
(POA) and Independent Monitoring Board (IMB).
2. Notices were issued to staff and prisoners informing them of the investigation
and inviting anyone with relevant information to make themself known.
Following this, a prisoner asked to see my investigators and was formally
interviewed. The investigators were given unrestricted access to the prison,
staff, prisoners, and to documentation relating to the man who died. They
were also able to speak with Kent Police in relation to issues of common
interest.
3. Prison officers, members of healthcare staff and prisoners were formally
interviewed, and those interviews were tape recorded. The services of official
interpreters were used to assist the investigation team. The interviews have
been transcribed and interviewees invited to sign and return them. A copy of
this report will be translated into Punjabi for the man’s family.
4. East Kent Coastal Primary Care Trust conducted a clinical review of the
man’s care and treatment. A Family Liaison Officer from my office contacted
the family representative. He asked the investigators to consider where the
man got the material to make the ligature and why it was so readily available.
He also asked whether there were any signs that the man was depressed or
suicidal, and whether he had spoken to anyone about how he was feeling.
The family representative said that he visited the man at Canterbury on the
Sunday (11 November) before he died when he seemed fine. He was looking
forward to speaking to him again on the following Tuesday. His death
therefore was unexpected and a huge shock.
5. My investigator wrote to HM Coroner to inform her of the nature and scope of
my investigation and to request a copy of the post mortem report. Upon
completion, this report will be sent to the Coroner to assist her enquiries into
the man’s death.
6. The man’s family and friends wanted to know the circumstances that led to his
death. I hope this report answers their questions but I realise it will not lessen
their grief.
5
BACKGROUND
HMP Canterbury
7. Canterbury has been a specialist prison for foreign national prisoners since
2006. It has an operational capacity (maximum crowded capacity) of 284
prisoners. The gaol lies close to the centre of the city of Canterbury and
dates from 1808. Originally, it was a ‘county gaol’ serving local courts. There
are three wings: A wing accommodates 142 prisoners, B wing 96 and C wing
46.
Independent Monitoring Board
8. Each prison has an Independent Monitoring Board (IMB), the role of which is
to monitor the care and treatment of prisoners. The IMB is independent of the
prison and its management, and members are not paid for the work they do.
9. The IMB at Canterbury has ten members of different ages and backgrounds,
drawn from the local community. The board has a formal meeting each
month; the Governor attends and presents a report. This allows for useful
updates and exchange of views. The IMB also has informal access to the
Governor at other times.
Suicide and self-harm monitoring
10. As at all prisons, Assessment, Care in Custody and Teamwork (ACCT) has
been introduced at Canterbury to monitor and support prisoners assessed as
at risk of suicide or self-harm. (The previous system was known as the
F2052SH procedure.) Once placed on ACCT, the prisoner is observed at pre-
determined intervals according to the perceived level of risk.
11. Each prisoner is assessed within 24 hours and then reviewed at intervals
decided on an individual basis. The ACCT guidance says that, to be effective,
the review should involve the key people who know the person at risk or are
involved in their care. The key questions for each review are listed as:
(cid:127) have the problems that caused the ACCT plan to be opened now been
resolved?
(cid:127) if not, what needs to be done to resolve them?
(cid:127) have any further problems arisen that are now causing distress and
more risk?
(cid:127) if so, what action can be taken to address these?
(cid:127) is the person at risk now in contact with friends, family or other
support?
(cid:127) does the person at risk now have something in their lives that they feel
good about?
(cid:127) if not, how can this be improved?
12. Over time, the reviews should also consider other factors such as:
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(cid:127) distress – has anything changed to make the person at risk more or
less desperate?
(cid:127) resources – has anything changed that makes the person at risk now
feel more or less alone?
(cid:127) previous suicidal behaviour – has anything changed that makes suicide
more familiar or more acceptable to the person at risk?
(cid:127) suicide intention or plan – has anything changed to show that the
person at risk is more or less prepared to kill themselves?
(cid:127) pattern of self-harm – is self-harm becoming more or less frequent?
13. Amongst other things, the ACCT guidance states that prisoners should be
cared for in a safe environment, and that it is for the case review team to
decide the most appropriate place to locate a particular individual. The man
who died had been identified as at risk of self-harm and was subject to self-
harm monitoring and support.
Samaritans
14. The Samaritans is an independent organisation that has trained volunteers
who will listen to prisoners’ concerns. Prisoners at Canterbury are able to talk
freely and in confidence with the Samaritans using telephones provided on
the wings.
Listeners
15. Listeners are prisoners trained by the Samaritans to offer confidential support
for prisoners in distress. They are available 24 hours every day and will listen
to concerns face to face and provide confidential support.
Consultative Committees
16. There are two consultative committees at Canterbury: the Residential
Consultative Committee and the Canteen Consultative Committee.
17. The Residential Committee is chaired by the Deputy Head of Residential, and
has two prisoner members from each wing. The Committee meets monthly to
discuss domestic issues within the residential units. The aim is to allow them
to highlight problems and bring forward suggestions to make the regime and
routines of the residential units run more smoothly, and to improve the quality
of life for everyone.
18. The Canteen Committee meets every three months and is chaired by either
the Head of Finance or the Finance Office Manager. Again, there is
representation from two prisoners from each of the wings.
Violence reduction
19. Canterbury’s policy is to promote a safe environment for all staff and
prisoners. The aim is to maintain an environment free from violence, threats
of violence, harassment or intimidation and other disruptive behaviour.
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20. All incidents (or suspected incidents) of bullying should be reported by staff to
a manager and investigated. Upon their arrival at Canterbury, all prisoners
are requested to sign up to the anti-bullying procedure.
Counselling, Assessment, Referral, Advice and Throughcare (CARAT)
21. In common with other prisons, prisoners can access the CARAT team
regarding any concerns about drugs or alcohol abuse.
Chaplaincy
22. Canterbury has a chaplaincy team that caters for all religious and spiritual
needs. They are supported by a number of visiting religious leaders.
Prisoners can apply to attend chaplaincy services. The man who died was
known to the chaplaincy department as he attended Sikh prayers.
Race equality
23. The Prison Service has a positive duty to eliminate unlawful discrimination,
and promote equality of opportunity and good relations between people of
different racial groups. Unlawful discrimination on the basis of colour, race,
nationality, ethnic or national origin, or religion is prohibited, as is any racially
abusive insulting language or behaviour on the part of any member of staff,
prisoner or visitor.
Immigration casework
24. As a prison dedicated to foreign national prisoners, Canterbury works with the
Border and Immigration Agency (BIA) to return prisoners to their home
country or resettle them in the United Kingdom. A team of BIA immigration
officers is employed within the prison and may interview any prisoner to
ascertain their immigration status. Immigration officers are responsible for the
service of all immigration related paperwork, and for explaining to prisoners
what they need to do with the documentation.
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Early Release Scheme (ERS)
25. Foreign national prisoners who are serving over three months imprisonment,
and whose offence is not of a violent or sexual nature, are eligible for the
Early Release Scheme (ERS). This means they may be returned to their
home country up to 135 days earlier than their original release date.
Prisoners do not have to apply for ERS. The prison puts forward the names
of those who are eligible for ERS and the prisoners are informed in writing if
this is done.
Facilitated Return Scheme (FRS)
26. If a prisoner is eligible for the ERS, they are also eligible for the Facilitated
Return Scheme (FRS). This provides prisoners with assistance to return to
their home country. Only a £43 discharge grant is paid in cash; the rest is
given in the form of training or business start-up costs once the individual has
returned home
Interpreting services at Canterbury
27. Staff at Canterbury make considerable efforts to provide interpreting services
for the prisoners in their charge. These include using the Big Word telephone
interpreting service, and using volunteer prisoner interpreters. A facility also
exists to obtain the services of independent interpreters.
HM Chief Inspector of Prisons’ inspection report
28. HM Chief Inspector of Prisons, Ms Anne Owers, conducted an announced
inspection of Canterbury between 20-24 August 2007.
Safety
29. Ms Owers found that there were good outcomes in every major area affecting
prison safety. The reception process was efficient and caring, and induction
was thorough. There was little evidence of bullying and there were good
systems to identify and manage bullies. ACCT documents were of good
quality and those at risk of self-harm received high standards of care.
Security was proportionate and security systems were effective. There was
little use of force, and adjudications (prison disciplinary hearings) were
conducted fairly and thoroughly. The segregation unit was not often used and
there was little evidence of substance abuse.
Respect
30. Staff prisoner relationships were positive and there were few obvious tensions
between different ethnic or national groups. Residential units were clean, but
in-cell toilets were poorly screened. Ms Owers found that healthcare staff
provided a good service, but there was no primary mental healthcare and no-
one trained in caring for victims of torture or trauma. There were some
weaknesses in the incentives and earned privileges scheme. The quality of
9
race relations management was variable and the investigations of racist
incidents were poor. However, the foreign national prisoner policy was good
and attempts had been made to provide independent immigration advice.
The on-site immigration team offered an improved service, but timely
communication from case holders was a problem and created much anxiety.
Legal services were inadequate.
Purposeful activity
31. Ms Owers reported strong leadership of learning and skills overall, but many
initiatives were in the early stages of development. There were enough work
and education places, but much of the work was unchallenging. The
education curriculum focussed excessively on English for speakers of other
languages, and this did not meet the diverse needs of the population.
Physical education and library provision was reasonable. Given the relatively
compliant population, time out of a cell for all prisoners could have been
increased. The chaplaincy team was effective and appreciated.
Resettlement
32. On resettlement issues, Ms Owers wrote as follows:
“Prisoners reported poorly on resettlement issues. The lack of
certainty about immigration status was a fundamental problem
undermining the prison’s ability to provide effective resettlement
planning and provision. The prison had made considerable efforts, but
had lacked guidance and support on how to work with a foreign
national population with diverse resettlement needs. There had been
no analysis of resettlement needs on which to base the kind of strategy
needed to provide equality of access. The pathway profile document
was an innovative way of assessing need, but in many cases had
inappropriately replaced the offender assessment system. The visitors’
centre was an excellent facility and contrasted with the poor
environment of the visits area.”
33. Ms Owers made nine recommendations that I reproduce here:
1. There should be a national policy for the management and support of
foreign national prisoners which provides clear practice and guidelines
to establishments, and which is supported by auditable standards.
2. The National Offender Management Service should give a clear
strategic lead on offender management for foreign nationals.
3. Defensible decisions on whether or not to proceed to deportation or
removal should be made and relayed as early as possible in sentence
and (where sentence length permits) at least six months before the
earliest date of release.
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4. When indicating an interest in a prisoner that may affect the governor’s
deliberations on home detention curfew, release on temporary licence
or re-categorisation, the Border and Immigration Agency should
provide prompt and detailed explanation of a prisoner’s status and
risks.
5. The immigration team at Canterbury should be properly resourced with
sufficient experienced staff to identify, explain and progress prisoners’
immigration queries, including via regular drop-in surgeries.
6. A prisoner resettlement needs analysis should be undertaken and
updated regularly using monitoring information.
7. There should be more work, linked to appropriate qualifications, to
meet the needs of a diverse foreign national population.
8. Learning and skills provision should be engaging and challenging and
based on regular needs analyses.
9. There should be enough legal visits rooms and sessions to meet
prisoners’ needs and allow confidentiality.
34. An action plan has been prepared at Canterbury to implement the Chief
Inspector’s recommendations.
Foreign National Prisoners
35. According to the Prison Service website (11 February 2008), “In the last ten
years the number of foreign nationals in prison has doubled and now
represents over 14% of the total prison population in England and Wales.
There are a huge range of nationalities and languages to be considered
alongside the cultural and religious diversity that the foreign nationals already
bring.”
36. The website entry continues:
“Prison staff are taking a proactive role in coping with their differing
needs. Many establishments hold regular meetings between staff and
prisoners to discuss the challenges facing foreign nationals, such as
immigration status, staying in contact with family, language difficulties
and resettlement. Some prisons produce magazines providing helpful
advice and points of contact for prisoners during their time in custody.
In addition to this, the invaluable booklet ‘Information and Advice for
Foreign National Prisoners' is available across the estate in 22
languages and contains substantial information on issues including
prison regimes, support organisations and contacting families.
“The Prison Service has worked hard to build closer relationships with
Embassies and High Commissions, some of whom provide their own
11
literature catering directly for their imprisoned citizens, as well as
consular assistance.
“The Prison Service and the Border and Immigration Agency (BIA)
have been working together during the last 18 months to ensure that
foreign nationals' immigration status is dealt with before their earliest
release date. This has helped to ease the worries of many prisoners
who were concerned when they would be removed from the United
Kingdom. BIA is also working to transfer a greater number of time
expired prisoners from Prison Service establishments to Immigration
Removal Centres.”
12
KEY FINDINGS
36. The man who is the subject of this report returned to the United Kingdom at
Stansted Airport in September 2007. He sought admission to the UK as a
EEA (European Economic Area) national, and was in possession of a
Portuguese passport. He was arrested and charged with possession and use
of a false instrument (the Portuguese passport). He was remanded in custody
to HMP Chelmsford. At his reception screening in prison he said he had no
pre-existing physical or mental health problems. Healthcare and reception
staff noted the lack of any apparent depressive or anxiety features and the
absence of any suicidal ideas or thoughts of self-harm. The man expressed
anger at finding himself in prison but appeared to healthcare staff to be
relatively settled. On 14 September 2007, the man was seen at Chelmsford
by a substance misuse worker who noted that he denied any previous misuse
of drugs or alcohol.
37. Later that month, the man appeared at Crown Court and was sentenced to 15
months imprisonment and recommended for deportation. He was seen again
in the healthcare reception at Chelmsford on 24 September, and once more
denied any thoughts of suicide or self-harm.
38. Subsequently, the man was transferred to HMP Wormwood Scrubs. He was
transferred for a final time to HMP Canterbury on 1 October 2007. Upon
reception at Canterbury, the man repeated the reception process and a
‘Pathways Profile’ booklet was opened for referral to different support
agencies. The man denied having any self-harm thoughts but said he missed
his family. He told staff he was married with two boys, aged 13 and nine, who
lived with his parents in India. He said he was desperate to return to India as
he missed his family. Whilst in the United Kingdom he had worked as a
builder with a weekly income of £150 and outgoings of £75.
39. The man had previously worked as builder in India but the wages were poor
and he had decided to come to the United Kingdom to find his fortune before
returning to India. He explained to staff that he had paid an agent the
equivalent of £10,000 to arrange his travel to the UK. He had paid off £6,000
of the debt but said that, now he was being returned to India, he had no idea
how he was going to pay the remaining sum. He said his mother was ill in
India and he had made arrangements to go home through his agent. He had
arranged to collect travel documentation from Spain, and had paid £2,000 for
a Portuguese passport.
40. The man was assessed as having good physical and mental health and
denied having thoughts of self-harm. He showed no evidence of depression,
mood disorders or psychotic presentation during his reception health screen.
41. After going through the reception process, the man was taken to A wing. He
was allocated a shared cell and was given reading and writing materials. The
cell contained bunk beds, a toilet, wash basin and a television. He received
visitors on 7 October who were spoken to by an officer. The man’s visitors
told the officer that the man felt safe at Canterbury and had made friends.
13
42. On 16 October, the man was interviewed by an immigration officer and the
option of the FRS was discussed. Later that day the man’s cellmate
expressed concerns to staff about the man’s general demeanour. The man
said he had family problems in India and felt that his life was over. His mood
appeared to staff to be very low. An Assessment, Care in Custody and
Teamwork (ACCT) document was opened and the man was observed half
hourly (this was subsequently reduced to three staff interactions a day, and
hourly at night).
43. The next day (17 October), the officer spoke to the man using his cellmate as
an interpreter. The man said he had a pain down his right side. He was
worried about his mother, missed his children and was desperate to return to
India. However, the immigration authorities had told him that he would have
to serve until his ERS. An ACCT assessment was carried out later that day
and it was decided to keep the man under observation and for staff to
continue to engage with him.
44. The same day, the man applied for the FRS and was provided with an
application form for an Indian emergency travel document which he was
asked to complete. He was given a phone call to a friend who could obtain
his passport. The following day, the man went to a labour board and was
assigned education classes in the morning and labour workshop in the
afternoon. Another prisoner acted as an interpreter for the man. He told my
investigation team that the man changed his mind all the time. He acted for
him at an immigration interview when the man was told that nothing could be
done for him before January. The man initially wanted to return to India but
then said he did not.
45. On 19 October, the man attended an ACCT case review. A different prisoner
acted as his interpreter. The man said he had not been sleeping and was
missing his family. He had asked for his family to send his passport to the
prison to speed up his deportation. It was noted in his ACCT document that
the man associated with other prisoners, used the telephone and had a good
core of friends who were supporting him. Entries in his ACCT document
showed he was attending work, exercising and sending out visiting orders to
his relatives.
46. On the morning of 22 October, the man told staff he was being picked on by
the prisoner who lived opposite him. (My investigators can find no evidence
that the incident was investigated as one of bullying.) At 1.10pm, the man
rang his cell bell and said he was unwell. He was walking around his cell
asking for the door to be opened. Arrangements were made for him to see
the doctor and medication was prescribed for hyperacidity.
47. Between 22 and 25 October, the man cooperated with the Emergency Travel
Document (ETD) process and indicated that his passport was at his home.
An ACCT review took place on 24 October, attended by the man and the
prisoner who had attended the last ACCT review, who again acted as an
interpreter. It was reported that the man was happy in education and was
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working well. Two days later, the man was seen by the prison chaplain in the
chaplaincy office. The man had been to Sikh prayers and told the chaplain
that he enjoyed the company and the prayers. The entries in his ACCT
records on 26 and 27 October showed he was in a positive frame of mind. On
27 October, he asked a Senior Officer (SO) for a move to C wing and was told
it would need to be considered by the senior officer on the wing.
48. Another member of the prison chaplaincy team spoke to the man on 28
October. He told her that he did not want to be in a cell alone when his
cellmate moved on, and wanted a move to C wing. The member of the
chaplaincy team thought there might have been an underlying problem with
bullying. The man had told another member of staff that his cellmate was
picking on him and taking things from his cell. Again, this report of bullying
was not formally reported and investigated.
49. On 29 October, the man complained of a headache and said he was stressed
about his family in India. He was advised to see the prison dentist. At
7.15am the following day, he was seen banging his head on the cell wall. An
officer tried to speak to him but he continued banging his head on the wall.
He stopped eventually, and said he was frustrated over his immigration
status.
50. The next day (30 October 2007), the man was reviewed in healthcare. He
again said he was missing his family in India. It was recorded that he was
pleasant and smiling with a stable mood and was not clinically depressed. It
was also noted that he had no thoughts of self-harm or psychotic symptoms.
A further entry in the Inmate Medical Record (IMR) said that the man had
refused a financial incentive to return to India. The member of the chaplaincy
team who had spoken with the man on 28 October, made an entry in the
man’s ACCT record on 31 October that he seemed to be in a dilemma
regarding immigration. He wanted to learn better English which was his goal
before returning to India. The man also wanted to move to workshop three
and was advised to speak to officers about his request.
51. Another officer became aware of the man when the ACCT document was
opened and carried out a review with others on 30 October. The same
prisoner as had interpreted for the man in previous ACCT reviews acted as
the man’s interpreter. The man was asked if he intended to take his own life,
but would not discuss it with those present. He said he would not stay in
England and was informed of his options. He said he owed £4,000 to
someone in India but “nothing would happen” if he did not pay the money. He
said he was still having problems sleeping. Arrangements were made for him
to see a member of healthcare regarding his mental health.
52. The man attended an immigration meeting on 1 November and went to the
Sikh service the following day. The prison chaplain recorded in his ACCT
document that the man appeared happy and said he had no concerns. The
ACCT review took place with the man and an interpreter present. The man
said he was not suicidal and would not harm himself. He was having
sleepless nights but was taking sleeping tablets. He still had immigration
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problems and asked to be moved to C wing where he knew people. It was
agreed that he would move that morning as his friends could provide support.
The review panel decided to close the ACCT document and review the man’s
self-harm status on 26 November.
53. The man was moved to C wing where he shared a cell with another prisoner.
The prisoner told my investigators that the man was obsessed with his
deportation. He thought that he would be left behind as his sentence was
disproportionate to other prisoners charged with the same offence. (This was
not the case. The Court of Appeal has held that the appropriate sentence for
the use of one false passport should usually be in the range of 12-18 months,
even after a guilty plea and involving an offender of previous good character.)
54. The was seen by healthcare staff after presenting with flu symptoms. He was
given two Kalms tablets (a non-prescription natural remedy to aid sleep). He
also saw immigration officers and said he wished to withdraw from FRS (he
said he had no fear of returning to India, but did have financial concerns). On
3 November, he was again seen in healthcare. It was recorded that he was
low in mood but relatively stable and without any thoughts of self-harm.
55. On the morning of 7 November, the man’s cellmate rang their cell bell. He
was concerned that the man had wrapped around his neck a piece of cloth
that he used as a prayer mat. The cellmate told staff that the man was
suffering from depression and had attempted to self-harm. No immediate
consideration was given to reopening the ACCT document, but the man was
assessed in healthcare and said he was not sleeping and was feeling cold.
He was physically examined and prescribed Nytol (a sedating medication) to
help him sleep. An appointment was made for him to see the doctor to
discuss his sleep problems that afternoon, although the clinical reviewer can
find no record of a consultation having taken place.
56. The ACCT document was reopened by a Senior Officer later that day. He
interviewed the man using the services of an interpreter, and an emergency
ACCT review was conducted with the man present. He said the cloth around
his neck was not a suicide attempt, but an attempt to relieve pressure from his
head. All present at the review felt that the man was not suicidal but might be
so nearer the time of his deportation. The review panel thought the man
believed he would remain in the UK. On 8 November, he was seen by the
member of the chaplaincy team who had spoken with the man about his
concerns previously, she noted in the ACCT document that he was concerned
about being deported. He said he had a friend in the workshop who was
supporting him.
57. A SO who knew the man from A and B wings was interviewed as part of the
investigation. In interview, she described him as a small man who was
supported by prisoners from the Sikh community. She believed he was a
vulnerable man, but had found no evidence that he was being bullied.
58. The man attended Sikh prayers on 8 November. The Sikh minister was
concerned as the man did not participate in the prayers and asked the wing
16
staff to monitor him. At 1.15pm, the man’s cellmate reported to staff that the
man had taken a number of tablets. He was seen by a member of healthcare
and denied taking the tablets or having thoughts of self-harm. He was
assessed as not being clinically depressed. However, it was decided to stop
his medication and a risk management plan was prepared that included
arrangements to see the prison doctor.
59. In a statement given to the Coroner’s officer, the Sikh minister said he saw the
man weekly at prayer meetings. The man was concerned about going home
to India without a job. The Sikh minister told my investigators that it is the
usual practice and custom of the Sikh faith that the head is covered for
prayers and some prisoners have their own head coverings. The man, who
had short hair, wore his own black head covering.
60. Another prisoner at Canterbury, acted as an interpreter on the weekend of
10/11 November when an officer spoke to the man in his cell. He noticed that
the man was upset and crying, saying he wanted to return to India using the
FRS scheme and that he would kill himself. A SO spoke to the man on
Sunday 11 November and noted in the ACCT document that he was starting
to acknowledge he had to work with staff if he wanted his concerns to be
resolved. It was also noted that the man appeared to accept he would be
deported with no financial assistance if he refused to apply.
61. The man had visitors that afternoon and the SO spoke to them first. The
man’s visitors wanted him to return to India under the FRS. The SO was told
that the man had a lot of family in India and there would be no loss of face if
he returned. The following day, the man appeared to staff to be happier as a
result of the previous day's visits. He attended education in the morning but
did not go to the workshop in the afternoon. He was seen speaking to
prisoners at 7.00pm on the wing landing and, when spoken to by staff, said he
was not feeling bad. He was locked in his cell for the night and observed
hourly in accordance with his ACCT document. At 7.30am the next morning,
he was lying on his bed.
62. One member of staff interviewed teaches English to foreign prisoners at HMP
Canterbury. She told my investigation team that the man spoke English and
could make himself understood. In class he used to sit next to two other men
from India who also spoke Punjabi as their first language. Occasionally, the
man had headaches and was allowed to have a break or go to the toilet.
63. The English teacher believed that his fellow Punjabi speakers thought the
man was pretending throughout his headaches. They did not ridicule him
openly, but she sensed they thought he was attention-seeking. She said that
the man was not a hard worker, but would participate in class.
64. The man had told the English teacher that he would be deported to India in
April 2008, but back there he could not earn enough money to feed his
children. He referred to his long sentence as bad luck. He felt he was
wasting his time in prison, rather than working and earning money to send to
17
his family in India. He believed his sentence was too long and that he should
be released earlier. Deportation would be devastating to his family’s income.
65. The day before his death (i.e. Monday 12 November), the man seemed very
different to her and was extremely happy. She described his face as bright
and very motivated, asking her to check his work. She was surprised at the
positive change in his demeanour and gave him a lot of praise. The English
teacher told my investigators she was shocked to learn of the man’s death as
this did not seem to her to fit in with his behaviour the day before when he
was at his happiest. (In fact, this is a phenomenon often noted amongst
successful suicides.)
66. The English teacher was supported during lessons by a classroom assistant.
The man had been identified to the classroom assistant as a person on a self-
harm watch (open ACCT form). He told the investigation team that the man
had said he was the eldest son and that he had responsibility for his mother
back home. He was distressed that he would not be released prior to her
death and this preyed heavily upon him. He also had a wife and children to
support. The man said his pay per hour in England was the same as the daily
rate in India. The classroom assistant believed the man also worried about
how he would be able to support his family when he was deported after
finishing his sentence.
Events of 13 November
67. On the morning of 13 November, the man’s cellmate got up and prayed at
7.05am. The man was on the bottom bunk and said, ‘What I shall do?’ At
7.50am, the cell was unlocked and the man’s cellmate left the cell at 8.05am
for outside exercise. He left the television switched on mute. As it was
raining, the cellmate returned to the wing after 15 minutes and collected some
milk before returning to his cell. As he entered the cell he saw the man
hanging. There was a ligature made from his prayer head covering attached
to the window bars and around his neck. The cellmate shook the man but he
did not move. He than rang the cell bell and stepped out onto the landing to
raise the alarm. Members of staff ran to the cell.
68. A Senior Officer and two officers were on the ground floor of C wing. One of
the officers, who knew the man as a prisoner who was on a self-harm watch,
noticed a cell bell light being activated. He looked up and saw the man’s
cellmate come out of cell C3.9 signalling for attention. The officer ran to the
cell with the Senior Officer. As they entered they saw the man hanging at the
rear of the cell. He was facing the door with a ligature attached to the window
bars. The officer took the weight off the man’s body and put his finger
between the ligature and his neck. The SO arrived and used his knife to cut
the ligature.
69. A Healthcare Officer (HCO) was on duty working in the triage room when he
received a call on his radio to go to C wing. Although there was no urgency in
the radio message, he made his way quickly to C wing where he was directed
by staff to cell C3.9. On entering the cell, he saw the SO and officer carrying
18
out resuscitation. The SO was carrying out chest compressions and the
officer was attempting to insert an airway into the man’s mouth.
70. The HCO helped insert the airway and then removed furniture from the cell to
give them more room. He checked the man for a pulse and signs of life but
found neither. The man’s pupils were fixed and dilated. The HCO swapped
roles with the SO and continued chest compressions until the paramedics
arrived and took over the resuscitation attempts. The HCO was of the opinion
that the man had died.
71. On the morning of 13 November, the prisoner who had previously acted as an
interpreter for the man the weekend previously collected his breakfast. When
he returned to his cell he heard staff calling for assistance. The prisoner went
to the man’s cell and saw him hanging.
72. The Principal Officer (PO) who was the orderly officer in charge of the
operational management of the prison started his duty at 7.00am on 13
November. During the morning he heard a call over the radio asking staff to
refrain from using the radio network and made his way to the control room to
enquire what the problem was. An SO was in the control room and said that
someone was having breathing problems on C wing. Realising the
seriousness of the situation, the PO ensured that the contingency plans for an
emergency were being followed and he also went to C wing. He spoke to
staff but did not go to the man’s cell. Nevertheless, he ensured the man’s
cellmate and other prisoners on the wing were supported.
73. The PO in charge of all the residential units at Canterbury, who occasionally
works as the orderly officer in charge of the operational running of the prison,
was told that the man had been found hanging on C wing and immediately
attended the wing. He went to cell C3.9 and saw the SO, the officer and the
HCO carrying out resuscitation. The paramedics arrived and took over.
74. The PO in charge of all residential units remained on the wing as the senior
manager, and locked the cell after the paramedics had pronounced that the
man had died. The cell was preserved as a potentional crime scene. After
the police had attended, and with their consent, the Sikh minister and a
member of the chaplaincy team went to the cell to say prayers. The PO in
charge ensured that staff and prisoners were supported and was present
during part of the hot debrief (a meeting for staff in the immediate aftermath of
an incident).
75. At the request of staff, the HCO told the man’s cellmate that the man had
died. He remained with the cellmate, offered him support, and made sure the
Sikh minister was called to see him. The HCO attended a hot debrief of the
incident later that day. In interview, he said he was critical that the ‘code blue’
call sign (indicating breathing difficulties) had not been used as this would
have indicated that the radio call was more urgent than it first appeared. This
would have allowed him to collect and take the defibrillator to the cell.
However, he believed that the defibrillator would only have confirmed that the
man had died.
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76. A sentenced prisoner, who had been at Canterbury since 25 May 2007, in
interview described the prison and staff as very good. He said that if officers
do not understand a prisoner they find a member of staff or another prisoner
who speaks the same language and use them to translate. He said the
chaplaincy team offered support to vulnerable prisoners.
77. The prisoner described the man who died as distressed. He was worried
about his family and was very depressed. He talked about difficulties in
returning to India, and had financial difficulties as he was a poor man. The
prisoners said that those who have agreed to be returned ‘fast track’ to their
countries are frustrated at the time taken for this to happen and the lack of
information.
78. Another prisoner who was interviewed by my investigators said that he had
shared a cell with the man who died and had attended the prison workshop
together. The man had asked the prisoner not to move out of their cell or he
would die. The prisoner said that the man told him about his personal
circumstances, and that he was upset about going back to India without being
a British citizen with permanent residency.
79. The prisoner had been moved out of their cell to another wing after fighting
with other prisoners. The man had accused the prisoner of deceiving him.
The prisoner alleged that he saw the man tie a knotted cloth around his neck
and that the man had asked him to kill him by that method. The prisoner had
not shared this information with prison staff.
Post Mortem
80. The post mortem found no evidence of significant injuries beyond those
consistent with hanging, and nothing to indicate that the man had been
forcibly restrained or involved in a struggle. The cause of death was due to
suspension. I understand that the toxicology results have not given the
Coroner any cause for concern.
Contact with family
81. A family friend who had visited the man at Canterbury was informed of his
death by the Sikh minister. The friend visited Canterbury and spoke to the
Governor regarding the circumstances of the man’s death. The Governor
offered financial support for the funeral arrangements and the repatriation of
the man’s body to India. This was accepted.
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ISSUES CONSIDERED IN THE INVESTIGATION
The discovery of the man hanging
82. Staff acted immediately and appropriately when the man was discovered
hanging in his cell. The ligature was cut, the man was placed on his back on
the floor of the cell, and resuscitation commenced and continued until the
arrival of the ambulance crew. The man was pronounced dead in his cell.
There is no suggestion of third party involvement.
83. The paperwork I have seen indicates that the contingency plans for a death in
custody were put into effect very well. Comprehensive logs were maintained,
all those who needed to be informed were contacted very speedily, and the
cell was sealed as a potential crime scene. However, the HCO who attended
the scene was rightly critical that the prison radio call sign ‘code blue’
(indicating breathing difficulties) was not used. This would have enabled him
to collect the defibrillator en route to the emergency.
The Governor/Head of Healthcare should remind staff to use the correct
radio procedures when dealing with medical emergencies.
ACCT
84. The ACCT case reviews, although comprehensive, were conducted in the
absence of anyone with specific training in mental health matters. Decisions
regarding referral for a mental health opinion were made by a team who
themselves had no specific mental health training. Whilst those members
have a commitment to, and training in, the assessment of suicide risk,
identification of suicidal intent is notoriously difficult. In the view of the clinical
reviewer the absence of an individual with a professional qualification in
mental health was a serious omission. The presence of the prisoner himself
at the case reviews allows an opportunity for mental health trained personnel
to ask questions regarding possible suicidal intent. The clinical reviewer says
this would be preferable to non-mental health staff simply enquiring whether
the individual intends to kill himself and taking the answer at face value.
85. Indeed, in only one of the man’s case reviews was there a representative from
healthcare (and it seems this was a general nurse rather than a psychiatric
nurse). Mention is made of “staffing problems” as being the reason why
healthcare could not attend case reviews. The clinical reviewer finds this to
be unsatisfactory.
86. On 7 November, staff were notified that the man had self-harmed by placing a
prayer head covering around his neck. However, the incident did not lead to
an immediate reopening of an ACCT document.
The Governor/Head of Healthcare should consider the attendance of a
registered mental health nurse or psychiatrist at a prisoner’s ACCT
review.
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The Governor should remind staff that, when a prisoner attempts to self-
harm, an ACCT document should be opened immediately.
Clinical care
87. The clinical reviewer judges that the development of specific prisons for
foreign nationals awaiting deportation may allow staff working in these
establishments to acquire specialist skills. However, I note his view that, for
the prisoners themselves, the constant emphasis on issues relating to a
compulsory return to their native land may prevent a consideration of other
matters affecting overall quality of life. Language, cultural issues and rivalries
may exacerbate pressures in such a designated establishment more than in a
generalist prison. To date, HM Chief Inspector of Prisons has reported
favourably upon Canterbury’s new role, but these are issues that the Prison
Service will need to keep under review.
88. At no point was the man’s depression ever treated. He was assessed and
supervised very comprehensively, but never actually treated. The
presentation of the features displayed by him would almost certainly have
triggered rather different responses in a community environment. There
would likely have been an urgent referral for an opinion by a consultant
psychiatrist, and an attempt at treatment of his depression with medication.
This did not happen at Canterbury and, although it is conceded that the
thresholds at which psychiatric help may be sought and treatment given may
be rather different in the community than in a custodial environment,
equivalence of care in both settings should be the aim.
89. On the morning of 7 November, an appointment was made for the man to see
the doctor to discuss his sleep problems. The clinical reviewer can find no
record of a consultation having taken place
The Governor/Head of Healthcare should consider referring a prisoner
displaying acts of self-harm to a registered mental health nurse or a
psychiatrist for a mental health assessment.
The Governor/Head of Healthcare should ensure that, when a prisoner is
referred to a doctor, the appointment actually takes place.
Bullying
90. There are no official prison documents relating to the man being bullied.
Although it is recorded that the man told staff he was being bullied, it does not
appear the allegation was properly documented and investigated.
The Governor should remind staff that all allegations of bullying should
be fully recorded and investigated.
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Border and Immigration Agency (BIA)
91. Although there is a team of immigration officers based at Canterbury, my
investigators found that prisoners complained there was still a lack of
information regarding their status. This mirrored the findings and
recommendation made by HM Chief Inspector of Prisons following her most
recent inspection (see pages 10-11 above).
92. The actions of BIA in respect of immigration casework are not within my remit
as Prisons and Probation Ombudsman. However, I hope these comments
can be shared by the Governor with his BIA colleagues.
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CONCLUSIONS
93. The man who is the subject of this report entered the UK Illegally to find work
and support his family back in India. He worked in London as a builder for
several years. When his mother became ill he attempted to return to India to
see her. He attempted to re-enter the UK using a false passport. He was
arrested and was sentenced to 15 months imprisonment.
94. In prison, the man became increasingly frustrated because he could not return
to India immediately, and could not support his family. He also believed that
the sentence he had received was greater than that of others charged with a
similar offence. Prisoners and staff recognised that he was upset and he was
correctly placed on an open ACCT document to offer him support against self-
harm. He was seen two days before his death by his visitors and appeared
well. He was described as unusually positive the following day at education.
95. In hindsight, the man must have been suffering a greater level of distress than
was apparent to any of the staff responsible for his care. However, I do not
think any criticism can properly be made of prison staff who worked hard to
engage with him. It is likely that some information about his risk of self-harm
was not shared by prisoners.
96. When the man was discovered hanging by his cellmate, staff acted quickly
and professionally in cutting him down and commencing resuscitation. The
contingency plans for a death in custody were implemented and allowed a
speedy entrance to the prison by the ambulance crew.
97. The man’s death was one of 23 apparently self-inflicted deaths amongst
foreign national prisoners during 2007. Uncertainty and frustration about his
future life back in India seems to have been a significant factor.
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RECOMMENDATIONS
1. The Governor/Head of Healthcare should remind staff to use the correct
radio procedures when dealing with medical emergencies.
2. The Governor/Head of Healthcare should consider the attendance of a
registered mental health nurse or psychiatrist at a prisoner’s ACCT
review.
3. The Governor should remind staff that, when a prisoner attempts to self-
harm, an ACCT document should be opened immediately.
4. The Governor/ Head of Healthcare should consider referring a prisoner
displaying acts of self-harm to a registered mental health nurse or a
psychiatrist for a mental health assessment.
5. The Governor/Head of Healthcare should ensure that, when a prisoner is
referred to a doctor, the appointment actually takes place.
6. The Governor should remind staff that all allegations of bullying should
be fully recorded and investigated.
25