Individual at Isle of Wight

Investigation into the circumstances surrounding the
death of a prisoner at HMP Camp Hill
Report by the Prisons and Probation Ombudsman for
England and Wales
January 2008
This is the report of an investigation into the death of a man who was found
hanging in his cell at HMP Camp Hill.
I would like to offer my own and my colleagues’ condolences to the man’s
wife, family and friends. I know that he came from a close knit family and that
he will be sadly missed. I hope that my report addresses all the family’s
concerns.
The investigation was carried out on my behalf by one of my investigators. A
clinical review was conducted by the Isle of Wight Primary Care Trust. I am
most grateful to the Governor and his staff for their co-operation and
assistance with my investigation.
This is the first apparently self inflicted death to have occurred at HMP Camp
Hill since September 2003 and the first since my office began investigating
deaths in custody. My investigation highlights a number of lessons to be
learnt with regard to the prison’s procedures when handling deaths in custody.
I make six recommendations.
It is evident that the man who is the subject of this investigation suffered
considerably from ill health and had for some time been in great pain. He also
had a history of mental health problems and had attempted to take his life on
a number of occasions. I believe that many of these issues could be
addressed in more depth than has been done so far in the Isle of Wight
Primary Care Trust’s report. One of my recommendations, therefore, is that a
further review of the clinical care afforded to the man should be undertaken.
This version of my report, published on my website, has been amended to
remove the names of the man who died and those of staff and prisoners
involved in my investigation.
Stephen Shaw CBE
Prisons and Probation Ombudsman January 2008
CONTENTS
Summary 4
The Investigation Process 5
HMP Camp Hill 6
Key Findings 7
Issues 15
Recommendations 18
SUMMARY
The man who is the subject of this investigation had a well documented
history of self harm and had on several occasions attempted to take his own
life. In 2003, the man made three attempts on his life before being sectioned
under the Mental Health Act.
In July 2005, the man was remanded in custody to HMP Winchester. In
September that year he was found hanging in his cell and later that month
made a number of cuts to his arms. In response to his actions and in order to
observe, assess and support the man, staff opened an Assessment, Care in
Custody and Teamwork (ACCT) booklet. This was closed a month later. In
October 2005, he was sentenced to five years’ imprisonment.
On 7 November, the man was transferred to HMP Camp Hill. That evening
he was admitted to hospital with acute abdominal pains and was
subsequently transferred to HMP Parkhurst’s healthcare centre. In
December, staff opened another ACCT on him. In January 2006, he was
found in possession of a ligature.
The man transferred back to Camp Hill in June 2006. In August, he
complained to staff that he was being bullied for his medication. In
September, his mother died. As a consequence of these events he was again
placed on an ACCT.
The man was admitted to hospital in October for surgery, during which he was
fitted with a catheter. Over the following months he complained to staff on a
number of occasions about the pain he was experiencing, often during the
night. Because of his health problems he was given access to additional
showers, clothing and bedding.
From November until his death in February 2007, the man continued to tell
discipline staff of the increasing pain that he was suffering. He was
prescribed painkillers, which on at least two occasions had to be obtained
from the healthcare centre at Parkhurst.
The man told staff and other prisoners that he was either suffering from, or
had been diagnosed with, cancer. During his time at Camp Hill, he was not
referred to a member of the mental health team. However, in February 2007,
the man saw the prison doctor, as a large lump had developed on his
stomach. It was during these assessments that the prison doctor referred him
for a mental health assessment by one of his general practitioner colleagues.
On the day before his death the man made a call to his wife and spoke with a
number of friends who were with her at the time. The man’s conversation with
his wife appears to have been light in mood, with him giving no indication as
to the state of his mind or of any self-harming intentions he may have had.
The man was found hanging in his cell by an officer in the early hours on 23
February 2007.
THE INVESTIGATION PROCESS
1. An investigator from my office carried out the investigation into the man’s
death. Notices were issued to staff and prisoners informing them of the
investigation and inviting them to contact my investigator should they wish.
2. My investigator visited Camp Hill and was shown the wing on which the
man spent the last months of his life. He met with the Governor of Camp
Hill, a member of the Independent Monitoring Board and the Police Liaison
Officer. He also made himself known to a representative of the local
branch of the Prison Officers’ Association. My investigator reviewed the
man’s prison and health records in addition to other documentation made
available to him, and interviewed a number of staff and prisoners.
3. An independent clinical review on behalf of the Isle of Wight Primary Care
Trust was undertaken.
4. My investigator spoke with a Detective Sergeant from Hampshire Police,
who is also acting on behalf of the Coroner. He confirmed that the police
had no concerns with regard to the circumstances of the man’s death. My
investigator has also been in contact with the Coroner’s office and a copy
of this report will be sent to the Coroner to assist him with his enquiries.
5. One of my family liaison officers wrote to the man’s wife on several
occasions during the investigation. Although my family liaison officer did
not speak directly with the man’s wife my family liaison officer and
investigator have both spoken to her legal representative offering to meet
with them.
HMP CAMP HILL
6. Built in 1912 using prisoner labour from nearby Parkhurst, Camp Hill is a
Category C training prison located on the Isle of Wight. Camp Hill has a
varied regime with education and various offending behaviour
programmes. Prisoners also have the opportunity to learn trades and gain
work experience in both textiles and engineering. St Patrick’s wing, where
the man was located, is considered to be one of the quieter wings in the
establishment and houses a large proportion of prisoners who find it
difficult to cope with the prison environment.
7. Health services at Camp Hill and at the other two prisons on the Isle of
Wight are commissioned by the Isle of Wight NHS Primary Care Trust.
There are three nurses on duty from 7.30am to 8.00pm Tuesday to Friday,
and from 7.30am to 5.30pm Saturday to Monday. During weekends and
evenings, one nurse is on duty. General Practitioners (GPs) from Median
Healthcare, a local community practice, attend Camp Hill for three, three-
hour sessions each week. Evenings and weekends are covered by on call
GP’s from the local PCT. There is no nursing cover based at Camp Hill
during the night.
KEY FINDINGS
8. The man who is the subject of this investigation had a history of self harm
and attempts at taking his own life. In December 2002, he told staff at
Camp Hill that he had lost his son to cancer and that his mother was also
suffering from the disease. It is recorded that he once attempted to take
his life, whilst on bail, but was saved by his brother.
9. In early 2003, the man’s prison records show that he made at least three
serious attempts on his life. It was during this period that he was
sectioned under the Mental Health Act and spent a period of time at
Ravenswood House. (Ravenswood House is a self-contained medium
secure unit and is the base for the Wessex Forensic Psychiatry Service.)
10. On 25 July 2005, the man was remanded in custody at HMP Winchester.
In October 2005, he was sentenced to five years’ imprisonment.
11. On 15 September 2005, the man was found hanging in his cell. In
response to his actions, staff opened an Assessment, Care in Custody and
Teamwork (ACCT) booklet. (This document is used to assess, observe
and support prisoners at risk of self harm. It highlights the problems and
possible trigger points of a prisoner at risk of self harm, and delivers a
multidisciplinary plan to give prisoners support and help through a period
of crisis.) The man told staff that he was “stressed” out and was being
intimidated by another prisoner. Staff recorded that he had placed the
ligature around his neck so that he could be moved to the healthcare
centre. On 25 September, the man deliberately made a number of cuts to
his arms. On 15 November, it was recorded that he had no further
thoughts of self harm and the ACCT booklet was closed.
12. On 7 November, the man was transferred from Winchester to Camp Hill.
During his reception it was recorded on his prisoner record that his wife
was his next of kin. (No telephone number or address was recorded, but
no indication that the man may not have wanted to provide these details
was indicated either.) That evening the man was admitted to hospital with
acute abdominal pains. He returned to the prison the following day,
transferring to the healthcare centre at Parkhurst on 12 November.
13. On 14 December 2005, staff at Parkhurst opened an ACCT booklet
because of the man’s agitated state. He had been concerned that he
would not receive a visit from his wife before Christmas. However, after
an assessment the decision was made to close the booklet. The man
believed that his comments and actions had been taken the wrong way by
staff.
14. The man was found with a ligature in his possession on 9 January 2006.
Staff at Parkhurst immediately opened another ACCT booklet. It was also
recorded that his mother was seriously ill at this time and that the man’s
mood was low. Over the following weeks he was seen on a regular basis
by members of the Mental Health in Reach Team (MHIRT) at the prison.
The ACCT booklet was closed on 23 March 2006. (The case reviews are
missing from the booklet so my investigator has been unable to establish
in detail the reasons behind the closure.)
In response to my draft report Camp Hill has since provided my
investigator with the case reviews as referred to above. The final review,
on 23 March, records that the man had no thoughts of self harm or suicide,
that he was expecting a visit from his family and that he felt that there was
no need for the ACCT document to remain open. A post closure review on
30 March, records that he had had no problems since the closing of the
ACCT document, the man stating that he felt stable and calm.
15. On 29 June, the man transferred back to Camp Hill from the healthcare
centre at Parkhurst.
16. On 19 July, the man was found wandering around the prison when he
should have been picking up his medication. In August, he told staff that
he was being bullied for his medication, and in September staff raised
concerns that he was possibly trading it. As a consequence, the man’s
medication was issued under supervision.
17. On 9 September, staff opened an ACCT booklet as the man had said that
he had had enough of life and would be better off dead. He told staff that
he was fed up with other prisoners pressurising him for his medication.
The following day (10 September), the man was moved to St Patrick’s
wing. (St Patrick’s wing is primarily occupied by older prisoners and
prisoners who are considered to be more vulnerable.) At a case review on
21 September, the man asked for the ACCT booklet to be closed, telling
staff that he no longer felt “hassled” by other prisoners.
18. On 27 September, the man’s mother died. He was given phone calls by
staff so that he could keep in contact with his wife and family.
19. On 13 October, staff removed sheeting from the man with which he was
attempting to make a noose. Staff recorded that he was suffering from
cancer and had difficulty coping, due to the loss of his mother who had
died of the same illness. The man also told staff that he was seriously in
debt on the wing and of his concern that other prisoners were bullying him
for his medication. An officer opened an ACCT booklet on him. The man
was assessed and a care plan implemented. On 16 October, the man was
admitted to hospital, returning to prison on 18 October. During a review on
20 October it was decided to close the ACCT booklet. (ACCT
assessments must be completed within 24 hours of an ACCT being
opened, however on this occasion it took two days. I appreciate that
during this time the man was in hospital. However, it is unfortunate that
the first case review also took two days to complete rather than 24 hours.
Although this had no bearing upon his death, I should like to remind the
Governor of Camp Hill of the importance of completing such assessments
promptly.)
20. During October 2006, Security Information Reports (SIRs) indicated that
the man was being harassed for his medication and it was suggested his
family would become ‘involved’ if he did not hand this over.
21. During that month, the man underwent surgery during which he was fitted
with a catheter. On 28 October, he complained of being in pain. He told
staff that he was having problems with his catheter and that he was
passing blood. The following night, the man again complained of pain and
staff obtained pain relief from the healthcare centre at Parkhurst. On the
evening of 30 October, further pain relief was requested from Parkhurst.
An officer recorded on the man’s wing history sheets that healthcare staff
in Parkhurst had told him that, “this is the last time that they would do this.”
22. On 2 November, arrangements were made for the man to have additional
bedding, if required, and to have additional access to showers. He was
issued with painkillers to take during the night but he continued to
experience pain. Towards the end of November, it was recorded that his
testicles were swollen and that there was blood in his catheter bag.
23. At approximately 6.00pm on 29 November, the man once again
complained of pain. Staff from St Patrick’s contacted the healthcare
centre at Parkhurst but were advised that nothing could be done until the
morning.
24. On 1 December, an officer recorded that the man had threatened to
remove his catheter. He had become hostile and threatening to staff, not
accepting decisions that had been made and refusing to take his
medication.
25. On 26 December, the man complained of ankle pain to an operational
support grade officer (OSG). It was recorded in the man’s wing history
sheets that, as night time staff were unable to issue medication, he should
go to healthcare the following morning. However, the following morning
the man declined treatment.
26. On 23 January 2007, a nurse wrote in the man’s medical record that wing
staff had reported he was acting strangely, appearing vague and
confused. The man was seen by the nurse who advised wing staff that he
should be observed and that healthcare should be contacted if necessary.
27. The last entry in the man’s wing history sheets was made by an officer on
17 February. He wrote that in the early evening the man rang his cell bell,
telling staff that he was in pain. The man was given four Paracetamol
tablets, and was told to see healthcare staff in the morning in order to
obtain stronger medication.
28. A prisoner on St Patrick’s wing, said that the man had told him and fellow
prisoners that he was suffering from cancer. The prisoner told my
investigators that the man had said he wanted to be with his mum in the
weeks leading to his death. The prisoner said that the day before his
death the man had looked ill and had been in pain.
29. The doctor, a GP from Medina Healthcare, saw the man on 14 and 19
February about the pain from which he had been suffering and about a
lump which had developed on his stomach. The doctor described the man
as someone who appeared nervous and anxious at times but was always
pleasant.
30. The doctor said that he was aware of the man’s history of self harm, but
meetings with him were always brief and had been focussed on his
physical condition. The doctor said that he had never discussed cancer
with the man. (However, my investigators have established, and it is
noted on a number of prison records, that the man led both staff and other
prisoners to believe that he was suffering from cancer.)
31. During his contact with the man on 14 February, the doctor had no
concern about the man’s mental health but referred him for further
assessment to a colleague who held a mental health clinic at the prison.
The doctor said that he had not known that the man had been sectioned
under the Mental Health Act but knew the man had been prescribed
Citalopram. The doctor said his concern:
“… was that he [the man] obviously hadn’t had a mental health review
for quite a considerable amount of time and had obviously been
discharged from the mental health in reach team. So I wanted to
make sure that actually somebody sits down and spends some time
and explores whether he still has ongoing issues.”
(During interview the doctor said that patients prescribed antidepressants
should be seen by a doctor for a review every six months or so.)
32. On 22 February, at 3.39pm, the man made a call to his wife and a number
of friends/relatives who were with her at the time. The telephone
conversation appears to have been light in mood and he gave no
indication about his state of mind, or any self-harming intentions he may
have had. At 4.17pm, the man spoke briefly to his wife again. He made a
final call to a male friend at 4.18pm. He talked for less than two minutes
before being cut off.
33. A therapeutic psychiatric nurse and member of the Mental Health in Reach
Team (MHIRT) at Camp Hill, said that he did not have any formal contact
with the man during his sentence. He said that he was not surprised that
the man had had no contact as he had not expressed any thoughts of self
harm. However, when told that the man had been on an ACCT document
whilst at the prison, the psychiatric nurse expressed surprise that he had
not been referred to a member of staff from the MHIRT.
In their response to my draft report Camp Hill reported that,
“There is no automatic referral to the Mental Health in Reach Team
(MHIRT) when a prisoner is subject to an ACCT process. Referral
would only be made where the assessor considered there to be a
specific Mental Health issue.”
34. A prisoner in a cell adjacent to the man said that at about 10.00pm on 22
February he heard someone speak with the man at his cell door and heard
the man say he was in pain, but the person concerned told him that there
was nothing that they could do. The prisoner was unable to confirm who
spoke with the man. (My investigator has also been unable to establish
who this was or if the man rang his cell bell at this time.)
35. At about 5.15am on 23 February, the OSG on duty on St Patrick’s wing,
started to check prisoners for the early morning roll check. The OSG
looked into the man’s cell. He told police that he could see the man, “…
standing at the foot of his bed near to the sink and window at the far end of
the cell.” The man’s position appeared strange, so the OSG called out
and rapped on the cell door. The OSG turned the cell light on and saw
that the man was suspended from a ligature attached to the window bars.
He immediately called for assistance over the radio.
36. At 5.21am, an OSG based in the communications room, received a call
from the OSG on the wing requesting that Oscar 1 attend St Patrick’s wing
immediately. (During night shifts in prison, a night orderly officer,
commonly known as Oscar 1 is responsible for the running of the prison.)
Oscar 1, who was checking the perimeter fence, told the communications
room that he would be a couple of minutes. This message was relayed
back to the OSG on the wing. However, the OSG on the wing told the
OSG in the communications room that it was urgent that Oscar 1 attend.
This message was again relayed back to Oscar 1. Oscar 1 then asked
what was going on. On speaking with the OSG on the wing for a third
time, the OSG in the communications room established that a prisoner had
been found hanging on the wing. Oscar 1 instructed the communications
room OSG to tell officers in the segregation unit that they should attend St
Patrick’s wing.
37. Two officers were told to attend St Patrick’s wing immediately. The first of
these officers said that, after he had put his boots on, he and the second
officer made their way straight to St Patrick’s wing, arriving several
minutes later. The OSG on St Patrick’s was waiting by the office when the
officers arrived and directed them to the man’s cell. On arriving at the cell
the first officer unlocked the cell and entered immediately. On seeing the
man hanging in a standing position in the corner of the cell between the
bunk beds and outside wall, the first officer to attend attempted to break
the ligature. The second officer returned to the wing office to fetch a pair
of ligature scissors (scissors specifically designed to cut ligatures).
38. The ligature broke and the first officer loosened it from around the man’s
neck. He checked for a pulse but could find none. The first officer
believed the man was dead as he was stiff and cold to the touch. Oscar 1
arrived at the cell at approximately 5.25am and, on observing the situation,
confirmed with the first officer that he had checked for signs of life. Oscar
1 said that he believed the man had been dead for some time and that
rigor mortis had set in. No cardio pulmonary resuscitation (CPR) was
attempted. Both officers withdrew from the cell, preserving any evidence
for the police.
39. Oscar 1 and the second officer then proceeded to the control room. The
second officer returned to the cell office and remained on the wing with the
OSG. In his police statement, the first officer said that several minutes
later he returned to the man’s cell in order to remove the ligature from
around the man’s neck. He did this in order to preserve the man’s dignity.
40. At 5.30am, the duty governor was contacted. He advised that the death in
custody contingency plan should be implemented immediately. At
5.34am, Oscar 1 contacted the healthcare centre at Parkhurst so the duty
doctor could attend and pronounce the man’s death (there being no
nursing cover during the night at Camp Hill). Oscar 1 considered calling
for an ambulance at this time. He said that, because paramedics would
have been unable to do anything, it would have been pointless for them to
attend. Oscar 1 said his priority was to get the doctor and police to the
prison as quickly as possible.
41. The duty doctor was called by Oscar 1 at about 5.40am and was informed
of the man’s death. The duty doctor told my investigator:
“I asked him [Oscar 1] about the protocol for this situation which he
obtained and it advised calling the ambulance, and I said that I would
visit.”
The duty doctor advised Oscar 1 that it was probably best if an ambulance
was called.
42. At 5.58am, an ambulance was called. It arrived at 6.07am. The duty
doctor said that:
“The ECG they [the paramedics] performed was flat and showed no
evidence of electrical activity from his [the man’s] heart.”
The duty doctor certified the man’s death at 6.28am.
43. Members of the prison’s care and welfare team and Independent
Monitoring Board were advised of the man’s death. At 6.55am, staff
discussed the circumstances of his death during a hot de-brief meeting.
Statements were taken and staff were given access to members of the
care team. Prisoners on open ACCT booklets were reviewed in light of the
death.
44. At 7.08am, the duty governor asked the police to notify the man’s next of
kin of his death. It was recorded in the incident log that this action was
taken as there were no contact details held by the prison. The man’s wife
was informed of her husband’s death at 11.42am by Sussex Police.
45. The man’s family made contact with the prison that afternoon. The deputy
family liaison officer assisted the family in arranging to view the man’s
body at the hospital mortuary. The man’s wife and a number of relatives
arrived at Camp Hill on 24 February. Although their arrival at the prison
was unexpected, the deputy family liaison officer arranged for them to
meet the prison chaplain, who was able to show the man’s cell to his wife
and members of her family.
46. On 2 March, a memorial service for the man was held on St Patrick’s wing.
It was attended by the Governor, staff and many prisoners who knew the
man. Members of the chaplaincy and the family liaison officer represented
the Prison Service at the man’s funeral and the prison made a substantial
contribution towards its cost.
Clinical Review
47. Isle of Wight Primary Care Trust has provided a clinical review into the
care the man received whilst at Camp Hill. In his executive summary, the
clinical reviewer said:
“The man was found dead in a single cell one morning in late February
2007. The cause of death given by the Home Office Pathologist was
‘ligature suspension’.
The Pathologist noted:
‘The death of the man was clearly the result of ligature suspension, the
pathological features of which were wholly in keeping with wilful self-
infliction.’
‘No evidence of any obviously painful or distressing somatic (physical)
medical condition. However, the presence of numerous old incised
wound scabs of the forearms and elbow folds typical of self-infliction at
times of very low self-esteem, may be of relevance in determining the
manner of death.’
In respect to ‘physical problems’, the man had a history of problems
passing urine (this had been treated in October 2006 with an
operation). He had also had recurrent discomfort in his groin/testicles
and he had to contend with life-long anticoagulation medication.
However, at post mortem, no serious physical pathology was found
and in particular no evidence of cancer.
In respect to his mental health, the man had a long history of
personality problems and resorting to self harm, including hanging.
Having considered the evidence, in my opinion, the healthcare that the
man received in HMP Camp Hill was equivalent to that he would have
received in the Community.”
48. I am grateful to the clinical reviewer for his report. However, I believe
there are a number of other issues of a clinical nature that would benefit
from further review:
• Interventions made by mental health staff between January 2006 and
February 2007.
• The clinical management of the man’s genito-urinary problems and
pain relief.
• The appropriateness and effectiveness of prescribed medication in
treating the man’s clinical and mental health conditions.
I therefore make the following recommendation:
The Chief Executive of the Isle of Wight Primary Care Trust should
arrange a further review of the clinical care afforded to the man who
died whilst in custody at HMP Camp Hill. This review should pay
particular attention to the mental health interventions and their
adequacy between January 2006 and February 2007. The review
should establish whether the man’s genito-urinary problems were
clinically managed effectively, the appropriateness of the medication
the man received and whether his identified clinical conditions were
treated effectively.
Post Mortem Report
49. The Post Mortem examination reported that the man’s death was as a
consequence of ligature suspension.
ISSUES
50. There is no coded radio call system in place at Camp Hill for staff to use in
an emergency, and during the night radios do not operate on an open
network. (Emergency radio call signs are used by staff in many prisons
when summoning assistance to suspected, or attempted, suicides and
other medical emergencies involving prisoners. Examples include a code
blue being called for prisoners who are experiencing breathing difficulties
and a code red for those suffering from a loss of blood. An open network
enables all staff in a prison to hear all communications made over the
radio.) Although the OSG on St Patrick’s wing reacted promptly when
radioing for assistance in the early hours on the day of the man’s death, it
was not initially clear to the communications room operator, and as a
consequence to the orderly officer, Oscar 1, what the nature of the
emergency was. The OSG based in the communications room was
required to make several calls before establishing that a prisoner had been
found hanging.
51. I appreciate that there is no mandatory requirement for establishments to
introduce such a code system and accept that minimal time was lost in
raising the alarm. However, I know that many prisons have adopted code
systems, finding them to be of great assistance in informing staff of the
nature of an emergency. I therefore make the following recommendation:
The Governor should consider introducing a system of radio call
signs for use during emergency situations. I recommend that
consideration also be given to switching radios to an open network
during such emergencies.
52. I note that one of the officers who responded had to put his boots on after
being alerted to attend St Patrick’s wing. Although I make no formal
recommendation, I would remind the Governor that all staff should be in a
state of readiness to respond promptly when required to do so.
53. On arrival at the man’s cell, the first officer to attend entered immediately.
Like all staff in the prison at the time he did not carry a ligature knife. Due
to staff not being fully aware as to the nature of the emergency they were
responding to, the second officer who attended had to return to the wing
office to collect a pair of ligature scissors. It was fortunate that, while the
second officer was absent, the first officer was able to loosen the ligature
from around the man’s neck and check for signs of life. Shortly after the
man’s death, ligature knives were issued to all staff working nights at
Camp Hill as a consequence of the introduction of national policy. I need
make no further recommendation.
54. Although staff at Camp Hill acted promptly in response to the emergency
call, it is apparent that a certain amount of confusion followed. Some staff
were unaware of the local procedures with regard to entering a cell at night
in response to a suspected death. My investigator reviewed the local night
instructions. He established that instruction 2.87, Nights – Death in
Custody/Suspected Death in Custody, lacked clarity in explaining to
officers the procedures to be followed in the event of discovering a
suspected suicide or death during the night. In particular, the instruction
was lacking in guidance as to when to enter a cell and what action should
be taken on discovering a prisoner in distress. For example, there is no
instruction advising staff to take the weight and cut the ligature from a
prisoner who is found to be hanging.
The Governor should review all Camp Hill’s night instructions that
relate to discovering a death or suspected death in custody.
Particular attention should be focussed on when a cell may be
unlocked and the staffing level that is required to do so.
55. It seems likely that the man who had been found by staff had been dead
for some time when he was discovered. However, it took approximately
35 minutes before an ambulance was called. This delay appears to have
been the result of some confusion as to what was the appropriate action to
take in such circumstances. I note that the night instructions do not give
any guidance as to when an ambulance should be called.
The Governor should draw to the attention of all staff the guidance
relating to the discovery of a death in custody, and the actions to be
taken including the calling of an ambulance.
56. A number of the post incident logs were not started until the arrival of the
duty governor and a number had not been fully completed. I also note that
a number of staff were not asked to attend the hot-debrief.
The Governor should remind all staff of the importance of completing
accurate, timely and comprehensive logs.
The Governor should ensure that a hot de-brief involving all relevant
staff takes place after any death in custody or other serious incident.
57. Shortly after 7.00am, the duty governor asked Hampshire Police to notify
the man’s wife of her husband’s death. The incident log said that no
contact details were held by the prison. Although the man’s current
address was not held by the prison on the Local Inmate Information
System (LIDS), it was recorded on a number of visiting orders held in the
man’s prison record. I make no formal recommendation but would remind
the Governor of the need to ensure that prisoners’ next of kin details are
kept up to date.
58. In section 3.1 of Camp Hill’s procedural document 69, Handling a Death in
Custody, it states that the next of kin should be notified as soon as
possible. It adds that, when available, a family liaison officer will be
appointed to contact the family. This guidance reflects in spirit the good
practice laid out in the Prison Service’s Guidance for Prison Family Liaison
Officers contained in Prison Service Order PSO 2710. However, the
guidance in paragraph 3.1 of Camp Hill’s procedural document should
underline that notification of a prisoner’s death to his family or next of kin
should preferably be made in person by prison staff and not by the police.
The PSO says that, when the distance is too great, staff should make an
effort to contact a local prison in order to break the news, and that the
police should only be contacted to inform the next of kin as a last resort.
The Governor should consider amending section 3 of Camp Hill’s
procedural document 69, Handling a Death in Custody, to reflect
more accurately the guidance published in PSO 2710, Follow up to
Deaths in Custody, when breaking the news of a prisoner’s death to
the next of kin.
RECOMMENDATIONS
The Chief Executive of the Isle of Wight Primary Care Trust should
arrange a further review of the clinical care afforded to the man who
died whilst in custody at HMP Camp Hill. This review should pay
particular attention to the mental health interventions and their
adequacy between January 2006 and February 2007. The review
should establish whether the man’s genito-urinary problems were
clinically managed effectively, the appropriateness of the medication
the man received and whether his identified clinical conditions were
treated effectively.
Accepted – The Chief Executive of the Isle of Wight PCT will conduct a
further review of the clinical care afforded to the man. It is intended that a
suitable clinician from the Hampshire Partnership Mental Health Trust will
conduct this review.
The Governor should consider introducing a system of radio call
signs for use during emergency situations. I recommend that
consideration also be given to switching radios to an open network
during such emergencies.
Accepted – A review of the recommendation to use radio call signs will
be completed. Advice will be given to controllers in respect of switching
to the open network during such emergencies.
The Governor should review all Camp Hill’s night instructions that
relate to discovering a death or suspected death in custody.
Particular attention should be focussed on when a cell may be
unlocked and the staffing level that is required to do so.
Accepted – Both night instructions and contingency plans currently
comply with this recommendation. Contingency plans were amended in
March 2007 and Local instructions 2.77 and 2.87 refer.
The Governor should draw to the attention of all staff the guidance
relating to the discovery of a death in custody, and the actions to be
taken including the calling of an ambulance.
Accepted – Both local Procedural Documents and Contingency plans
now reflect this recommendation. A local staff information notice will be
issued to ensure staff are aware of these changes.
The Governor should remind all staff of the importance of
completing accurate, timely and comprehensive logs.
Accepted – A Local Staff Information Notice will be issued to ensure staff
are aware of this recommendation.
The Governor should ensure that a hot de-brief involving all relevant
staff takes place after any death in custody or other serious incident.
Accepted – This requirement is currently included in the Contingency
Plans. All Operational Managers will be reminded of this requirement in
writing.
The Governor should consider amending section 3 of Camp Hill’s
procedural document 69, Handling a Death in Custody, to reflect
more accurately the guidance published in PSO 2710, Follow up to
Deaths in Custody, when breaking the news of a prisoner’s death to
the next of kin.
Accepted – An Amendment will be made to Procedural Document 65,
Handling a Death in Custody.