Individual at Exeter

The Investigation into the circumstances
surrounding the death of a man in custody
at HMP Exeter
on 14 August 2004
Report by the
Prisons and Probation Ombudsman
for England and Wales
March 2005
This is the report of an investigation into the circumstances surrounding the death of a man
on 14 August 2004 at HMP Exeter. The investigation was carried out under the transitional
arrangement for investigating deaths in custody agreed between my office and the Prison
Service, and which ran until 30 November 2004. The investigation was conducted by the
Deputy Governor of HMP The Verne, and overseen by a member of my team.
A clinical review of the care and treatment received by the man was undertaken by the
Medical Officer HMP Dorchester. He concluded that “such an unfortunate incident could not
have been predicted. I would commend Healthcare Staff for the clarity and methodical way
the Inmate Medical Record (IMR) was maintained throughout this period”. I agree with his
views.
I would like to thank the Governor of Exeter for making the necessary arrangements to
accommodate the investigation team. Additionally I wish to thank the Principal Officer and the
Head of Business Development for their assistance as liaison officers.
The report makes six recommendations for the prison and identifies one area of good
practice.
The loss of any family member is tragic, but especially so whilst they are in custody. I offer
my sincere condolences to the man’s family and friends. His children have now lost both
parents. No words of mine could capture the sadness of their young lives.
STEPHEN SHAW CBE
Prisons and Probation Ombudsman
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CONTENTS
Page
SUMMARY 3
INVESTIGATION PROCESS 4
THE MAN 5
HMP EXETER 6
FINDINGS 7
RECOMMENDATIONS 11
GOOD PRACTICE 11
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SUMMARY
1. The man was remanded into custody on 24 May 2004 by the Central Devon
Magistrates’ Court, having been charged with murder. Upon his initial reception, he
was allocated to the prison Healthcare Centre for observation and assessment. This
is normal practice for someone facing such a serious charge. The assessment
identified an earlier suicide attempt (1981) and, due to concerns about his children
and raised risk of self-harm, the nurse completed the Self-Harm at Risk Warning
form, F2052SH. The F2052SH is used by the Prison Service to identify anyone who
may be at risk of self-harm and to monitor their behaviour, moods and comments. It
is a multi-disciplinary document and involves holding a case conference, with the
prisoner in attendance, and identifying any support mechanisms that need to be in
place. In the man’s case, the document was later closed on 13 June following a case
conference.
2. Following the hospital assessment period, the man was moved into the main prison
and accommodated in a single cell. He was allocated work in the reception area,
which is a highly trusted position for any prisoner to work in and a measure of how
well he had settled down.
3. On the morning of 14 August at 6:25am, the man was discovered hanging from the
window bar by an officer who was checking the wing roll. Medical assistance was
requested. The prison doctor pronounced him dead at 7.10am.
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INVESTIGATION PROCESS
4. Terms of Reference were issued and the Deputy Governor of HMP The Verne was
commissioned to carry out the investigation, with support from one of my
investigators.
5. The investigation began by my investigator meeting the Deputy Governor of HMP The
Verne and the Governor of HMP Exeter. The Governor briefed the team about what
had occurred. A Principal Officer was appointed by him to act as Liaison Officer.
6. My investigator and the Deputy Governor of HMP The Verne met with a member of
the Independent Monitoring Board and Prison Officers’ Association and explained
how the investigation would proceed.
7. The Principal Officer had produced a comprehensive document containing all the
necessary information relating to the man. He also arranged for facilities to be
available for the investigation team.
8. The area where the man died was visited and examined. Following this, the team
released the cell back to the Governor. The area of the prison where the man worked
was also visited.
9. All available documentation was examined. A list of key staff who attended to the
man and of prisoners was drawn up in readiness for interviewing.
10. My investigator met with the Coroner and later with the man’s mother and sister at the
family home. His family were given the opportunity to raise any concerns that they
might have. No concerns were raised. They asked my investigator to return and brief
them on the findings, once the report was available.
11. The Deputy Governor of HMP The Verne was briefed as to how the investigation
should proceed. Under the transitional arrangements for investigating deaths in
custody, he took over responsibility for the investigation, overseen by my investigator.
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THE MAN
12. He was born on 9 January 1957 and was one of two adopted children. He had an
adopted sister, who now lives in the Midlands. His mother still lives in the Exeter
area. The man was educated at boarding school and local authority education
schools in the Exeter area. He left school at the age of 16 and joined a local factory,
where he remained until leaving to become a welder. He later returned to the factory
where he had begun work after leaving school and gained a supervisory position on
the production side of the factory.
13. The man had been married for 17 years and had two children aged 13 and 11 at the
time he was arrested. The marriage was going through an unsettled period and his
wife had begun divorce proceedings. He was aware that his wife had been seeing
another man, but did not know who.
14. On 21 May at 8.03pm, the police received a telephone call via 999 from the man to
say that he had stabbed his wife at the home address in Devon. The police
responded and initially arrested him on suspicion of wounding. Once it had been
established that his wife was dead, he was arrested on suspicion of murder. He was
taken to hospital for treatment to a stab wound on his left leg and right hand.
Following treatment, he was taken to Exeter Custody Centre for questioning.
15. His period of custody did not cause any concern to staff. He was described by staff
and prisoners as very polite and quiet. The wing files did not have any recorded
negative entries or warnings. The Security File had one entry indicating that he was a
potential suicide risk. This had been obtained from the initial assessment files raised
following his initial reception into custody and was not new information.
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HMP EXETER
16. The prison is located within the City of Exeter and was built around 1850. The
Certified Normal Accommodation is 314 and the Operational Capacity 533. The
prison holds both adult male remand and convicted prisoners committed to custody
from Cornwall, Devon and South West Somerset. Additionally it holds young men
between the ages of 18 and 21. On 14 August, the population was 502.
17. The Healthcare Centre has one Principal Officer and one Senior Officer. The nursing
staff complement is : One H Grade, one F Grade, 11 E Grade (full time), two E Grade
(part time), one D Grade, and one B Grade. The Healthcare Centre has a “Green
Light” assessment and is staffed 24 hours.
18. The Standards and Security Audit carried out in May 2003 assessed the prison as
“Good”.
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FINDINGS
19. The man died on August 14 whilst in Exeter Prison. The autopsy report, produced by
the Home Office Pathologist for Devon and Cornwall Constabulary, identifies the
cause of death as hanging.
20. He had been remanded into custody by the Central Devon Magistrates’ Court on 24
May 2004 for an offence of murder. Following his remand into custody he was
transferred to Exeter Prison. He was further remanded by Exeter Crown Court on 2
June and 6 August. The Police National Computer (PNC) printout shows that he was
not known previously to the police.
21. On his arrival into custody, he was allocated initially to the prison Healthcare Centre
and discharged into the main wing accommodation by the prison doctor on 31 May.
He underwent assessment by Healthcare staff as a potential risk of self-harm or
suicide, which resulted in a Self-Harm at Risk Form (F2052SH) being opened by an
Healthcare Officer. The form was subsequently closed on 13 June following a multi-
disciplinary team meeting, which the man attended. He was noted as being positive
and speaking openly about the offence and fully accepting his responsibility. The
review summary noted that the man stated that he was not suicidal.
22. The prison’s local procedures for dealing with the F2052SH system were audited by
the Standards Audit Unit in April/May 2003. The overall marking was 83 per cent,
which gave an assessment of “Good”. An examination of the F2052SH file opened
on the man shows a number of entries where the authors have not printed their name
and simply signed the entry, making it difficult to audit. This is contrary to the
document instruction. It was also found that a number of entries have gaps between
them, which is poor practice and both findings require correction.
The Governor should remind staff that all entries into the F2052SH document
clearly identify the person making the entry with printed name, signature, and
time. Additionally, there should be no gaps between entries.
23. As the man was facing a mandatory sentence for his offence, an Officer interviewed
him as a potential life sentence prisoner on 27 May. The report noted that the man
had said that he did not require any support as he preferred to keep his thoughts to
himself. The Officer did not raise any concerns regarding him.
24. All prisoners arriving into custody for the first time are assessed by the “First Night”
staff and a Cell Sharing Risk Assessment carried out to assess the level of risk to
others. The man was assessed as low risk. The Case Management Record
indicates at section E that he had made a self-harm attempt in 1981, due to domestic
reasons. It does not identify how the self-harm attempt was made. Section F notes
specific concerns raised by him regarding sleeping and his children.
The Governor should remind staff that the Case Management Record identifies
how any previous self-harm/suicide attempt was carried out and when.
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25. Following the man’s transfer from the Healthcare Centre to normal location, he was
allocated work within the prison reception. He remained working in the reception
department up until his death.
26. On 13 August, he attended his work place as usual and remained in the department
until approximately 9.00pm. He had given no cause for concern to either the
reception staff or other prisoners working in the area. The Reception Officer said in
his statement that there was no indication that anything was wrong and that the man
did not seem to be down in the dumps.
27. A prisoner who worked with the man, said that he was positive when he returned to
the wing the evening prior to his death. Another prisoner employed in the reception
area, said that the day was normal and that he had been talking to the man through
the window the evening prior to his death and had said that he would see him in the
morning. The man had not given either of the prisoners any cause for concern
28. The man returned to his cell, A4:36, at approximately 8.00pm following completion of
his work in the reception department. He had been allocated to this cell since his
transfer from the prison hospital on 31 May. The cell was a single occupancy room.
When he returned to the cell he found a letter on his bed from a firm of solicitors
which had been posted in by his own solicitor. The letter explains to his solicitor the
legal position regarding his property and future maintenance contribution for his
children. Prison staff delivered the letter to his cell for him to read on his return. As
the letter was from a solicitor, it would not be routine for prison staff to read the
contents. The staff therefore would not have realised the significance of the contents.
29. The Senior Officer said that at 5.00pm he had been having a drink of tea with the man
and that he appeared quite happy. Once he had been made aware that the man had
died he spoke to other prisoners who worked in the reception area. They said that
the man informed them that he had a letter and gave a facial expression of not being
too happy. They did not see him again.
30. An Operational Support Grade (OSG) carried out a roll check of A4 landing at 8.54pm
and said that she observed the man looking out of the window. He did not
acknowledge her. The wing has a movement detector sensor which then operates a
video camera. Unfortunately, the detector located at the area the man was allocated
to failed to work. However, the video evidence does show that the OSG began her
roll check at 8.56pm on the left side of the landing. When she entered the far left
hand side the image disappears and does not re-appear until she activated the
detector in the lower right side of the landing. The fault has since been corrected.
The Governor should introduce a regular auditable maintenance check to test
the cameras and sensor operation.
31. On 14 August at approximately 6:25am, the OSG carrying out a roll check discovered
the man hanging from the window bars of cell A4:36. Roll checks are undertaken to
establish that the prison population agrees with the recorded total and to ensure that
individuals are safe and secure. The man was at the window of the cell and the OSG
could observe a ligature around his neck. He summoned assistance from the
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communications room and from staff within the unit. Staff attended soon after his
request for assistance. The OSG was unable to open the cell door, as his normal
duty was to patrol the external area of the prison and therefore he was not permitted
to carry a cell key with him.
32. The prison Incident Log shows that at 6.25am a radio message was received from
call sign “November two” requesting “Hotel one” to attend A4:36. Hotel one is the call
sign of the Healthcare staff.
33. The Orderly Officer, radio call sign “Oscar one”, acknowledged at 6.28am by radio
that he was on his way to collect a Nurse from the Healthcare Centre. Once the
Orderly Officer had been informed that the incident was one of a prisoner hanging, he
requested an ambulance to be called. The control room staff made a 999 call at
6.29am.
34. The cell door was unlocked and opened by a Senior Officer. Another OSG assisted
the Senior Officer with lifting the man and removing the ligature. This OSG, who is a
Paramedic Reservist in the Army, checked for vital signs, carotid pulse, eye
movement, breathing and chest noise. He was unable to find any indication. He said
that he had found Rigor Mortis and the eyes to be fixed and dilated. The skin was
cold and clammy with the limbs extremely stiff.
35. A nurse arrived shortly after. Having assessed the body, the nurse concluded that it
would be inappropriate to attempt resuscitation. The Clinical Review agrees with this
view. The nurse was on duty in the Healthcare Centre when the urgent message call
was transmitted. As he was on night duty, he did not have keys available to him to
allow him access into the incident area. The procedure for obtaining medical
assistance during the night is that the Orderly Officer has to escort the nurse to the
incident scene. In this case the short time delay was not relevant. However, due to
the nurse having to wait for the Orderly Officer to attend, it is possible that valuable
time could be lost in giving medical aid. This requires reviewing.
The Governor should review the procedures and carry out a risk assessment
for accessing urgent medical assistance during the night time.
36. The prison doctor pronounced the man dead at 7.10am. The cell was then locked
and a member of staff positioned outside the door to prevent entry and protect the
evidence.
37. The prison contingency plans for dealing with a death in custody were activated. The
Duty Governor was telephoned at home and informed of the death. He attended the
prison promptly. When he arrived at the scene, the cell door was locked and he gave
instructions that the door should not be unlocked until the police arrived as it was a
potential crime scene. However, the Chaplain requested to say a prayer over the
body of the man, which the Duty Governor allowed and the cell door was unlocked.
This was a compassionate and decent thing to agree to, and I make no criticism of
the action. However, as a potential crime scene the door should not have been
unlocked until the police had given authority.
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The Governor should ensure that all staff are aware that a potential crime scene
should not be entered until authority has been given by the police. This should
be entered into the local contingency plans.
38. The ligature was found to be a form of nylon “Baler” twine as used in the prison
reception and clothing exchange area. An Officer explained in his statement how the
towels arrive bound by the twine and the method of disposal. The investigator
concluded that the control and disposal of the twine was not sufficiently robust and
alerted the Deputy Governor to this fact.
The Governor should introduce a system to account for the twine.
39. As well as the solicitor’s letter identified at paragraph 15, two further letters written by
the man and dated 13 August were found. One was jointly to his mother and sister.
40. The Governor, Family Liaison Officer and Chaplain were very supportive to the family,
which is to be commended. On 15 August, the man’s sister wrote to the Governor
thanking him and the staff. The letter suggests that the final straw for her brother was
receiving the solicitor’s letter.
41. The Chaplain had spoken to the man previously and had never had any cause for
concern regarding his welfare. The Chaplain took the funeral service and also
arranged for a memorial service to take place in the prison chapel, which prisoners
and staff could attend. The service was held on 25 August.
42. My investigator met the man’s sister and mother and they suggested that he had
never come to terms with being adopted. They also suggested that, as he had
attempted suicide previously, he would be well aware of how to hide his feelings and
disguise his true intentions and that nothing could have prevented him committing
suicide. They spoke very highly of the prison and the care and attention afforded
them.
43. The investigation found that the man was well cared for and appropriately supported
during his time in prison.
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RECOMMENDATIONS
1. The Governor should remind staff that all entries into the F2052SH document clearly
identify the person making the entry with printed name, signature, and time.
Additionally, there should be no gaps between entries.
2. The Governor should remind staff that the Case Management Record identifies how
any previous self-harm/suicide attempt was carried out and when.
3. The Governor should introduce a regular auditable maintenance check to test the
cameras and sensor operation.
4. The Governor should review the procedures and carry out a risk assessment for
accessing urgent medical assistance during the night time.
5. The Governor should ensure that all staff are aware that a potential crime scene
should not be entered until authority has been given by the police. This should be
entered into the local contingency plans
6. The Governor should introduce a system to account for the twine.
GOOD PRACTICE
1. The Governor should commend Healthcare Staff for the clear and methodical way the
Inmate Medical Record was completed.
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